What medications are effective for treating bulimia nervosa (BN) without purging?

Medication Treatment for Bulimia Nervosa Without Purging

Fluoxetine at 60 mg/day is the recommended pharmacological treatment for bulimia nervosa, including non-purging type, as it has been shown to significantly reduce binge eating behaviors. 1

First-Line Treatment Options

• Cognitive-behavioral therapy (CBT) remains the cornerstone psychological treatment for bulimia nervosa, focusing on normalizing eating behaviors and addressing psychological aspects like fear of weight gain and body image disturbance 2
• Fluoxetine at 60 mg/day is the FDA-approved medication for bulimia nervosa, administered in the morning, as this dose was statistically significantly superior to placebo in reducing the frequency of binge-eating behaviors 1
• For some patients, it may be advisable to titrate up to the target dose of 60 mg/day over several days to minimize side effects 1

Medication Administration and Dosing

• Treatment should be initiated with fluoxetine 60 mg/day administered in the morning 1
• Fluoxetine doses above 60 mg/day have not been systematically studied in patients with bulimia and are not recommended 1
• A lower or less frequent dosage should be used in patients with hepatic impairment, the elderly, and for patients with concurrent disease or on multiple medications 1
• The full therapeutic effect may be delayed until 5 weeks of treatment or longer 1

Efficacy and Duration of Treatment

• In controlled clinical trials, fluoxetine 60 mg/day was shown to be effective in reducing binge eating behaviors in patients with moderate to severe bulimia nervosa 1
• The efficacy of fluoxetine in maintaining response in bulimia nervosa was demonstrated for up to 52 weeks in patients who responded during an 8-week acute treatment phase 1, 3
• Long-term studies have shown fluoxetine to be safe and effective for up to 16 weeks in patients with bulimia nervosa 3

Combination Treatment Approach

• The combination of fluoxetine with psychological treatment (particularly CBT) has shown greater improvement in binge eating and depression than psychological treatment with placebo 4
• Cognitive-behavioral therapy plus medication is superior to medication alone in treating bulimia nervosa 4
• A meta-analysis found that combination treatments were superior to single psychotherapy, with a number needed to treat (NNT) of 8 for a mean treatment duration of 15 weeks 5

Important Considerations and Monitoring

• Regular monitoring is essential to assess response and adjust treatment as needed 2
• Patients should be periodically reassessed to determine the need for maintenance treatment 1
• Technology-based interventions, including guided computer-based interventions and videoconferencing, may be helpful adjuncts for treating bulimia nervosa, especially for patients facing barriers such as shame, stigma, or lack of access to specialized providers 6

Common Pitfalls and Caveats

• High dropout rates can occur in treatment settings, particularly in primary care, which can hamper treatment effectiveness 7
• Treatment in primary care settings may be challenging, with some patients finding treatment programs too demanding while others find them not intensive enough 7
• Patients with comorbid conditions may require adjusted medication dosing or additional interventions 2
• Bulimia nervosa often begins in adolescence, with the peak age of onset in late adolescence, requiring age-appropriate treatment approaches 6