eMedicine Specialties > Emergency Medicine > Psychosocial
Bulimia: Treatment & Medication
Updated: Sep 19, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Emergency Department Care
Comprehensive guidelines for the management of bulimia nervosa are provided by the American Psychiatric Association, Practice Guidelines for the Treatment of Patients With Eating Disorders, Third Edition.
- Complications of bulimia treatable in the emergency setting may include volume depletion, electrolyte abnormalities, esophagitis, Mallory-Weiss tear, esophageal or gastric rupture, pancreatitis, arrhythmias, or adverse effects of medication (eg, ipecac, appetite suppressants).
- Associated illnesses, including depression, anxiety disorders, and substance abuse, increase the risk of other illness and injury. Directly question patients regarding suicidal ideation.
- Patients should be warned against the use of diet pills and amphetamines, as well as energy pills and diet teas that claim to be all-natural. All-natural supplements often contain herbal forms of caffeine and ephedrine and have been associated with hypertension and cerebrovascular accident.
- As new therapies to treat bulimia are introduced, considering possible adverse effects from these new therapies is important. Possible adverse effects may include renal lithiasis, glaucoma, seizure, and metabolic derangements.
- Patients with eating disorders who are seen for an apparently unrelated problem benefit from an emergency physician who recognizes an eating disorder and provides initial management and suitable referral.
Consultations
- For patients who are unable to halt the dangerous sequence of dieting, binging, and purging, admission to a psychiatric unit may be necessary to break the cycle.
- Psychiatric hospitalization may also be necessary for patients with severe depression and suicidal ideation, weight loss greater than 30% over 3 months, failure to maintain outpatient weight contract, or family crisis.
- Admission to a medical facility is warranted for patients with significant electrolyte/metabolic disturbance or other physical complication of binging or purging (eg, Mallory-Weiss tear, esophageal rupture, pancreatitis).
- All patients suspected of having an eating disorder should be referred to a psychiatrist for further evaluation. If possible, arrangements should be made for follow-up within 2 days.
Medication
Treatment of eating disorders usually combines individual psychotherapy (usually a cognitive-behavioral approach), group or family therapy, and pharmacotherapy. The pharmacotherapy of bulimia nervosa is based on 2 pathophysiologic models: seizure disorder model and affective disorder model. Medications should be prescribed by the treating psychiatrist.
Note: The US Food and Drug Administration (FDA) has issued warnings that use of antidepressant medications poses a small but significantly increased risk of suicidal ideation/suicide attempt for children and adolescents especially in the first few months of treatment. A black box warning advisory was issued in 2004 to this effect. No suicides occurred in the trials reviewed. Meta-analysis shows that benefits appear to outweigh risks in treatment of major depression.
Antidepressants
These agents are reported to reduce binge eating, vomiting, and depression. They are also reported to improve eating habits, although their impact on body dissatisfaction remains unclear.
Fluoxetine is FDA-approved for the treatment of bulimia nervosa.
Fluoxetine (Prozac)
Has received attention because of its specific effects on serotonin and efficacy in comorbid conditions (eg, depression, OCD, kleptomania). Decreases the frequency of bulimic behavior by 50-60% in 6-8 wk.
Adult
20 mg/d PO qam; after several wk, increase by 20 mg/d prn; average dose range 60-80 mg/d
Pediatric
Not established; suggested dose 20 mg/d
Increases toxicity of diazepam and trazodone by decreasing clearance; increases toxicity of MAOIs and highly protein-bound drugs
Documented hypersensitivity; MAOIs concurrently or in previous 2 wk; association with prolonged QT interval currently in question
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in patients with hepatic impairment or history of seizures; discontinue MAOIs at least 14 d before initiating therapy
Imipramine (Tofranil)
Has demonstrated clear superiority over placebo in double-blind trials for treating specific symptoms of bulimia nervosa.
Adult
25 mg PO tid/qid initially; increase gradually prn; not to exceed 300 mg/d
Alternatively, maximum of 100 mg/d IM in divided doses; change to PO as soon as possible
Pediatric
Children: 1.5 mg/kg/d PO with dosage increments of 1 mg/kg q3-4d; taken qd or in 2-4 equally divided doses; not to exceed 5 mg/kg
Adolescents: Initially, 25-50 mg/d PO; increase dosage in increments prn; not to exceed 100 mg/d in single or divided doses
Increases toxicity of sympathomimetic agents, such as isoproterenol and epinephrine, by potentiating effects; inhibits antihypertensive effects of clonidine
Documented hypersensitivity; narrow-angle glaucoma; acute recovery phase following MI; MAOIs or fluoxetine concurrently or in previous 2 wk
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May impair mental or physical abilities required for performance of potentially hazardous tasks; caution in cardiovascular disease, conduction disturbances, seizure disorders, urinary retention, hyperthyroidism, or thyroid replacement
Desipramine (Norpramin)
Has demonstrated clear superiority over placebo in double-blind trials for treating specific symptoms of bulimia nervosa.
