What medications are used to treat binge eating disorder?

Medications for Binge Eating Disorder

Lisdexamfetamine is the only FDA-approved medication specifically for moderate-to-severe binge eating disorder and should be your first-line pharmacologic choice when medication is indicated. 1, 2, 3

When to Consider Medication

Pharmacotherapy should be considered in the following clinical scenarios:

• After psychotherapy trial: When patients have not responded adequately to eating disorder-focused cognitive-behavioral therapy (CBT) or interpersonal therapy 1, 2
• Patient preference: When patients prefer medication over psychotherapy 1, 2
• Comorbid obesity: When patients have comorbid obesity (BMI ≥30 kg/m² or BMI ≥27 kg/m² with weight-related comorbidities) 1, 2

Important caveat: Medication should never be used as monotherapy but always in combination with an intensive lifestyle program including diet, exercise, and behavioral modification. 4

Medication Selection Algorithm

First-Line: Lisdexamfetamine

• Use for: Moderate-to-severe BED, especially when weight management is a goal 2
• Dosing: Follow titration protocol to minimize side effects 1, 3
• Evidence: Only FDA-approved medication specifically for BED; demonstrated efficacy in reducing binge-eating frequency and related psychopathology 2, 5, 6
• Weight effects: Reduces both weight and appetite 6
• Common side effects: Headache, gastrointestinal upset, sleep disturbance, and sympathetic nervous system arousal (relative risk 1.63 to 4.28 compared to placebo) 6

Alternative Options When Lisdexamfetamine Is Not Appropriate

Topiramate (often as phentermine/topiramate ER combination):

• Use for: Patients with obesity as primary concern or as part of combination therapy 1, 2
• Evidence: Substantial evidence for reducing binge eating behaviors and body weight 1, 2, 6
• Weight effects: Reduces weight and increases sympathetic nervous system arousal 6

Naltrexone/Bupropion (Contrave):

• Use for: Patients with significant food cravings or addictive eating patterns 1, 2
• Additional benefits: May benefit patients with comorbid depression or those trying to quit smoking 1, 2
• Evidence: Demonstrated efficacy for weight management in patients describing food cravings or addictive eating behaviors 1, 2

Second-Generation Antidepressants (SGAs):

• Evidence: Fluoxetine, fluvoxamine, sertraline, and citalopram modestly but significantly reduce binge-eating frequency and body weight over the short term 7
• Specific data: SGAs increased binge-eating abstinence (relative risk 1.67), reduced binge-eating-related obsessions and compulsions (mean difference -3.84), and reduced symptoms of depression (mean difference -1.97) 6
• Use for: Patients with comorbid anxiety or depression where treating the psychiatric comorbidity may contextually benefit BED 5

Critical Contraindications and Cautions

Avoid in BED patients with obesity:

• Mirtazapine and tricyclic antidepressants due to weight gain potential 1, 2

Cardiovascular considerations:

• Avoid sympathomimetic agents (phentermine, phentermine/topiramate ER) in patients with cardiovascular disease 4
• Safer alternatives for CVD patients include lorcaserin and orlistat 4

Monitoring and Duration

• Initial assessment: Monthly for the first 3 months 4
• Ongoing monitoring: At least every 3 months thereafter 4, 1
• Discontinuation criteria: If ≤5% weight loss at 12 weeks, discontinue and consider alternative medication or other treatments 4
• Long-term use: Monitor for side effects and adjust dosing as needed 1, 2

Special Populations

Patients with Type 2 Diabetes:

• Consider GLP-1 analogues (e.g., liraglutide) that reduce hyperglycemia in addition to first-line metformin, as these promote weight loss 4