Medication Summary
The goals of pharmacotherapy are to stop or reduce the compulsive behavior, to reduce morbidity, and to prevent complications.
Although nalmefene is an opioid antagonist that is not new, a recent small-size, open-label study found the drug to be well tolerated with no serious adverse effects in patients with comorbid borderline personality disorder (BPD) and alcohol use disorder (AUD). The drug demonstrated potential efficacy in improving self-injurious behavior and binge eating as well as in reducing alcohol consumption. [58]
Antidepressants
Class Summary
These agents have been reported to reduce binge eating, vomiting, and depression, and to improve eating habits although their impact on body dissatisfaction remains unclear.
Paroxetine (Paxil, Pexeva)
Alternative DOC. Potent selective inhibitor of neuronal serotonin reuptake. Also has a weak effect on norepinephrine and dopamine neuronal reuptake.
For maintenance dosing, make dosage adjustments to maintain patient on lowest effective dosage, and reassess patient periodically to determine need for continued treatment.
Fluoxetine (Prozac)
Selectively inhibits presynaptic serotonin reuptake with minimal or no effect in the reuptake of norepinephrine or dopamine.
May cause more gastrointestinal adverse effects than other SSRIs now currently available, which is the reason it is not recommended as a first choice. May be given as a liquid and a capsule.
May give as 1 dose or divided doses. Presence of food does not appreciably alter levels of the medication. May take up to 4-6 weeks to achieve steady state levels of the medication as it has longest half-life (72 h).
Long half-life is both an advantage and a drawback. If it works well, an occasional missed dose is not a problem; if problems occur, eliminating all active metabolites takes a long time. The choice depends on adverse effects and drug interactions. Adverse effects of SSRIs seem to be quite idiosyncratic; thus, relatively few reasons exist to prefer one over another at this point if dosing is started at a conservative level and advanced as tolerated.
Indicated for the treatment of binge-eating and self-induced vomiting in patients with moderate-to-severe bulimia nervosa.
The antidepressant, anti–obsessive-compulsive, and antibulimic actions are presumed to be linked to inhibition of CNS neuronal uptake of serotonin.
Sertraline (Zoloft)
Selectively inhibits presynaptic serotonin reuptake.
Fluvoxamine (Luvox CR)
Enhances serotonin activity due to selective reuptake inhibition at neuronal membrane. Does not significantly bind to alpha-adrenergic, histamine, or cholinergic receptors and thus has fewer side effects than tricyclic antidepressants.
Has been shown to reduce repetitive thoughts, maladaptive behaviors, and aggression, and to increase social relatedness and language use.
Escitalopram (Lexapro)
Selective serotonin reuptake inhibitor (SSRI) and S-enantiomer of citalopram. Used for the treatment of depression. Mechanism of action is thought to be potentiation of serotonergic activity in central nervous system resulting from inhibition of CNS neuronal reuptake of serotonin. Onset of depression relief may be obtained after 1-2 wk, which is sooner than other antidepressants.
Stimulants
Class Summary
Agents in this class may be used off-label in some cases to prevent weight gain from binge-eating disorder and has the potential to decrease impulsive eating.
Lisdexamfetamine (Vyvanse)
Inactive prodrug of dextroamphetamine. Elicits CNS stimulant activity. Blocks norepinephrine and dopamine reuptake in presynaptic neurons and increases release of these monoamines in extraneuronal space. It is indicated for treatment of moderate-to-severe binge eating disorder.
Antidiabetics, Glucagon-like Peptide-1 Agonists
Class Summary
These agents may regulate neuropeptide Y, which may help to control weight.
Liraglutide (Saxenda)
Incretin mimetic; analogue of human glucagonlike peptide-1 (GLP-1); acts as GLP-1 receptor agonist to increase insulin secretion in the presence of elevated blood glucose; delays gastric emptying to decrease postprandial glucose; also decreases glucagon secretion. It is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with a body mass index (BMI) of ≥30 (obesity) or adults with a BMI of ≥27 (overweight) who have at least 1 weight-related condition (eg, hypertension, type 2 diabetes, dyslipidemia). It is not specifically indicated for BED.
Exenatide (Bydureon, Byetta)
Incretin mimetic agent that mimics glucose-dependent insulin secretion and several other antihyperglycemic actions of incretins. Improves glycemic control in patients with type 2 diabetes mellitus by enhancing glucose-dependent insulin secretion by pancreatic beta cells, suppresses inappropriately elevated glucagon secretion, and slows gastric emptying. Drug's 39–amino acid sequence partially overlaps that of the human incretin, glucagonlike peptide-1. Indicated as adjunctive therapy to improve glycemic control in patients with type 2 diabetes who are taking metformin or a sulfonylurea but have not achieved glycemic control.
Anorexiants
Class Summary
These agents may help to control weight.
Lorcaserin (Belviq)
February 13, 2020: FDA requested lorcaserin be withdrawn from the market owing to a potential risk of cancer
Thought to decrease food consumption and promote satiety by selectively activates 5-HT2C receptors on anorexigenic pro-opiomelanocortin neurons located in the hypothalamus
Phentermine (Adipex-P, Suprenza)
Sympathomimetic amine, increases release and reuptake of norepinephrine and dopamine. Anorexiant effect occurs as result of satiety center stimulation in the hypothalamic and limbic areas of the brain. Pharmacological component of comprehensive weight reduction program (behavioral modification, caloric restriction, exercise) intended for patients with initial BMI 3 30 kg/m2 or 3 27 kg/m2 if other risk factors (eg, diabetes, hyperlipidemia, hypertension) are present.
Lipase inhibitors
Class Summary
These agents inhibit absorption of dietary fats.
Orlistat (Alli, Xenical)
Gastrointestinal lipase inhibitor that induces weight loss by inhibiting nutrient absorption. Effectiveness in producing weight loss does not depend on systemic absorption. May reduce absorption of some fat-soluble vitamins (A, D, E, K) and beta-carotene. Administer multivitamin supplement containing fat-soluble vitamins PO qd 2 h ac or 1 h pc or every PM at bedtime. The prescription strength (Xenical) contains 120 mg/cap. The over-the-counter (OTC) strength (Alli) contains 60 mg/cap.
Anticonvulsants
Class Summary
Anticonvulsants that decrease obsessive compulsive behavior may be effective.
Topiramate (Qudexy XR, Topiragen, Trokendy XR, Topamax)
Sulfamate-substituted monosaccharide with broad spectrum of antiepileptic activity that may have state-dependent sodium channel– blocking action. Potentiates inhibitory activity of neurotransmitter GABA. May block glutamate activity.
Zonisamide (Zonegran)
Does not affect GABA activity. Through action at sodium and calcium channels may stabilize neuronal membranes and suppress neuronal hypersynchronization.
Lamotrigine (Lamictal)
Inhibits voltage-sensitive sodium channels and release of glutamate (an excitatory amino acid).
