A 20-year-old college student comes to the office due to persistent fatigue, irregular menstrual periods, and difficulty losing weight despite intensive exercise. Several times a week, the patient has episodes where she uncontrollably consumes large amounts of cookies, bread, and potato chips. She feels disgusted with herself afterward and subsequently does additional exercise. Although the patient hates her appearance and constantly compares herself to her slimmer friends, she denies feeling persistently depressed. She has no other medical problems. Weight is 70 kg (154.3 lb) and height is 160 cm (5 ft 3 in). Blood pressure is 100/60 mm Hg and pulse is 92/min. Examination shows pharyngeal erythema and minimal parotid enlargement bilaterally. Potassium level is 3.4 mEq/L and amylase is 140 U/L. Pregnancy test is negative. Which of the following medications would be most effective in treating this patient?
Eating disorders | ||
Diagnosis | Clinical features | Treatment |
Anorexia nervosa |
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Bulimia nervosa |
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Binge-eating disorder |
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SSRI = selective serotonin reuptake inhibitor. | ||
This patient's history of recurrent binge eating followed by compensatory exercise—accompanied by physical findings and laboratory values suggestive of self-induced vomiting (pharyngeal erythema, parotid enlargement, hypokalemia and hyperamylasemia)—is consistent with bulimia nervosa. Other findings seen in bulimia include hypotension, tachycardia, dry skin, menstrual irregularities, erosion of dental enamel, and metabolic alkalosis.
Treatment options for bulimia nervosa include nutritional rehabilitation (establishing a structured and consistent meal pattern), cognitive-behavioral therapy, and pharmacotherapy with selective serotonin reuptake inhibitors (SSRIs). Fluoxetine is considered the drug of choice and has the best evidence of being most effective in combination with nutritional rehabilitation and psychotherapy.
(Choice A) The antidepressant bupropion is a norepinephrine dopamine reuptake inhibitor that is contraindicated in bulimia nervosa due to elevated risk of seizures.
(Choice B) Tricyclic antidepressants such as desipramine are not first-line treatment for bulimia nervosa.
(Choice D) The amphetamine lisdexamfetamine has been used to treat binge eating disorder, but not bulimia nervosa.
(Choice E) Multiple studies support the efficacy of the SSRI fluoxetine in the treatment of bulimia nervosa.
(Choice F) Olanzapine, an antipsychotic associated with weight gain, has been used in patients with anorexia nervosa who fail to gain weight with psychotherapy alone. It has no role in the treatment of bulimia nervosa.
Educational objective
Treatment options for bulimia nervosa include nutritional rehabilitation, cognitive-behavioral therapy, and pharmacotherapy with selective serotonin reuptake inhibitors. Fluoxetine is the drug of choice.