Pharmacological Treatment of Bulimia Nervosa
A Review of Available Medications
by Mary EUen Trunko. MD
and Walter H. Kaye. MD
B
ulimia nervosa (BN) is a disorder with a complex cause.
The disorder is most commonly seen in women, generally with
onset in adolescence. It is characterized by binge eating (consumption of
an unusually large amount of food accompanied by feeling a loss of control), inappropriate compensatory
measures to prevent weight gain (including purging by vomiting, abuse
of laxatives and diuretics, strict dieting, and excessive exercise), obsessive fears of being fat, and negative
self-evaluation influenced largely by
body shape and weight.' BN is often
associated with anxiety, depression,
obsessionality, substance abuse, and
poor impulse control.
Antidepressants are the mainstay
of pharmacological treatment for BN.
In the 1980s and early 1990s they
were established as more effective
than placebo in treating BN in double-blind, placebo-controlled trials
that tested a variety of medication
classes, including tricyclic antidepressants, monoamine oxidase inhibitors, and more recently, SSR1s.l
Success was most commonly measured by a decrease in the number of
bingeing and purging episodes, and
although the studies varied widely,
many patients achieved short-term
reductions of 50% to 75% in one or
both areas.' Much less attention has
been focused on whether antidepressants are as useful in reducing mood
and impulse control problems often
comorbid with BN.
While the observed reductions in
eating-disorderedbehaviors were significant, it is important to realize that
many patients who responded to
medication continued to binge and
purge at a frequency that still met criteria for a diagnosis of BN at the end
of the studies. Only a minority of patients attained remission of the bingeing and purging symptoms.'
Another caveat concerns the clinical applicabilityof trial data, because
some have estimated that one-third to
one-half of patients who present for
treatment of BN would have been
excluded from treatment studies because of accompanying substance
abuse, personality disorders, current
or earlier use of psychotropic medication, and other factors.'
With their relatively benign adverseeffect profiles, SSRIs are the first-line
pharmacological treatment of BN.'"
Fluoxetine is the most studied of the
antidepressants in this country, and
the only medication approved by the
FDA for treatment of BN. The indication was granted in 1996, after 2
large, multicenter, controlled trials
convincingly demonstrated that fluoxetine was more efficacious than
placebo for treatment of BN.
for the treatment of BN.
Results with sertraline have been
more promising, although the results
of only one small randomized trial
with 20 patients have been reported.
Of interest, significant improvement
versus placebo occurred with only
100 mgld, in contrast with the relatively high doses required for fluoxetine.'>The reason for this finding is
unknown, but replication on a larger
scale would be beneficial.
Little work has been undertaken in
controlled trials to compare various
SSRIs for BN. One randomized controlled trial of 6 weeks' duration that
CHECK POINTS
,/ Fluoxetine is by far the most studied of the antidepressants, and the only
medicationapproved by the FDA for treating bulimia nervosa (BN).
,/While significant reductions in eating-disordered behaviors have been
observed with antidepressants, only a minority of patients attained remission of the bingelng and purging symptoms.
,/Controlled trials are needed to assess the efficacy of serotonin-norepinephrine reuptake inhibitorsfor treating BN.
,/Drug action for BN symptoms may be related to variance in the serotonergic abnormalities found in BN patients versus those who have major
depression, which has led to case reports and small trials of novel
medications such as topiramate and ondansetron.
,/ Augmentation with atypical antipsychotics may be an area of future
research.
The first, an 8-week study that included nearly 400 patients, showed a
response at a relatively high dosage of
60 mg/d, while a dosage of 20 mgld
was no different from placebo.' The
second trial, with a duration of 16
weeks, revealed that a starting dosage
of 60 mg/d was generally well tolerated in this patient population.'
