What is the best medication for an adult patient with binge eating disorder?

Best Medication for Binge Eating Disorder

Lisdexamfetamine (50-70 mg/day) is the best medication for binge eating disorder, as it is the only FDA-approved drug specifically for moderate-to-severe BED in adults and has demonstrated superior efficacy in reducing binge eating days compared to all other pharmacological options. 1

FDA-Approved First-Line Pharmacotherapy

• Lisdexamfetamine is the sole FDA-approved medication for moderate-to-severe BED, with doses of 50-70 mg/day showing statistically significant superiority over placebo in two pivotal 12-week trials 2, 1
• The medication follows a titration protocol starting at 30 mg/day for 1 week, then increasing to 50 mg/day, with further increases to 70 mg/day as tolerated and clinically indicated 3, 1
• In clinical trials, lisdexamfetamine reduced binge eating days per week by approximately 1.35-1.66 days more than placebo at 12 weeks, with sustained efficacy demonstrated up to 52 weeks 1, 4

When to Consider Medication vs. Psychotherapy

• Psychotherapy (specifically CBT or interpersonal therapy) remains the recommended initial treatment approach for BED 3, 2
• Lisdexamfetamine should be prescribed when patients prefer medication over psychotherapy, have not responded adequately to psychotherapy alone, or have comorbid obesity requiring concurrent management 3, 5

Alternative Off-Label Medication Options

Topiramate

• Topiramate has substantial evidence for reducing binge eating behaviors and is often used as part of combination therapy (phentermine/topiramate ER) 3, 5
• This option is particularly useful for patients with obesity as the primary concern, though it is FDA-approved only for obesity, not BED specifically 3
• Use is limited by its adverse event profile including cognitive side effects 6

Naltrexone/Bupropion (Contrave)

• This combination is particularly beneficial for patients describing food cravings or addictive eating patterns 3, 5
• Consider naltrexone/bupropion for patients with comorbid depression or those attempting smoking cessation 3, 5
• The mechanism involves activating POMC neurons in the arcuate nucleus, releasing alpha-melanocyte-stimulating hormone 3

Medication Selection Algorithm

For moderate-to-severe BED: Start with lisdexamfetamine 50-70 mg/day as first-line pharmacotherapy 2, 5

For BED with significant food cravings/addictive patterns: Consider naltrexone/bupropion 3, 5

For BED with obesity as primary concern: Consider topiramate or naltrexone/bupropion 3, 5

For BED with comorbid depression: Naltrexone/bupropion may provide dual benefit 3, 5

Critical Monitoring Requirements

• Assess efficacy and safety monthly for the first 3 months, then at least every 3 months 3
• Discontinue medication if less than 5% weight loss at 12 weeks when weight management is a treatment goal 3
• Monitor for cardiovascular effects including blood pressure and heart rate regularly, as lisdexamfetamine can increase both 1
• Screen for psychiatric symptoms including new or worsening psychotic symptoms, mania, or depression 1

Important Cautions and Contraindications

• Avoid weight gain-inducing medications such as mirtazapine, tricyclic antidepressants, olanzapine, clozapine, and valproate in BED patients with obesity 3, 5, 7
• Lisdexamfetamine is contraindicated in patients taking MAOIs within the last 14 days, those with cardiovascular disease, and those with history of substance abuse (use with extreme caution) 1
• The most common adverse events with lisdexamfetamine include dry mouth, headache, and insomnia, though most are mild to moderate in intensity 4
• Lisdexamfetamine is a Schedule II controlled substance with potential for abuse, misuse, and dependence 1

Role of Adjunctive Therapy

• Medications should be used as adjuncts to lifestyle modifications, not as monotherapy 3
• Treatment requires coordination with a multidisciplinary team including mental health practitioners and registered dietitians 2