Medication Options for Binge Eating Disorder
Primary Recommendation
For adults with binge eating disorder who prefer medication or have not responded to psychotherapy alone, prescribe either lisdexamfetamine (50-70 mg/day) or an antidepressant medication, with lisdexamfetamine being the only FDA-approved option specifically for moderate-to-severe BED. 1, 2
Treatment Algorithm
First-Line Approach
- Psychotherapy remains the initial treatment: Eating disorder-focused cognitive-behavioral therapy (CBT) or interpersonal therapy should be offered first, in either individual or group formats 1, 3
- Medication should be considered when patients prefer medication over psychotherapy, have minimal or no response to psychotherapy alone by 6 weeks, or have comorbid obesity 1, 4, 5
FDA-Approved Medication
Lisdexamfetamine (Vyvanse®)
- The only FDA-approved medication specifically for moderate-to-severe BED in adults 2, 6
- Dosing: 50-70 mg/day following a titration protocol to minimize side effects 5, 6
- Demonstrated robust efficacy with mean reduction of 1.50 binge-eating episodes and 3.33 odds ratio for remission 7
- Particularly appropriate when weight management is a concurrent goal 5
- Critical warnings from FDA label: Risk of abuse/misuse, contraindicated with MAOIs or within 14 days of MAOI use, avoid in patients with serious heart disease, monitor blood pressure and heart rate, and assess for psychiatric symptoms 2
- Most common adverse events: dry mouth, headache, insomnia, anxiety, and diarrhea 6, 7
Off-Label Medication Options
Topiramate
- Highest efficacy among all agents with mean reduction of 1.72 binge-eating episodes and 3.99 odds ratio for remission 7
- Substantial evidence for reducing binge eating behaviors 5, 8
- Often used as part of combination therapy (phentermine/topiramate ER) 5
- Particularly useful for patients with obesity as primary concern 5
Naltrexone/Bupropion (Contrave)
- Evidence for weight management and reducing binge eating 5, 3
- Specifically indicated for patients describing food cravings or addictive eating behaviors 5, 3
- Additional benefit in patients with comorbid depression or those trying to quit smoking 5, 3
Antidepressants
- The American Psychiatric Association suggests antidepressant medication as an alternative option 1
- Fluoxetine is FDA-approved for bulimia nervosa (60 mg daily) but not specifically for BED 9
- SSRIs (citalopram, fluoxetine, sertraline) and SNRIs (duloxetine, venlafaxine) may be considered, particularly when comorbid anxiety or depression exists 8
Medication Selection Strategy
Choose lisdexamfetamine when:
- Moderate-to-severe BED is present 2, 6
- Weight management is a treatment goal 5
- Patient has no contraindications (heart disease, substance abuse history, uncontrolled hypertension) 2
Choose topiramate or naltrexone/bupropion when:
- Obesity is the primary concern 5, 3
- Patient has significant food cravings or addictive eating patterns (favor naltrexone/bupropion) 5, 3
- Lisdexamfetamine is contraindicated or not tolerated 8
Choose antidepressants when:
- Comorbid depression or anxiety disorders are present 8
- Patient prefers to avoid stimulant medications 1
Critical Cautions
Medications to AVOID:
- Do not prescribe weight gain-inducing medications in BED patients with obesity, including mirtazapine, tricyclic antidepressants, olanzapine, clozapine, and valproate 5, 3, 8
Monitoring Requirements:
- Monitor for side effects and adjust dosing as needed for long-term treatment 5, 3
- For lisdexamfetamine: regular blood pressure and heart rate monitoring, assessment for psychiatric symptoms, and evaluation for abuse potential 2
Special Populations
- BED affects individuals of all genders and is associated with development of obesity 4, 5
- Lisdexamfetamine is not approved for use in children with BED 2
- Lisdexamfetamine passes into breast milk; patients should not breastfeed during treatment 2
- Pregnancy considerations: lisdexamfetamine may harm the unborn baby 2