Bupropion has been more effective than placebo for treating:
- uncomplicated obesity (short- and long-term)
- obesity associated with depressive symptoms
- bulimia nervosa (although bupropion is contraindicated in these patients because of seizure risk).26,28,29
No controlled trials have studied bupropion for BED. When using dosages effective in depressive disorders, we find bupropion helpful in reducing binge eating, body weight, and depressive symptoms in BED patients.
Appetite suppressants decrease appetite and weight, may increase satiety, and may reduce depressive symptoms.
Sibutramine—a serotonin, norepinephrine, and dopamine reuptake inhibitor indicated for managing obesity—has been reported effective in BED in a 12-week, randomized, double-blind, placebo-controlled trial. A 15-mg/d dosage reduced binge frequency, body weight, and depressive symptoms more effectively than placebo in 60 obese patients with BED.30 Most-frequent adverse effects (dry mouth and constipation) were mild and benign, and no significant complications were observed.
Sibutramine’s mechanism of action in BED is unknown. However, it suppressed food intake during binge-eating episodes in patients with BED in a randomized, controlled, cross-over laboratory study.31
Orlistat. We know of no published controlled studies of the lipase inhibitor orlistat in treating BED. In our experience, some patients do well with this agent, though we have observed infrequent purging episodes with it in patients with BED.
With orlistat, 120 mg tid, our BED patients have experienced weight loss comparable to that seen in uncomplicated obesity at similar dosages. Orlistat seems most effective for:
- patients whose binge eating is in remission
- those who responded to behavioral weightloss treatment, a psychological treatment, or another medication.
Anticonvulsants such as topiramate and zonisamide have been shown effective in treating obesity32,33 and are sometimes used to treat BED. Obese BED patients with mood disorders often do best with psychotherapy plus medication
Topiramate at dosages of 50 to 600 mg/d (median 212 mg/d) reduced binge-eating frequency, obsessive-compulsive features of binge eating, and body weight more effectively than placebo in a 14-week study of 61 obese patients with BED. These effects were maintained across 48 weeks in an open-label extension trial.34
Zonisamide, mean 513 mg/d, produced similar results during a prospective, open-label, 12-week trial in 15 patients with BED.35 A controlled trial to replicate these findings is ongoing.
BED may respond to anticonvulsant therapy for several reasons:
- Some anticonvulsants are effective in treating bipolar disorder, which may occur with BED.12
- Some anticonvulsants have shown benefit in conditions associated with pathologic impulsivity, such as substance abuse, impulse-control, and cluster B disorders.10
Growing evidence shows that bulimia nervosa and BED may be associated with pathologic impulsivity.
Combination therapies are generally more effective than monotherapies in patients with mood disorders, uncomplicated obesity, and possibly bulimia nervosa. Even so, few trials have systematically studied combination therapy in managing patients with BED.
Two studies compared psychotherapy and antidepressants alone and in combination in treating BED.21,23 Both showed that CBT alone was more effective in decreasing binge frequency than desipramine alone,21 fluoxetine alone,23 and the combination of CBT and medication. On the other hand, patients who took desipramine either alone or in combination experienced a greater degree of weight loss than those who did not take desipramine.21
In another combination therapy, exercise has been shown to be an effective adjunct to CBT in maintenance treatment of obese women with BED.36
No studies have compared behavioral weight management or a specialized psychotherapy in combination with an antiobesity drug or a weight-loss anticonvulsant in treating BED.
Treatment recommendations
In our experience, BED patients—particularly those with obesity and psychopathology—often do best with some combination of psychological treatment and medication:
- The psychological component may be behavioral weight-loss treatment, a specialized psychotherapy such as CBT or IPT, or some combination of behavioral weight-loss treatment and specialized psychotherapy.
- The medication component may consist of an antidepressant, anticonvulsant, antiobesity drug, or multiple drugs (such as an SSRI or sibutramine with topiramate for BED with major depression, or topiramate with lithium for BED with bipolar disorder).
Although combination therapies may be optimal for some patients, this approach remains unproven in controlled trials.
Patient preference. In addition to comorbidities, patient preference is an important consideration when choosing BED treatments. We determine our patients’ preferences by educating them as much as possible about their options. We explain the benefits and weaknesses of all treatments and encourage them to participate in forming their individualized treatment plans.
Patients sometimes have strong treatment preferences. Some prefer psychological treatments, whereas others prefer medications. Working with patient preferences enhances treatment adherence. For example, patients who fail a preferred treatment are often more willing to adhere to another treatment modality about which they initially were skeptical.