Trials with other SSRIs have been
scant. Several conducted with fluvoxamine had problems with tolerability and mixed results regarding efficacyFn1In a large randomized trial
involving 267 patients, fluvoxamine
was no better than placebo for shortor long-term (1 year) treatment of
outpatients with BN. The investigators acknowledged that the dosage
range of 50 to 300 mg/d may have
been too low to show a treatment effect with this illness; however, titration to higher doses may have led to
even more adverse events.'" Overall,
there is little evidence for the use of
fluvoxamine as an SSRI of choice
i,nvolved 91 inpatients was designed
to explore a genetic basis for drug response. No such basis was elucidated,
but the authors reported that fluoxetine, fluvoxamine, citalopram, and
paroxetine were all superior to placebo." Findings from a smaller controlled study in which patients were
randomized to either citalopram or
fluoxetine indicate that both groups
had significant improvement in eating
p~ychopathology.~~
Other antidepressants
Success with the SSRIs lends support
to the theory of altered serotonin activity in BN. Nonetheless, neurotransmitter dysregulation in the disorder is more complex, and it has
been known for some time that the
noradrenergic system is implicated as
ell.'^.'^ In a study -by Kruger and
Kennedy," some tricyclic antidepressants with prominent noradrenergic
effects, including desipramine and
imipramine, were shown to reduce
binge eating and purging.
This class of drugs may be associated with greater adverse effects in
BN and thus these drugs are rarely
used.' However, it is surprising that
no controlled trials have been conducted with the newer generation
noradrenergic antidepressants. Small
open trials in Austria and Italy used
reboxetine, a selective noradrenaline
reuptake inhibitor not available in the
United States. Results showed a decrease in bingeing and purging symptoms as well as other psychological
variable^.^^.^^
There are no reports of venlafaxine as a treatment for BN; however, a
retrospective review found some efficacy for this serotonin-norepinephrine reuptake inhibitor (SNRI) in patients with the related condition of
binge-eating disorder.' The other currently prescribed SNRI, duloxetine,
has appeared in a single case report of
treatment-refractoryBN, in which the
patient achieved remission of bingeing and purging symptoms on a high
dosage of 120 mgld." Clearly, controlled trials are needed to assess the
efficacy of SNRIs for treating BN.
Bupropion is another antidepressant worth mentioning. In 1988, the
immediate-release formulation was
found to be effective in reducing BN
symptoms in a controlled study; however, 4 of 69 patients who received
the drug had generalized seizures,
resulting in its contraindication by the
FDA for use in eating disorders."
Subseqhently, the investigators of the
study reported doing an intensive
examination of the patients who had
experienced seizures. They found no
common features in these patients'
medical histories, laboratory results,
concomitant medication use, or other
variables that might explain predisposition to seizure, and concluded
that the increased incidence of seizures could not be explained?*"
Although no study has attempted to
replicate these findings using the lower doses and longer-acting forms of
the drug more commonly prescribed
today, clinicians in the eating disorders field generally avoid using bupropion when treating patients with
BN.
Antidepressants were initially proposed for treatment of BN because
(Please see Bullrnla Nervosa,poge56)
1
56
PsycHlnrRlc TIMES
EATING D I S O R D E R S - I ]
w w w psychiatrictimes.com
Bulimia Nervosa
Continued from page 52
of the frequent accompanying mood
symptoms of these patients. However, such medications also have proved
helpful in patients with BN without
comorbid anxiety and depressive disorders; they appear to independently
target symptoms of binge eating,
purging, and preoccupation with
shape and eight.'^ This result, along
with a generally more rapid onset of
action and, for fluoxetine, a higher
dosage requirement than is seen with
treatment of depression, suggests that
drug action for BN symptoms may
occur by a different mechanism, perhaps relating in part to underlying
variance in the serotonergic abnormalities found in BN patients versus
those with major depression." Such
a possibility has led to case reports
and small trials of novel medications, most notably topiramate and
ondansetron.
