Treatment of Bulimia Nervosa
The recommended treatment for bulimia nervosa is a combination of eating disorder-focused cognitive-behavioral therapy (CBT) and fluoxetine 60 mg daily, as this approach has been shown to most effectively reduce binge-eating and purging behaviors. 1, 2
Initial Assessment
- A comprehensive psychiatric evaluation should include weighing the patient and quantifying eating and weight control behaviors (frequency, intensity, time spent on binge eating, purging, exercise) 1
- Assessment should identify co-occurring psychiatric disorders, which are common in bulimia nervosa 1, 2
- Physical examination must include vital signs, height, weight, BMI, and signs of purging behaviors 1
- Laboratory assessment should include complete blood count, comprehensive metabolic panel, electrolytes, liver enzymes, and renal function tests 1
- An electrocardiogram is recommended for patients with severe purging behavior 1, 2
First-Line Treatment Approach
Psychotherapy
- Eating disorder-focused cognitive-behavioral therapy (CBT) is the cornerstone psychological treatment for bulimia nervosa 1, 2
- CBT focuses on normalizing eating behaviors and addressing psychological aspects like fear of weight gain and body image disturbance 2, 3
- Group CBT (including interpersonal elements) has also shown effectiveness in treating bulimia nervosa 3
- For adolescents and emerging adults with involved caregivers, eating disorder-focused family-based treatment is suggested 1
Pharmacotherapy
- Fluoxetine at 60 mg/day is the recommended pharmacological treatment, as this dose was statistically significantly superior to placebo in reducing binge-eating and vomiting 2, 4
- Fluoxetine should be administered in the morning 4
- Fluoxetine should be prescribed either initially or if there is minimal or no response to psychotherapy alone by 6 weeks of treatment 1, 4
- Doses above 60 mg/day have not been systematically studied in patients with bulimia nervosa 4
Treatment Considerations
Dosage Adjustments
- Lower or less frequent dosage should be used in patients with hepatic impairment 4
- Lower or less frequent dosage should also be considered for elderly patients and those with concurrent disease or on multiple medications 4
- Dosage adjustments for renal impairment are not routinely necessary 4
Maintenance Treatment
- Systematic evaluation has demonstrated benefit of maintenance treatment with fluoxetine 60 mg/day for up to 52 weeks in patients who responded during an 8-week acute treatment phase 4
- Patients should be periodically reassessed to determine the need for continued treatment 4
Monitoring and Follow-up
- Regular monitoring of weight, vital signs, and laboratory parameters is essential 1
- Patients should be evaluated for medical complications, which can include electrolyte disturbances, acid-base imbalances, and local complications from purging behaviors 5
Predictors of Treatment Response
Poor treatment response is associated with:
- Reduction in purging of less than 70% by treatment session 6 6
- Poor social adjustment and lower BMI (indicating greater dietary restriction) 6
- Longer history of disorder, excessive laxative abuse, severe depression, and greater body weight dissatisfaction 7
- Substance abuse history, self-harm behaviors, low self-esteem, and borderline personality disorder 7
Early progress in therapy is the best predictor of successful outcome 6
Treatment Challenges
- Some patients may not engage in or respond to standard CBT and may require more intensive treatment approaches 7
- Patients with multiple comorbidities or severe symptoms may benefit from a coordinated multidisciplinary team approach incorporating medical, psychiatric, psychological, and nutritional expertise 2