Pharmacological treatment for bulimia nervosa in adults and young people

Pharmacological treatment can be used for the management of bulimia nervosa in patients who have a limited or no response to psychological treatment alone, or where there is difficulty in accessing treatment. Pharmacological treatment with an antidepressant can be used adjunctively in patients with a comorbid mood disorder (eg major depression).

Pharmacological treatment for bulimia nervosa in children should be undertaken by a specialist.

In choosing pharmacological treatment, consider the harm–benefit profile of the drug, in particular the:

risk of drug interactions
risk of adverse effects, see here for antidepressants
patient’s comorbidities.

Selective serotonin reuptake inhibitors (SSRIs), particularly fluoxetine, have the strongest evidence for use in patients with bulimia nervosa; there is some evidence for citalopram, fluvoxamine and sertraline. SSRIs modify eating behaviours through serotonin-mediated effects on satiety, and have a beneficial effect on mood. Fluvoxamine and sertraline have a lower risk of QT-interval prolongation than fluoxetine and citalopram, they may be preferred in patients at risk of hypokalaemia and cardiac arrythmias. However, the long-term efficacy has not been established and the optimal duration of therapy is unknown—regular review of pharmacological treatment every 3 to 6 months is recommended.

For pharmacological treatment of bulimia nervosa in adults and young people, use:

1 fluoxetine 20 mg orally, daily in the morning. Assess the patient’s response to therapy every 1 to 2 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 20 mg no more often than weekly until an acceptable response is achieved or a daily dose of 60 mg is reached. Continue at the same dose for at least 6 months, then consider deprescribing bulimia nervosa fluoxetine fluoxetine fluoxetine

2 citalopram 10 mg orally, daily in the morning. Assess the patient’s response to therapy every 1 to 2 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 10 mg no more often than weekly until an acceptable response is achieved or a daily dose of 40 mg is reached. Continue at the same dose for at least 6 months, then consider deprescribing bulimia nervosa citalopram citalopram citalopram

2 fluvoxamine 50 mg orally, daily in the evening. Assess the patient’s response to therapy every 1 to 2 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 50 mg no more often than weekly until an acceptable response is achieved or a daily dose of 300 mg is reached. Doses above 150 mg daily may be given in 2 divided doses for better tolerability. Continue at the same dose for at least 6 months, then consider deprescribing bulimia nervosa fluvoxamine fluvoxamine fluvoxamine

2 sertraline 50 mg orally, daily in the morning. Assess the patient’s response to therapy every 1 to 2 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 50 mg no more often than weekly until an acceptable response is achieved or a daily dose of 200 mg is reached. Continue at the same dose for at least 6 months, then consider deprescribing. bulimia nervosa sertraline sertraline sertraline

For efficacy, doses at the upper end of the described dose range are usually required.

There is a small evidence base for the use of topiramate for bulimia nervosa, and it may be used by specialists for patients who have not responded to treatment with other agents. Topiramate should not be used in patients who are underweight because it is associated with weight loss.