Recommended Medication for Bulimia Nervosa
Fluoxetine 60 mg daily is the recommended medication for this patient with bulimia nervosa, initiated alongside cognitive-behavioral therapy. 1, 2
Rationale for Fluoxetine 60 mg Daily
Fluoxetine is the only FDA-approved medication for bulimia nervosa and should be administered at 60 mg/day in the morning, not the standard antidepressant dose of 20 mg/day. 3
The 60 mg dose was statistically significantly superior to placebo in reducing the frequency of binge-eating and vomiting in controlled trials, while the 20 mg dose showed intermediate effects between 60 mg and placebo. 3, 4
The American Psychiatric Association specifically recommends fluoxetine 60 mg daily as the primary pharmacologic agent for bulimia nervosa, with strong evidence supporting this recommendation. 1, 2
Treatment Algorithm
Initiation Strategy:
Start fluoxetine alongside eating disorder-focused cognitive-behavioral therapy (CBT), which is the cornerstone psychological treatment. 2, 5
For some patients, it may be advisable to titrate up to the 60 mg target dose over several days, though the full therapeutic effect may be delayed until 5 weeks of treatment or longer. 3
Administer the medication in the morning as a single daily dose. 1, 3
When to Initiate Medication:
The American Psychiatric Association suggests initiating fluoxetine alongside CBT from the start, or if there is minimal or no response to psychotherapy alone by 6 weeks of treatment. 1
Medication combined with psychological treatment produces greater improvement in binge eating and depression than psychological treatment with placebo. 5
Critical Dosing Pitfall to Avoid
Do not use standard antidepressant doses of fluoxetine (20 mg) for bulimia nervosa. The American Psychiatric Association specifically advises against this common error—the recommended dose is 60 mg daily. 1
Fluoxetine doses above 60 mg/day have not been systematically studied in patients with bulimia nervosa. 3
Maintenance Treatment
Fluoxetine 60 mg/day has demonstrated benefit for maintenance treatment for periods 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 treatment. 3
Multidisciplinary Coordination
Treatment requires coordination among medical, psychiatric, psychological, and nutritional expertise, with fluoxetine as one component of comprehensive care. 1
The patient's BMI of 30.4 kg/m² indicates obesity, which is not uncommon in bulimia nervosa and requires nutritional counseling alongside psychiatric treatment. 2
Alternative Medications (Lower Quality Evidence)
While fluoxetine is the gold standard, other SSRIs have shown efficacy in smaller trials:
Sertraline 100 mg/day demonstrated significant reduction in binge-eating and purging in a small randomized controlled trial. 6
Fluvoxamine 200 mg/day showed effectiveness in reducing binge-eating crises and purging episodes in a small trial. 7
However, these alternatives lack FDA approval for bulimia nervosa and should only be considered if fluoxetine is ineffective or poorly tolerated. 5