What is the role of venlafaxine (Serotonin-Norepinephrine Reuptake Inhibitor) in treating Binge Eating Disorder?

Venlafaxine in Binge Eating Disorder

Venlafaxine is not a first-line medication for Binge Eating Disorder (BED) and has limited evidence supporting its use compared to FDA-approved options like lisdexamfetamine.

Evidence for Venlafaxine in BED

Venlafaxine, a Serotonin-Norepinephrine Reuptake Inhibitor (SNRI), has been studied in BED with some promising but limited results:

• A retrospective review of 35 overweight or obese patients with BED showed that venlafaxine (mean dose 222 mg/day) resulted in significant reductions in binge frequency, with 88% of patients showing at least a moderate response 1
• 43% of patients in this study lost 5% or more of their baseline weight 1

However, this evidence is from a small, uncontrolled retrospective study, making it much weaker than evidence for other medications.

First-Line and Preferred Medications for BED

Current guidelines recommend the following medications for BED:

1. Lisdexamfetamine: FDA-approved specifically for BED 2, 3
2. Fluoxetine: 60 mg daily, effective for BED and bulimia nervosa 2
3. Topiramate: Shown efficacy for BED, though optimal dosing requires further study 2
4. Duloxetine: Another SNRI that modulates serotonergic and noradrenergic pathways for mood regulation and impulse control in BED 2
5. Naltrexone/bupropion combination: For BED with food cravings or addictive eating behaviors 2

Safety Considerations with Venlafaxine

Venlafaxine has several safety concerns that must be considered:

• Cardiovascular effects: Associated with sustained clinical hypertension, increased blood pressure, and increased pulse 4. In the BED study, 17% of patients experienced blood pressure increases 1
• Discontinuation symptoms: Venlafaxine has been associated with significant discontinuation symptoms 4
• Suicide risk: May be associated with greater suicide risk than other SNRIs, and both venlafaxine and desvenlafaxine have been associated with overdose fatalities 4
• Common side effects: Diaphoresis, dry mouth, abdominal discomfort, nausea, vomiting, diarrhea, dizziness, headache, tremor, insomnia, somnolence, decreased appetite, and weight loss 4
• Sexual dysfunction: Sexual adverse events are common with venlafaxine 4

Practical Approach to Using Venlafaxine in BED

If considering venlafaxine for BED (after first-line options have failed):

1. Dosing: Extended-release formulation allows for once-daily dosing, while immediate release may require multiple daily doses 4
2. Target dose: Based on limited evidence, around 222 mg/day (range 75-300 mg/day) 1
3. Monitoring: Regular assessment of blood pressure, pulse, and weight is essential 4, 2
4. Duration: Treatment duration in the study was a median of 120 days (range 28-300 days) 1

Treatment Algorithm for BED

1. First-line pharmacotherapy:

   • Lisdexamfetamine (FDA-approved) 2, 3, 5
   • Fluoxetine 60 mg daily 2

2. Second-line options:

   • Topiramate 2, 6
   • Duloxetine 2
   • Naltrexone/bupropion combination 2

3. Third-line/alternative options (when first and second-line treatments fail or are contraindicated):

   • Venlafaxine 1
   • Other SSRIs (sertraline, citalopram, fluvoxamine) 7

4. Concurrent psychotherapy: All medication treatments should be combined with eating disorder-focused psychotherapy, particularly Cognitive-Behavioral Therapy (CBT) 2

Cautions and Pitfalls

• Avoid using venlafaxine in patients with uncontrolled hypertension or cardiovascular disease due to its effects on blood pressure 4
• Be cautious about using venlafaxine in patients at high risk for suicide 4
• Do not abruptly discontinue venlafaxine due to risk of discontinuation syndrome; always taper gradually 4
• Avoid concomitant use with MAOIs due to risk of serotonin syndrome 4
• Monitor for drug interactions, though venlafaxine may have less effect on the CYP450 system compared to some SSRIs 4

In conclusion, while venlafaxine shows some promise for BED based on limited evidence, it should be considered only after FDA-approved and better-studied medications have been tried or ruled out due to its side effect profile and limited evidence base.