What other medications are FDA-approved for binge eating disorder aside from lisdexamfetamine (Vyvanse)?

FDA-Approved Medications for Binge Eating Disorder

Currently, lisdexamfetamine is the ONLY FDA-approved medication specifically for binge eating disorder 1, 2, 3. No other medications have received FDA approval for this indication.

Off-Label Medication Options with Evidence

While no other FDA-approved options exist for BED specifically, several medications have demonstrated efficacy in clinical trials and can be considered as off-label alternatives:

Topiramate (Strong Evidence)

• Topiramate has the most robust evidence among off-label options for reducing binge eating behaviors and body weight in BED 4, 5, 6, 7.
• Often used as part of combination therapy (phentermine/topiramate ER, brand name Qsymia), though this combination is FDA-approved only for obesity, not BED specifically 8.
• Particularly useful when obesity is the primary concern alongside BED 4, 9, 10.
• Mechanism involves modulation of GABA receptors, carbonic anhydrase inhibition, and glutamate antagonism to reduce appetite and increase satiation 8.

Naltrexone/Bupropion (Contrave)

• FDA-approved for obesity but not BED specifically 8.
• Particularly beneficial for patients describing food cravings or addictive eating patterns 4, 9, 10.
• Additional benefit in patients with comorbid depression or those attempting smoking cessation 4, 9.
• Works synergistically by activating POMC neurons in the arcuate nucleus, releasing alpha-melanocyte-stimulating hormone 8.

SSRIs (Modest Evidence)

• Fluoxetine is FDA-approved for bulimia nervosa (not BED), making it the only FDA-approved medication for any binge eating condition besides lisdexamfetamine 11, 2.
• Fluoxetine, fluvoxamine, sertraline, and citalopram have shown modest but significant reductions in binge eating frequency and body weight in short-term studies 5, 7.
• Consider when comorbid anxiety or depression is present 5, 6.

Clinical Decision Algorithm

When lisdexamfetamine is not suitable or preferred:

1. If obesity is the primary concern: Consider topiramate or naltrexone/bupropion 4, 9, 10

2. If food cravings/addictive eating patterns predominate: Prioritize naltrexone/bupropion 4, 9, 10

3. If comorbid depression or anxiety: Consider SSRIs (fluoxetine, sertraline, citalopram) or naltrexone/bupropion if also attempting smoking cessation 5, 6

4. If cardiovascular disease is present: Avoid sympathomimetic agents (phentermine, phentermine/topiramate ER); safer alternatives include topiramate alone or naltrexone/bupropion 8, 10

Critical Contraindications

Avoid these medications in BED patients with obesity due to weight gain potential:

• Mirtazapine 4, 9, 10, 5
• Tricyclic antidepressants 4, 9, 10, 5
• Atypical antipsychotics (olanzapine, clozapine) 5
• Valproate 5

Monitoring Requirements

• Assess efficacy and safety monthly for the first 3 months, then at least every 3 months 8, 10
• Discontinue medication if ≤5% weight loss at 12 weeks and consider alternative medication or other treatments 8, 10

Important Caveats

• Psychotherapy (specifically CBT or interpersonal therapy) remains the recommended first-line treatment for BED 4, 9
• Medications should be used as adjuncts to lifestyle modifications, not as monotherapy 8
• The evidence base for off-label medications is significantly weaker than for lisdexamfetamine, which has undergone rigorous phase 3 trials demonstrating efficacy 1, 3
• Novel GLP-1 receptor agonists (liraglutide, semaglutide) and dual GIP/GLP-1 agonists (tirzepatide) show promise for reducing binge eating in individuals with obesity, but their role in BED treatment remains unclear 5