Adult
75 mg/d PO in equally divided doses initially; increase gradually prn; not to exceed 300 mg/d
Pediatric
<6 years: Not established
6-12 years: 1-5 mg/kg/d PO in equally divided doses; not to exceed 5 mg/kg either qd or in 2-4 equally divided doses
>12 years: 25-50 mg/d PO initially; gradually increase to 100 mg/d prn; not to exceed 150 mg/d; may give in single or equally divided doses
Decreases antihypertensive effects of clonidine but increases effects of sympathomimetics and benzodiazepines; effects increase with phenytoin, carbamazepine, or barbiturates
Documented hypersensitivity; narrow-angle glaucoma; acute recovery phase following MI; MAOIs or fluoxetine concurrently or in previous 2 wk
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in cardiovascular disease, conduction disturbances, seizure disorders, urinary retention, hyperthyroidism, or thyroid replacement
Phenelzine (Nardil)
MAOI that has demonstrated clear superiority over placebo in double-blind trials for treating specific symptoms of bulimia nervosa. Usually reserved for patients who do not tolerate or respond to the traditional cyclic or second-generation antidepressants.
Adult
15 mg PO divided tid initially; increase gradually to 60-90 mg/d prn during early phase of treatment; after maximum benefit achieved, reduce dosage slowly over several wk
Maintenance dose may be as low as 15 mg/d or qod; may continue taking medication as long as required
Pediatric
<16 years: Not established
>16 years: Administer as in adults
Increases effects/toxicity of barbiturates and CNS depressants; toxicity increases when taken concurrently with fluoxetine, disulfiram, levodopa, sympathomimetics, or tyramine-containing foods
Documented hypersensitivity; pheochromocytoma; hepatic or renal disease; cardiovascular disease; cerebrovascular defect
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Patients who are hyperactive, hyperexcitable, or have glaucoma
Lithium (Eskalith, Lithane, Lithobid)
Has demonstrated clear superiority over placebo in double-blind trials for treating specific symptoms of bulimia nervosa. Reserved for use in patients with comorbid bipolar affective disorders.
Adult
300-600 mg PO tid/qid
Average maintenance dose 2.4 g/d or 450-900 mg bid of sustained-release form
Pediatric
<6 years: Not established
6-12 years: 15-60 mg/kg/d PO divided tid/qid; not to exceed usual adult dose
>12 years: Administer as in adults
Increases toxicity of thiazide diuretics, haloperidol, phenothiazines, neuromuscular blockers, carbamazepine, fluoxetine, and ACE inhibitors
Documented hypersensitivity; severe cardiovascular disease
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Lithium toxicity closely related to serum levels and can occur at therapeutic doses; serum lithium determinations required to monitor therapy
Trazodone (Desyrel)
Antagonist at the 5-HT2 receptor and inhibits the reuptake of 5-HT. Also has negligible affinity for cholinergic and histaminergic receptors.
Adult
Initial: 150 mg/d PO and may increase by 50 mg/d q3-4d; not to exceed 400 mg/d in divided doses
Average dose is 300 mg/d
Maintenance: Once an adequate response has been achieved, dosage may be gradually reduced with subsequent adjustment depending on response; keep the dose at the lowest effective level
Pediatric
<6 years: Not established
6-18 years: Initially, administer 1.5-2 mg/kg/d PO in divided doses
Increase dose gradually q3-4d prn; not to exceed 6 mg/kg/d
May enhance response to alcohol, barbiturates, and other CNS depressants; digoxin and phenytoin serum levels may increase in patients receiving trazodone concurrently; may decrease hypoprothrombinemic effects of warfarin
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Hypotension, including orthostatic hypotension and syncope, has occurred; may produce drowsiness, dizziness, or blurred vision; patients taking this medication should observe caution while driving or performing other tasks requiring alertness, coordination, or dexterity
Antiepileptic
This agent is a sulfamate-substituted monosaccharide that potentiates the inhibitory activity of the neurotransmitter gamma-aminobutyrate (GABA). It may block glutamate activity. It is not necessary to monitor topiramate plasma concentrations to optimize topiramate therapy.
Topiramate (Topamax)
In a 10-week, randomized, double-blind, placebo-controlled trial to examine efficacy in the treatment of bulimia nervosa, treatment significantly reduced the number of days on which patients binged and/or purged.8
Topiramate treatment improved multiple behavioral dimensions of bulimia nervosa; binge and purge behaviors were reduced, and measurable improvements occurred in self-esteem, eating attitudes, anxiety, and body image.8
Adult
Average dose in clinical trials: 100 mg/d PO, range 25-400 mg/d PO
Pediatric
Not established
Phenytoin, carbamazepine, and valproic acid can significantly decrease topiramate levels; reduces digoxin and norethindrone levels when administered concomitantly; concomitant use with carbonic anhydrase inhibitors may increase risk of renal stone formation and should be avoided; use topiramate with extreme caution when administering concurrently with CNS depressants since may have an additive effect in CNS depression as well as other cognitive or neuropsychiatric adverse events
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Risk of developing a kidney stone formation is increased 2-4 times that of untreated population; risk may be reduced by increasing fluid intake; caution in renal or hepatic impairment; patients taking topiramate should seek immediate medical attention if they experience blurred vision or periorbital pain; continued usage after symptoms develop can lead to glaucoma; primary treatment is discontinuation of topiramate; if left untreated, serious sequelae, including permanent vision loss, may occur
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| Overview: Bulimia |
| Differential Diagnoses & Workup: Bulimia |
 Treatment & Medication: Bulimia |
| Follow-up: Bulimia |
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Further Reading
Keywords
bulimia, eating disorder, anorexia nervosa, AN, binge eating disorder, binge/purge, binge-purge, purging, self-induced vomiting, laxative abuse, BN, bulimic, bulimia nervosa, gastric rupture, Mallory-Weiss tear, eating disorder management