Topiramate
The anticonvulsant topiramate has
been linked to appetite suppression
and weight loss, and interest in its
use in BN followed suggestions of efficacy in patients with binge eating
disorder.'" Results from the first randomized, double-blind, placebo-controlled trial of topiramate in BN were
reported in 2003. The 10-week trial
of 69 patients began with a dosage
of 25 mgld titrated to a maximum of
400 mg/d (median 100 mgld). Topi-
ramate was found to be more efficacious than placebo in decreasing
frequency of bingeing and purging
behaviors (to a similar degree as that
seen in antidepressant trials) and in
improving other psychological measures, including anxiety, self-esteem,
eating attitudes, and body image. Adverse events were generally mild to
moderate, resolved with time or dose
reduction, and did not usually lead to
withdrawal from the
A 10week controlled trial in 2004 found
similar results with regard to reductions in bingeing and purging behaviors, and a decrease in weight was
reported in the topiramate group.
There was an unusually low dropout rate among the 60 participants,
possibly because the study enrolled
only patients with moderate BN, or
because the dose was increased slowly and remained relatively low (25 to
250 mgld)." Despite the report that
there were few intolerable adverse effects in these small studies, adverse
reactions to topiramate are common
in clinical psychiatric practice, which
tends to limit its use.
symptoms by stimulating afferent
branches of the vagus nerve and
thereby initiating the vomiting reflex.
One group of investigators has postulated that an escalating cycle of
bingeing and purging behaviors in
chronic BN results at least in part
from a desensitization in the threshold for activation of vagal afferent
fibers, with dysregulation of satiety
mechani~ms.~
The results of a randomized, double-blind trial of 25 patients with severe, chronic BN showed that ondansetron was more effective than
placebo in reducing binge eating and
purging by vomiting during a 4-week
period." Past criticisms of potential
ondansetron use have included expense and short half-life. While the
drug is now available as a generic, the
problem of multiple daily dosing still
remains. If an extended-release version of ondansetron becomes available, larger and longer studies that include an assessment of the impact on
psychological features of BN could
be of interest.
Ondansetron
A few other medications have been
studied in a limited number of small
trials. Endogenous opioids are believed to be involved in the regulation
of food intake, and the opioid antagonist naltrexone attracted attention in
the late 1980s after it was observed to
decrease appetite in some patients
recently detoxified from opioid dependence. Unfortunately, when sub-
Other medications
Another novel agent proposed for
treatment of BN is the antiemetic ondansetron, a selective 5-HT,antagonist approved for the prevention of
nausea and vomiting in cancer patients undergoing chemotherapy or
radiation treatment. It targets serotonin release from enterochromaffin
cells in the gut that may cause the
sequently tested in patients with BN,
the standard naltrexone doses used
in addiction were found ineffective.
There appeared to be some efficacy in
open-label studies at 200 to 300 mgd,
but because tlus dosage is high enough
to raise concerns of liver toxicity, naltrexone is not reco~nmended.~'~~~
Lithiumcarbonate was no more effective than placebo for symptoms of
BN in one controlled trial. Mean plasma concentrations at the low end of
the usual therapeutic range may have
affected outcomeM;nonetheless, lithium use entails a potential toxicity risk
for patients who continue purging.
Carbamazepine did not prove beneficial in an early controlled trial with
6 patients."
