Medication for Bulimia Nervosa
Fluoxetine 60 mg daily, administered in the morning, is the recommended medication for treating bulimia nervosa—this is the only FDA-approved medication with strong evidence for reducing binge-eating and purging behaviors. 1, 2, 3
First-Line Pharmacologic Treatment
Fluoxetine at 60 mg/day is the only dose statistically superior to placebo for reducing the frequency of binge-eating and vomiting episodes in bulimia nervosa. 1, 2, 3
Standard antidepressant doses of fluoxetine (20 mg) are inadequate and should not be used for bulimia nervosa—the 60 mg dose is essential for therapeutic effect. 2
The medication should be administered in the morning as a single daily dose. 1, 3
For some patients, titrating up to the 60 mg target dose over several days may be advisable to improve tolerability. 3
When to Initiate Medication
The American Psychiatric Association suggests initiating fluoxetine alongside cognitive-behavioral therapy (CBT) as part of comprehensive treatment. 2
Alternatively, fluoxetine should be added if there is minimal or no response to psychotherapy alone by 6 weeks of treatment. 2
Fluoxetine is particularly useful for patients who have not responded adequately to psychological treatment alone or who have relapsed following psychotherapy. 4
Treatment Duration and Maintenance
Systematic evaluation has demonstrated benefit of continuing fluoxetine 60 mg/day for up to 52 weeks in patients who responded during an 8-week acute treatment phase. 3
Patients should be periodically reassessed to determine the need for continued maintenance treatment. 3
Combination Therapy Advantage
Cognitive-behavioral therapy plus fluoxetine is superior to medication alone in treating bulimia nervosa. 5
The combination of medication and psychological treatment produces greater improvement in binge eating and depression compared to placebo plus psychological treatment. 5
A two-stage medication intervention using fluoxetine adds modestly but meaningfully to the benefit of psychological treatment. 5
Alternative SSRIs (When Fluoxetine Cannot Be Used)
While fluoxetine is the only FDA-approved medication, other SSRIs have shown efficacy in controlled trials:
Sertraline 100 mg/day demonstrated statistically significant reduction in binge-eating crises and purging episodes compared to placebo over 12 weeks. 6
Fluvoxamine 200 mg/day showed statistically significant reduction in binge-eating and purging episodes over 12 weeks. 7
However, these alternatives lack FDA approval and should only be considered when fluoxetine is contraindicated or not tolerated. 2
Critical Pitfall to Avoid
Do not use 20 mg fluoxetine for bulimia nervosa—only the 60 mg dose has proven efficacy, and using standard antidepressant dosing will result in treatment failure. 2, 3
Integration with Comprehensive Care
Medication should be delivered as part of a coordinated multidisciplinary team incorporating medical, psychiatric, psychological, and nutritional expertise. 1
Eating disorder-focused cognitive-behavioral therapy remains the cornerstone psychological treatment and should be combined with pharmacotherapy for optimal outcomes. 1, 2