Bupropion Should NOT Be Used for Bulimia Nervosa with Binging and Purging
Bupropion is absolutely contraindicated in patients with bulimia nervosa or anorexia nervosa due to a significantly elevated risk of seizures. 1
Why Bupropion is Dangerous in Bulimia
The FDA drug label explicitly states that bupropion is contraindicated in patients with a current or prior diagnosis of bulimia or anorexia nervosa, as a higher incidence of seizures was observed in such patients. 1 This contraindication stems from a multicenter controlled trial where 4 out of 55 bulimic patients (7.3%) experienced grand mal seizures while taking bupropion—a seizure rate far exceeding that observed in other patient populations treated with this medication. 2
The mechanism behind this increased seizure risk relates to the electrolyte disturbances and metabolic abnormalities caused by purging behaviors, which lower the seizure threshold when combined with bupropion's inherent proconvulsant properties. 1, 2
Evidence Against Bupropion's Efficacy for Bulimia
Beyond the safety concerns, bupropion lacks efficacy for the core symptoms of bulimia nervosa:
Bupropion does not reduce binge eating or purging behaviors. In a randomized controlled trial of 61 overweight women with binge-eating disorder, bupropion 300 mg/day showed no significant improvement in binge-eating frequency, food craving, or eating disorder psychopathology compared to placebo. 3
The only benefit observed was modest weight loss (1.8% vs 0.6% BMI loss), which is clinically insignificant and does not address the underlying eating disorder pathology. 3
Bupropion has documented abuse potential in eating disorder patients. A case report describes a patient with bulimia nervosa who abused bupropion XR up to 3,000-4,500 mg/day to control binge eating and suppress appetite, ultimately resulting in grand mal seizures. 4 This highlights that the stimulant and anorexic effects of bupropion can be exploited by patients with eating disorders, creating additional risk. 4
What Actually Works for Bulimia Nervosa
The American Psychiatric Association recommends eating disorder-focused cognitive-behavioral therapy (CBT) as first-line treatment for bulimia nervosa, focusing on normalizing eating behaviors and addressing body image disturbance. 5
If pharmacotherapy is indicated, fluoxetine 60 mg/day is the only FDA-approved medication for bulimia nervosa and has demonstrated statistically significant superiority over placebo in reducing binge-eating and vomiting frequency. 5
Treatment Algorithm for Bulimia Nervosa:
Initiate eating disorder-focused CBT as the primary intervention, which has shown 39% remission rates compared to 20% for antidepressants alone. 6
Consider adding fluoxetine 60 mg/day (administered in the morning) if psychotherapy alone is insufficient, as combination treatment achieves 49% remission rates versus 36% for psychotherapy alone. 5, 6
Monitor for treatment response through quantification of binge and purge episodes, assessment of electrolyte abnormalities (particularly potassium), and ECG monitoring for patients with severe purging behaviors. 5
Screen for co-occurring psychiatric disorders (depression, anxiety, substance use) which are common in bulimia nervosa and may require additional treatment. 5
Critical Pitfall to Avoid
Never prescribe bupropion to any patient with a current or past history of bulimia nervosa or anorexia nervosa, regardless of whether they are currently symptomatic. 1 Clinicians must specifically screen for eating disorder histories before prescribing bupropion for any indication (depression, smoking cessation, weight loss). 7, 4 If a patient on bupropion presents with seizures, consider the possibility of an undiagnosed or undisclosed eating disorder. 4