A future direction of research tray
involve the atypical antipsychotics,
which have not been formally studied
for use in BN. Interest in this medication class stems from preliminary data that show efficacy in some patients
with anorexia nervosa, as well as reports of efficacy when used as an augmenting agent in depression and anxiety disorder^.'^"'
At the University of California San
Diego Center for Eating Disorders
Treatment and Research, we occasionally use low-dose atypical antipsychotics to augment antidepressants in some of our patients who
have more chronic and severe BN and
whose disorder has proved refractory to the established treatments (typically, these patients also have not
achieved remission of comorbid de-
Practical suggestions for pharmacological management of BN
Antidepressants are a useful part of the treatment plan for many patients with bulimia nervosa @N); medication is recommended when the patient has concurrent depression,
anxiety, or obsessionality, does not have access to a therapist q ~ a l i i e d ~ ~ t rBN
b awith
l cognitiv~hehavloraItherapy; or engages in a particularly frequent, disruptive cycle
of bingeing and purging; an antidepressant may also be added.when thb patient has a poor or only partial response to psychotherapeutlctreatmenP
SSRls are first-linetherapy because they have the most evidence for efficacy and,the least Ilkellhood of adverse effects; formal guidelines for the treatment of BN recommend
starting with fluoxetinew;as a practic& matter,Githod aa ev!dence,base comparing the SSRls, w&typi&llymake an initial drug choice using the same considerations
(potential adverse effects, response in relatives, and so on) that might be weighed when selecting medication for depression or anxiety disorders
With fluoxetine,a dose higherthan that generally used,t? tregt depression is Considered more effective for many pabents with BNw; some evidence exists that patients can
begin by receiving 60 mgEd; however, many p~en@+w~feci~lyfl;lbse
naive.to$sycho!rogic medi~~tiori-farebetter with a starting dosage of 10 to 20 mgld titrated fairly
rapidly to 60 to 80 tngld; we use a dmilgr desln'gstratgggwith other SSRls "
, ,
No reliable data exist with regardta.derati~n'gfk&m&sith
antitidepres~an$;birt a minimum of 9 to K! m~nthsis cohsidered.advisable
For a pahent who does not respond tom does not tolerate SSRI~therears few specific recbrnmendatipns; tncycl~csand monoamine oxidase inh~bitorshave shown some
benef~t,but are infrequently used in this population because of saw concernss: the serotonin-nowpaephnne reuptake inhibitors (SNRls) have not been studied but have
some theoretical suppod for use, and in practice,s tdd of an SNRl may be a reasonable next step
TopIramate has been found to reduce bingeing and purging, blrt'beca~sea~erse
events are common, the American Psychiatric Assoclabon has stated It should be considered
for BN only when other medications af&neffkctive?: apot8ntial.e~epfion~tbi$is
adjunctive usein patients with comorb~dbipolar disorder; caution IS advtsed regarding
the use of topiramate for EN patientswith lowzor normal weight, because the drug's tendency to promote weightloss could be precarious In ~nd~viduals
constantly
striving for an unhealhy deg&@afthihnes
In severe, chronic, treatment-refractory BN, atypical ant4psychotic augmentation of aqQdeprewtsappears% U helpful for some patients anecdotally; patients may be more
.
receptive to the newer, generally deight-neutraldrugs; the~afegmd.efflmcy of this-approach'has nof'bea formally studied, and trlal data are needed before aiypical
. ..
antipsychotics can be recommended
1.\.
r""----------EATING DISORDERS
pression or anxiety on various antidepressants). These patients often are
also of relatively low weight and display the rigid, restrictive thought processes more typical of patients with
anorexia nervosa.
While case reports and small open
trials of anorexia nervosa, mostly
with inpatients, have focused on
olanzepine, quetiapine, and risperi-
done, in consideration that the weight
gain sometimes attributed to these
medications may benefit emaciated
patients, we have found use of these
particular medications in our BN outpatients to be problematic. Even in
cases where patients accept the need
to attain a higher target weight, fear
of uncontrollable weight gain prevents most patients from agreeing to
a medication trial, and those who do
rarely remain adherent. In addition,
some investigators have expressed
concern that these medications, especially olanzapine, might exacerbate
binge eating symptoms in patients
with eating disorders."
We have had more success in starting patients on the generally weightneutral antipsychotics aripiprazole
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PSYCHIATRIC TIMES
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57
psych~atrict~rne
co
srn
and ziprasidone. Our patients who
find these medications helpful describe a reduction in distress around
eating, more willingness to attempt
their prescribed meal plans, fewer
obsessional thoughts about food,
exercise, weight, and body image,
and less tendency to dwell on these
thoughts when they do occur. For
some, reductions in bingeing, purging, and restrictive eating behaviors
have been demonstrated clinicallv.
