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).
Pharmacological treatment
The following drug classes offer hope for improving or curing eating disorders.
Anticonvulsants
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
antidepressants
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.
antipsychotics
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
Stimulants
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.
Conclusion
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.
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