Are Glucagon-like peptide-1 (GLP-1) receptor agonists, such as liraglutide (Victoza) or semaglutide (Ozempic), safe to use in individuals with disordered eating?

GLP-1 Receptor Agonists in Disordered Eating: Safety Concerns and Clinical Recommendations

GLP-1 receptor agonists should generally be avoided in patients with active eating disorders due to potential exacerbation of eating disorder psychopathology, lack of sufficient safety data, and risk of worsening restrictive behaviors or body image concerns. 1

Current Evidence on Safety and Risk

The evidence regarding GLP-1 receptor agonists in eating disorder populations is extremely limited, and what exists raises significant concerns:

• There is insufficient evidence to support the use of GLP-1 receptor agonists for treating eating disorder symptoms at this time, and preliminary research suggests these medications could potentially exacerbate or contribute to the development of eating disorder pathology. 1

• GLP-1 receptor agonists may negatively impact eating disorder treatment by reinforcing weight-focused behaviors and potentially worsening body image concerns, particularly given their mechanism of appetite suppression and delayed gastric emptying. 1

• The gastrointestinal adverse effects of GLP-1 receptor agonists—including nausea (40% with liraglutide), vomiting (16%), diarrhea, and constipation—could be particularly problematic in eating disorder populations where these symptoms may trigger or worsen disordered eating behaviors. 2

Specific Eating Disorder Considerations

Binge Eating Disorder

While some preliminary data exists for binge eating disorder, the evidence remains insufficient for clinical recommendation:

• One retrospective cohort study showed semaglutide reduced Binge Eating Scale scores more than lisdexamfetamine or topiramate, but this was an open-label, uncontrolled study with significant methodological limitations. 3

• Dysregulation of the endogenous GLP-1 system has been associated with binge eating in preclinical models, and GLP-1 receptor agonists may suppress overconsumption during binge episodes. 4

• A 24-week study combining liraglutide with intensive behavioral therapy showed greater short-term reductions in dietary disinhibition and binge eating compared to behavioral therapy alone, but these differences were no longer significant at 52 weeks. 5

Despite these preliminary findings, the studies have substantial design limitations, and more rigorous research is required before GLP-1 receptor agonists can be recommended for binge eating disorder treatment. 1

Restrictive Eating Disorders

For anorexia nervosa, bulimia nervosa, and other restrictive eating disorders, GLP-1 receptor agonists pose particularly high risks:

• The appetite-suppressing effects and weight loss outcomes (14.9-20.9% body weight reduction) directly contradict treatment goals in restrictive eating disorders. 6

• Dehydration is the most frequent serious adverse event with liraglutide (23.93%), dulaglutide (20.90%), semaglutide (25.10%), and tirzepatide (32.86%), which could be especially dangerous in malnourished patients with eating disorders. 7

• The medications' effects on shape and weight concern—while potentially beneficial in obesity—could reinforce pathological preoccupation with body image in eating disorder populations. 5

Metabolic and Nutritional Safety Concerns

Real-world pharmacovigilance data reveals significant metabolic and nutritional adverse events:

• Semaglutide (ROR 3.34), liraglutide (ROR 2.78), and exenatide (ROR 2.15) are all significantly associated with metabolism and nutrition disorders in FDA adverse event reporting. 7

• The number of adverse event signals detected ranges from 12-22 for commonly used agents (exenatide, liraglutide, semaglutide, dulaglutide), with dehydration showing an early failure-type profile requiring special attention. 7

• GLP-1 receptor agonists delay gastric emptying, which can impact absorption of oral medications and may worsen symptoms in patients with gastroparesis—a common comorbidity in eating disorders. 2

Clinical Algorithm for Decision-Making

When a patient with disordered eating presents requesting or already taking a GLP-1 receptor agonist:

1. Active eating disorder (anorexia nervosa, bulimia nervosa, restrictive eating): Contraindicate GLP-1 receptor agonists; prioritize eating disorder treatment with specialized care. 1

2. Binge eating disorder with obesity:

   • First-line: Intensive behavioral therapy alone or with FDA-approved lisdexamfetamine 3, 5
   • Consider GLP-1 receptor agonists only if: (a) standard treatments have failed, (b) patient is medically stable, (c) close monitoring for eating disorder symptom exacerbation is possible, and (d) patient understands the limited evidence base 1, 3

3. History of eating disorder, now in recovery with obesity:

   • Assess stability of recovery (minimum 12 months symptom-free recommended)
   • Screen for residual body image concerns and weight preoccupation
   • If proceeding, use slow titration and monitor closely for relapse of eating disorder symptoms 2, 1

4. Subclinical disordered eating behaviors: Avoid GLP-1 receptor agonists until eating behaviors normalize with behavioral intervention. 1

Monitoring Requirements if Treatment Proceeds

If GLP-1 receptor agonists are used despite eating disorder history (only in carefully selected binge eating disorder cases):

• Weekly assessment for the first month for eating disorder symptom exacerbation, including binge frequency, compensatory behaviors, and body image concerns 1

• Monitor for dehydration and electrolyte abnormalities given the high risk of serious dehydration events, particularly during dose escalation 7

• Assess nutritional status regularly, as the combination of reduced food intake and gastrointestinal side effects may lead to nutritional deficiencies 2, 6

• Coordinate care with eating disorder specialists to ensure comprehensive monitoring and early intervention if symptoms worsen 1

Critical Contraindications

Beyond eating disorder concerns, standard contraindications apply:

• Personal or family history of medullary thyroid cancer or multiple endocrine neoplasia syndrome type 2 2, 6
• Active gastroparesis or severe gastrointestinal motility disorders 2
• Recent heart failure decompensation (for GLP-1 receptor agonists) 2

Common Pitfalls to Avoid

• Do not assume weight loss benefits outweigh eating disorder risks in patients with active or recent eating disorder history—the potential for symptom exacerbation is substantial 1

• Do not rely on patient self-report alone for eating disorder screening; use validated instruments and collateral information when possible 1

• Do not continue GLP-1 receptor agonists if eating disorder symptoms emerge or worsen, even if weight loss goals are being achieved 1

• Do not prescribe GLP-1 receptor agonists as a substitute for evidence-based eating disorder treatment in patients with binge eating disorder—behavioral interventions remain first-line 3, 5