Eating disorders, classified as serious psychiatric disorders, have not only medical and psychological consequences, but also economic and social consequences.1-3
They are notoriously difficult to manage and usually require both behavioral and nutritional intervention.1.4 Non-response and relapse are common.5 And while clinicians use drugs with varying degrees of success, few drugs are effective. table 11.6-11 summarizes the 3 primary eating disorders: anorexia nervosa (AN), binge eating disorder (BED), and bulimia nervosa (BN).
The following drug classes offer hope for improving or curing eating disorders.
Prescribed off-label for BN, topiramate (median dose 100 mg/day; range 25 to 400 mg/day) was superior to placebo in reducing symptoms as well as body weight.12 Although usually well tolerated at low doses, topiramate has been reported to cause cognitive blurriness and paresthesia in fingers and toes by some patients.12 Results from studies of zonisamide (Zonegran) indicated that it may reduce binge eating and body weight in the short term and at 1 year follow-up, but may be poorly tolerated.13-16
Unfortunately, randomized controlled trials (RCTs) have not identified antidepressants that help manage AN.17,18 Neither first- nor second-generation antidepressants improve eating and weight outcomes. In addition, bupropion is contraindicated in eating disorders because of an increased risk of seizures.17,18
Antidepressants are sometimes used successfully for BN. Experts prefer selective serotonin reuptake inhibitors (SSRIs) over first-generation antidepressants because of their better safety profile. Research supports the use of several SSRIs, but suggests that a high dose of fluoxetine is most effective. Two 8-week studies showed that participants who took 60 mg of fluoxetine per day experienced significantly less binge eating and vomiting than those who took 20 mg per day and those who took placebo.19.20 Other studies have shown that participants who continued to take fluoxetine were significantly less likely to relapse, and that the drug is also effective in adolescents.21-23 Fluoxetine was approved by the FDA in 1994 for the preservation of BN.24
The use of citalopram, escitalopram, fluvoxamine, and fluoxetine for BED is similar to the use of fluoxetine for BN.13 Overall, SSRIs reduce binge eating compared to placebo. A recent meta-analysis of 7 placebo-controlled RCTs found that antidepressant treatment also lowers remission rates.25 However, antidepressants have no effect on the weight of individuals with BED.
Research results showed that olanzapine, an atypical antipsychotic, has a modest effect on weight recovery.26-28 In a recent RCT, 152 adult outpatients with AN received olanzapine (median dose 7.77 mg/day; range 2.5 to 10 mg/day) or placebo for 16 weeks. Olanzapine was associated with an average increase of about 1 pound per month more than placebo. However, the cognitive rigidity and obsession associated with AN — and the self-reported anxiety — did not improve significantly.29
Researchers have also turned to BED stimulants for their tendency to suppress appetite. The FDA approved lisdexamfetamine for use in BED in 2015. A short, double-blind RCT compared the chemical (30 mg/day, 50 mg/day, and 70 mg/day) with placebo. Binge eating decreased significantly more in participants who took doses of 50 and 70 mg than in those who took placebo.30 Two additional 12-week studies replicated these results and found that body weight, general well-being and obsessive-compulsive symptoms were also improved.30 Subsequent studies suggest that lisdexamfetamine may be better at preventing relapse than placebo.31 Although considered effective and safe, lisdexamfetamine has adverse effects and a potential for abuse that should warrant careful pre-treatment evaluation and monitoring during treatment.24 Limited research is available to support the use of other stimulants in BED. table 212-30 summarizes the use of medication in eating disorders.
While many drugs have been researched as a treatment for eating disorders, few have achieved success. AN remains the most difficult to manage. Better results have been achieved with BN and BED, and as a result the FDA has approved 2 drugs: fluoxetine 60 mg per day for BN and lisdexamfetamine for BED.
About the author
Jeannette Y. Wick, MBA, RPh, FASCP, is the director of pharmacy professional development at the University of Connecticut at Storrs.
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th edition. American Psychiatric Association; 2013.
2. van Hoeken D, Hoek HW. Overview of the burden of eating disorders: mortality, disability, costs, quality of life and family burden. Curr Opin Psychiatry. 2020;33(6):521-527. doi:10.1097/YCO.0000000000000641
3. Streatfeild J, Hickson J, Austin SB, et al. Social and economic costs of eating disorders in the United States: evidence to inform policy action. Int J Eating Disorder. 2021;54(5):851-868. doi:10.1002/eat.23486
4. American Psychiatric Association. Treatment of patients with eating disorders, third edition. Ben J Psychiatrist. 2006;163(suppl 7):4-54.