Mood tends to improve as well. However, it must be emphasized that
without trial data, use of the atypical
antipsychotics in BN remains experimental. Any desired benefit must be
weighed against potential adverse effects, including the unlikely but possible risk of tardive dyskinesia.
Long-term pharmacological
management
There are minimal controlled trial data on long-term efficacy of pharmacotherapy for BN. A relatively large
study designed to isolate long-term
potential benefits of antidepressant
medication, conducted in 2002, was
hampered by significant rates of attrition in both study drug and placebo
arms. The trial began with 232 patients who received an 8-week course
of fluoxetine, 60 tng/d, under singleblind treatment conditions. Of this
group, 150 patients were considered
responders (ie, a 50% or greater decrease in weekly vomiting episodes),
and were randomly assigned to continued fluoxetine treatment or placebo for a I-year double-blind relapse
prevention phase.
Findings included a lower rate of
relapse for the fluoxetine group, but
the investigators noted a worsening
on all measures of efficacy over time.
They concluded that phamiacotherapy alone may not be adequate treatment after acute response for most
patients."' Perhaps even more concerning was a less than 20% acutephase remission rate in this study.
This result, which is described as consistent with data froin other trials, reveals that the vast majority of responders were still bingeing and purging
at the beginning of maintenance therapy, which indicates that the idea of
relapse prevention may be dubious
for most trial participants.
Pharmacological
management of BN in
adolescents
It should be mentioned that data
regarding pharmacological treatment
of BN have been gathered almost
exclusively from adult patients. One
(Please see Bulimia Nervora, page 58)
1
Bulimia Nervosa
Contlnmd hm paw 67
small open trial of fluoxetine in adolescents with BN suggested it was
useful and well tolerated," but in general, clinicians are left to extrapolate
from the adult trial literature in treating young patients. Because of the
physical and psychological morbidity and risk of chronicity when BN remains poorly treated, we tend to use
the same criteria (Table)in initiating
SSRIs in adolescents,with the full informed consent of both patients and
their parents.
Treatment combining
medication and psychotherapy
At least 6 controlled trials have assessed direct comparisons of outcome
for patients with BN treated with psychotherapy, pharmacotherapy, or a
c~mbination.~."In general, results
showed a greater decrease in the frequency of bingeing and purging
episodes with cognitive-behavioral
therapy than with antidepressant
medication when each was used alone.
With treatments used in combination,
the results to date have been mixed.
Although several trials indicate that
medication conferred no significant
benefit beyond that achieved with psychotherapy, on balance, study results
slightly favored the addition of medication to psychotherapy for many
patients.? In the clinical community,
there is a consensus that an approach
including both psychother& and
medication is woah considering in
most cases.l
Future directions
Psychotropic medications, especially
the SSRIs, are helpful for some patients with BN, at least in the short
term. More than a decade has elapsed
since the FDA approved fluoxetine
for use in adult patients with BN, and
few notable developments in medication management have taken place
since that time. The extent of efficacy
of SSRIs and other medications has
been questioned since relatively few
individuals abstain from binge eating
and purging behaviors, and relapse
during treatment is common.u9
Medications that have received some
attention but are in need of fuaher investigation include the SNRIs,topiramate, and possibly ondansetron.
Augmentation of antidepressants also has not been investigated, and the
atypical antipsychotics should be
studied for this use.
Dr Tmnko is assistant dinlcal professo~;and
Dr Kaye is professor md director of the Eating
controlleded.Ah, Thec 2004;21:232-237.
13. Enegovesl S. Rlboldi C. 01 Bella D. Bulimianervosa, CHTTLPR polymorphism and treatment rem s e to four SSRls: asinale-blind studv. JCl/nk,&awl.
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'
14. L m b u n i RAmiantoF, DelsedimeN, et al. Citab
pram \nwsus fluoxetine for Me treatment of patlents
with bulimia nervosa:a single-blindrandomizedeontrolled biel. Ahr ThK 2006,23481 -494.
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Venlafaxlne (Eftexor) ,
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