Review Question - QID 218369

This patient with recurrent episodes of binge eating, inappropriate compensatory behavior to prevent weight gain (self-induced vomiting), self-worth pathologically influenced by body weight, and a normal BMI most likely has bulimia nervosa. First-line therapy for bulimia nervosa is the selective serotonin reuptake inhibitor (SSRI) fluoxetine.

Bulimia nervosa is a disease defined by episodes of binge eating and inappropriate compensatory behaviors at least once a week for 3 months, as well as excessive concern about body weight and shape. Unlike anorexia nervosa, patients with bulimia will have a normal or high BMI. Binge eating episodes involve eating an excessive amount of food during a short period; during these episodes, patients feel they lack control over their eating. Compensatory behaviors can include inappropriate use of medications such as laxatives or diuretics, self-induced vomiting, and excessive exercise. The treatment for bulimia nervosa is a combination of psychotherapy, nutritional support, and pharmacotherapy. First-line pharmacotherapy is with the SSRI fluoxetine. This agent is preferred due to tolerability, as well as efficacy for behavioral and cognitive symptoms. Second-line therapy is with an alternative SSRI such as sertraline, escitalopram, or fluvoxamine. Third-line pharmacotherapy includes tricyclic antidepressants (TCA), trazodone, monoamine oxidase inhibitors (MAOIs), and topiramate.

Treasure et al. review the definition, epidemiology, pathophysiology, and treatment of bulimia nervosa. The authors note that 60% of patients failed to fully abstain from core bulimia nervosa symptoms despite receiving the best available treatments. The authors recommend family-based therapy in addition to pharmacotherapy for patients with bulimia nervosa.

Incorrect Answers:
Answer 1: Bupropion is an antidepressant that can be used for depression, seasonal affective disorder, and smoking cessation. Bupropion can cause seizures in patients with eating disorders; therefore, it is contraindicated in patients that have a history of bulimia nervosa or anorexia nervosa.

Answer 2: Desipramine is a tricyclic antidepressant (TCA) which is a third-line treatment for patients with bulimia. It is preferred over other third-line therapies such as trazodone, topiramate, and monoamine oxidase inhibitors (MAOI) in patients who either have comorbid anxiety or unipolar depressive disorder or a BMI between 18.5 and 22 kg/m^2. TCAs are more likely to cause weight gain than SSRIs.

Answer 4: Paroxetine is an SSRI that is not typically used in bulimia. Among SSRIs, paroxetine causes the most weight gain. This medication-induced weight change is problematic in patients with bulimia, who by definition have made inappropriate efforts to lose weight.

Answer 5: Topiramate is a third-line medication for bulimia. It is preferred over other third-line therapies among patients who do not have a comorbid anxiety disorder or unipolar depressive disorder and who also do not have a BMI between 18.5 and 22 kg/m^2.

Bullet Summary:
Fluoxetine is the first-line pharmacotherapy for bulimia nervosa.