5. Khalsa SS, Portnoff LC, McCurdy-McKinnon D, Feusner JD. What happens after the treatment? A systematic review of relapse, remission and recovery in anorexia nervosa. J Eating disorder. 2017;5:20. doi:10.1186/s40337-017-0145-3
6. Fichter MM, Quadflieg N. Mortality in eating disorders – results of a large prospective clinical longitudinal study. Int J Eating disorder. 2016;49(4):391-401. doi:10.1002/eat.22501
7. Muratore AF, Attia E. Current therapeutic approaches to anorexia nervosa: state-of-the-art. Clin Ther. 2021;43(1):85-94. doi:10.1016/j.clinthera.2020.11.006
8. Westmoreland P, Krantz MJ, Mehler PS. Medical complications of anorexia nervosa and bulimia. Ben J Med. 2016;129(1):30-37. doi:10.1016/j.amjmed.2015.06.031
9. Gibson D, Workman C, Mehler PS. Medical complications of anorexia nervosa and bulimia nervosa. Psychiatrist Clin North Am. 2019;42(2):263-274. doi:10.1016/j.psc.2019.01.009
10. Mitchell JE. Medical comorbidities and medical complications associated with binge eating disorder. Int J Eating Disorder. 2016;49(3):319-323. doi:10.1002/eat.22452
11. Wassenaar E, Friedman J, Mehler PS. Medical complications of binge eating disorder. Psychiatrist Clin North Am. 2019;42(2):275-286. doi:10.1016/j.psc.2019.01.010
12. Nickel C, Tritt K, Muehlbacher M, et al. Topiramate treatment in patients with bulimia nervosa: a randomized, double-blind, placebo-controlled trial. Int J Eating Disorder. 2005;38(4):295-300. doi:10.1002/eat.20202
13. McElroy SL. Pharmacological Treatments for Binge Eating Disorder. J Clin Psychiatry. 2017;78(suppl 1):14-19. doi:10.4088/JCP.sh16003su1c.03
14. McElroy SL, Kotwal R, Guerdjikova AI, et al. Zonisamide in the treatment of binge eating disorder with obesity: a randomized controlled trial. J Clin Psychiatry. 2006;67(12):1897-1906. doi:10.4088/jcp.v67n1209
15. McElroy SL, Kotwal R, Hudson JI, Nelson EB, Keck PE. Zonisamide in the treatment of binge eating disorder: an open-label, prospective study. J Clin Psychiatry. 2004;65(1):50-56. doi:10.4088/jcp.v65n0108
16. Ricca V, Castellini G, Lo Sauro C, Rotella CM, Faravelli C. Zonisamide combined with cognitive behavioral therapy in binge eating disorder: a one-year follow-up study. Psychiatry (Edgmont). 2009;6(11):23-28.
17. Marvanova M, Gramith K. The role of antidepressants in the treatment of adults with anorexia nervosa. Mental Health Clinic. 2018;8(3):127-137. doi:10.9740/mhc.2018.05.127
18. Himmerich H, Kan C, Au K, Treasure J. Pharmacological treatment of eating disorders, comorbid mental health problems, malnutrition and physical health consequences. Pharmacol Ther. 2021;217:107667. doi:10.1016/j.pharmthera.2020.107667
19. Fluoxetine Bulimia Nervosa Collaborative Study Group. Fluoxetine in the treatment of bulimia nervosa. A multicenter, placebo-controlled, double-blind study. Arch Gene Psychiatry. 1992;49(2):139-147.
20. Goldstein DJ, Wilson MG, Thompson VL, Potvin JH, Rampey AH Jr; Fluoxetine Bulimia Nervosa Research Group. Long-term treatment with fluoxetine of bulimia nervosa. Br J Psychiatry. 1995;166(5):660-666. doi:10.1192/bjp.166.5.660
21. Romano SJ, Halmi KA, Sarkar NP, Koke SC, Lee JS. A placebo-controlled trial of fluoxetine in continued treatment of bulimia nervosa after successful acute fluoxetine treatment. Ben J Psychiatry. 2002;159(1):96-102. doi:10.1176/appi.ajp.159.1.96
22. Pope HG Jr, Hudson JI. Antidepressant drug therapy for bulimia: current status. J Clin Psychiatry. 1986;47(7):339-345.
23. Kotler LA, Devlin MJ, Davies M, Walsh BT. An open trial of fluoxetine for adolescents with bulimia nervosa. J Kind Adolescent Psychopharmacol. 2003;13(3):329-335. doi: 10.1089/104454603322572660
24. Bello NT, Yeomans BL. Safety of pharmacotherapy options for bulimia nervosa and binge eating disorder. Expert opinion on drug security. 2018;17(1):17-23. doi:10.1080/14740338.2018.1395854
25. Stefano SC, Bacaltchuk J, Blay SL, Appolinario JC. Antidepressants in short-term treatment of binge eating disorder: systematic review and meta-analysis. eating behavior. 2008;9(2):129-136. doi:10.1016/j.eatbeh.2007.03.006
26. Bissada H, Tasca GA, Barber AM, Bradwejn J. Olanzapine in the treatment of low body weight and obsessive thinking in women with anorexia nervosa: a randomized, double-blind, placebo-controlled trial. Ben J Psychiatry. 2008;165(10):1281-1288. doi:10.1176/appi.ajp.2008.07121900
27. Dold M, Aigner M, Klabunde M, Treasure J, Kasper S. Second-generation antipsychotics in anorexia nervosa: a meta-analysis of randomized controlled trials. Psychother Psychosom. 2015;84(2):110-116. doi: 10.1159/000369978
28. Attia E, Kaplan AS, Walsh BT, Gershkovich M, Yilmaz Z, Musante D, et al. Olanzapine versus placebo for outpatients with anorexia nervosa. Psycho Med. 2011;41(10):2177-2182. doi:10.1017/S0033291711000390
29. Attia E, Steinglass JE, Walsh BT, Wang Y, Wu P, Schreyer C, et al. Olanzapine versus placebo in adult outpatients with anorexia nervosa: a randomized clinical trial. Ben J Psychiatry. 2019;176(6):449-456. doi:10.1176/appi.ajp.2018.18101125
30. McElroy SL, Mitchell JE, Wilfley D, Gasior M, Ferreira-Cornwell MC, McKay M, et al. Lisdexamfetamine dimesylate effects on binge eating and obsessive-compulsive and impulsive features in adults with binge eating disorder. Eur Eat Disord Rev. 2016;24(3):223-231. doi:10.1002/erv.2418
31. Hudson JI, McElroy SL, Ferreira-Cornwell MC, Radewonuk J, Gasior M. Efficacy of lisdexamfetamine in adults with moderate to severe binge eating disorder: a randomized clinical trial. JAMA psychiatrist. 2017;74(9):903-910. doi:10.1001/jamapsychiatry.2017.1889