Medication Summary
The medications most commonly used to treat bulimia are antidepressants, typically selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants (TCAs). A Cochrane Database Review showed that patients with bulimia nervosa (BN) who were treated with antidepressants were more likely to interrupt their treatment prematurely due to adverse events and patients treated with TCAs dropped out of treatment more frequently than patients treated with placebo. [30] Of note, the opposite was found in those treated with fluoxetine, suggesting that it may be a more acceptable treatment as it is typically better tolerated. In some cases, CBT may be a more acceptable first-line treatment than medication, especially in patients concerned about medication side effects [31] or in those without comorbid anxiety or depression.
Other classes of medications, including mood stabilizers (eg, lithium), antiemetics, antipsychotics, serotonin/norepinephrine reuptake inhibitors (SNRIs), anticonvulsants, and trazodone, have been investigated for the treatment of eating disorders. [32, 33, 13, 30]
In 2011, the World Federation of Societies of Biological Psychiatry (WFSB) compiled an extensive review regarding pharmacological treatment of eating disorders. [34] Their report provides guidelines regarding the use of TCAs, SSRIs, MAOIs, mood stabilizers, and naltrexone, among others. In brief, the most robust evidence is for the use of fluoxetine in treating bulimia. It has been well studied and received a recommendation grade of 1, meaning that it has a good risk-to-benefit ratio and has undergone a number of randomized controlled trials. These same guidelines assign a moderate risk-to-benefit ratio to TCAs and topiramate.
Topiramate has been assigned grade A evidence based on 2 randomized controlled studies, which showed improvement over placebo. The use of topiramate in children and adolescents has not been well established and the use of topiramate in adults carries a moderate risk-to-benefit ratio, given a number of potential use-limiting adverse effects, including sedation, cognitive impairment, and dizziness. There have been case reports but no randomized trials investigating carbamazepine and oxcarbazepine.
Selective serotonin reuptake inhibitors (SSRIs)
Class Summary
SSRI medications are thought to help ameliorate depressive symptoms associated with bulimia and to help patients achieve a healthier body image.
SSRIs are greatly preferred over the other classes of antidepressants. Because the adverse effect profile of SSRIs is less prominent, improved compliance is promoted. SSRIs do not have the cardiac arrhythmia risk associated with TCAs. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered when treating a child or adolescent with mood disorder.
Physicians are advised to be aware of the following information and use appropriate caution when considering treatment with SSRIs in the pediatric population.
In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of "depressive illness." After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.
In October 2003, the US Food and Drug Administration (FDA) issued a public health advisory regarding reports of suicidality in pediatric patients being treated with antidepressant medications for major depressive disorder. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA has asked that additional studies be performed because suicidality occurred in both treated and untreated patients with major depression and, thus, could not be definitively linked to drug treatment.
However, a study of more than 65,000 children and adults treated for depression from 1992-2002 by the Group Health Cooperative in Seattle found that suicide risk declines, not rises, with the use of antidepressants. This is the largest study to date to address this issue. Another study published in the Journal of the American Medical Association in 2004 showed that a combination of CBT plus SSRI treatment (fluoxetine) significantly decreases suicidal thinking in patients with depression, and the reduction is far greater than with placebo or therapy alone. [35]
Currently, evidence does not associate obsessive compulsive disorder (OCD) and other anxiety disorders treated with SSRIs with an increased risk of suicide.
Fluoxetine (Prozac)
Antidepressant medication that selectively inhibits presynaptic serotonin reuptake with minimal or no effect in the reuptake of norepinephrine or dopamine. Higher doses than those used to treat depression are typically needed in the treatment of bulimia nervosa.
Tricyclic antidepressants
Class Summary
TCAs are thought to help ameliorate depressive symptoms associated with bulimia and to help patients achieve a healthier body image.
Desipramine (Norpramin)
TCAs are only considered when safer antidepressants, such as SSRIs, are not effective. May increase synaptic concentration of norepinephrine in CNS by inhibiting reuptake by presynaptic neuronal membrane. May have effects in the desensitization of adenyl cyclase, down regulation of beta-adrenergic receptors, and down regulation of serotonin receptors. However, TCAs are generally not considered in the treatment of bulimia in children and are rarely considered in the treatment of bulimia in adolescents.
Antiemetics
Class Summary
Some studies recommend short-term use of antiemetics at the onset of a patient's treatment. Antiemetics are thought to reduce a patient's stimuli to vomit and help patients through the few weeks it takes for antidepressants to become fully effective. [36] The WFSB assigns andansetron grade B evidence but recommends limiting its use secondary to adverse effects.
Ondansetron (Zofran)
Selective 5-HT3-receptor antagonist that blocks serotonin both peripherally and centrally.
