First-Line Medication Treatment for Binge Eating Disorder
Psychotherapy, specifically eating disorder-focused cognitive-behavioral therapy (CBT) or interpersonal therapy, is the recommended first-line treatment for binge eating disorder, not medication. 1, 2, 3 However, when medication is indicated—either due to patient preference, inadequate response to psychotherapy alone, or comorbid obesity—lisdexamfetamine (50-70 mg/day) is the only FDA-approved medication and represents the first-line pharmacologic option for moderate-to-severe binge eating disorder. 4, 2, 3, 5
When to Consider Medication
Medications should be considered in the following clinical scenarios:
- Patient preference for medication over psychotherapy 4, 2
- Minimal or no response to psychotherapy alone by 6 weeks of treatment 4, 2
- Comorbid obesity requiring weight management 4, 2
FDA-Approved First-Line Medication
Lisdexamfetamine is the only FDA-approved medication specifically for moderate-to-severe BED, with doses of 50-70 mg/day demonstrating statistically significant superiority over placebo. 3, 5
- Dosing typically follows a titration protocol to minimize side effects 4, 2
- This medication is particularly appropriate when weight management is a concurrent treatment goal 4, 2
Alternative Medication Options (Off-Label)
When lisdexamfetamine is not suitable or available, several off-label options have evidence supporting their use:
Topiramate
- The American Gastroenterological Association recommends topiramate for reducing binge eating behaviors and body weight, particularly in patients with obesity as the primary concern 4
- Often used as part of combination therapy (phentermine/topiramate ER) 4, 2
- Must be avoided in patients with cardiovascular disease, uncontrolled hypertension, and is teratogenic 4
- Consistently shown to decrease binge eating in BED across multiple RCTs 6
Naltrexone/Bupropion (Contrave)
- Particularly useful for patients who describe food cravings or addictive eating behaviors 4, 2
- May benefit patients with comorbid depression or those trying to quit smoking 4, 2
- The American Heart Association recommends monitoring blood pressure and heart rate periodically, especially during the first 12 weeks of treatment 4
SSRIs (Selective Serotonin Reuptake Inhibitors)
- Fluoxetine (60 mg daily) is FDA-approved for bulimia nervosa and can be considered as an alternative medication option for BED, though evidence is more limited than for lisdexamfetamine 3, 7
- Other SSRIs (fluvoxamine, sertraline, citalopram) have shown modest but significant reduction in binge eating frequency and body weight over the short term 8, 9, 6
Medication Selection Algorithm
Follow this decision pathway:
First choice: Lisdexamfetamine (50-70 mg/day) for moderate-to-severe BED, especially when weight management is a goal 4, 2, 3
Second choice: Topiramate or naltrexone/bupropion for patients with obesity as primary concern 4, 2
Third choice: Naltrexone/bupropion for patients with significant food cravings or addictive eating patterns 4, 2
Consider SSRIs as alternative options when stimulants are contraindicated 3
Important Cautions and Contraindications
- Avoid weight gain-inducing medications such as mirtazapine and tricyclic antidepressants in BED patients with obesity 4, 2
- Bupropion is contraindicated in patients with bulimia nervosa 10
- Monitor for side effects and adjust dosing as needed for long-term treatment 4, 2
- The American College of Gastroenterology recommends assessing efficacy and safety monthly for the first 3 months, then at least every 3 months, and discontinuing medication if ≤5% weight loss at 12 weeks 2
Critical Clinical Pitfalls
- Medications should be used as adjuncts to lifestyle modifications, not as monotherapy 2
- Do not prescribe medication without first offering or attempting psychotherapy, as CBT and interpersonal therapy remain the evidence-based first-line treatments 1, 2, 3
- Regular monitoring should assess binge eating frequency, psychological distress, and treatment adherence 3