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Treatment of Binge Eating Disorder

Opinion statement

Binge eating disorder is a common eating disorder that recently has received increasing attention. Goals in treating binge eating disorder typically include controlling binge eating and diminishing excess body weight. A variety of treatment approaches have been used, including diet/lifestyle modification, psychotherapy, and pharmacologic treatment. Diet and lifestyle interventions are somewhat effective in diminishing the binge eating behavior and lead to modest weight loss, but the weight effects are limited and not typically lasting. A number of psychotherapies have been shown to be beneficial, mostly for stopping binge eating, and tend to show little impact on weight loss. Numerous pharmacologic interventions have been developed, with the focus on antidepressants (used for their anti-binge eating effects) and weight loss drugs. Both have been shown to be helpful but again, for antidepressants, bringing about lasting weight loss appears to be difficult. The most effective approach to treating binge eating disorder (if available) is likely psychotherapy combined with medication management as indicated.

Introduction

Binge eating disorder (BED) was first described by Stunkard in 1959 [1]. It is characterized by binge eating, consisting of eating large amounts of food with a sense of loss of control. In BED, there is no compensatory behavior. In addition to those core features, BED is associated with other features, including eating alone due to embarrassment, eating more rapidly, eating until uncomfortably full, eating when not physically hungry, and feeling disgusted with oneself after eating. Onset of BED often occurs in the teens, but presentation for treatment is usually much later, sometimes in the 20s but typically in the 30s, 40s, or 50s. Obesity co-occurs with BED in most individuals with BED. There is some evidence for increased risk of complications of obesity among obese individuals with BED as compared with non-binge obese, but this question is not firmly settled. Regardless, there is evidence for increased mortality [2]. Psychiatric comorbidity is high, with mood disorders, anxiety disorders, and substance abuse all being quite common.

There are three cornerstones to treatment of BED, as is true for all eating disorders; nutritional therapy, psychotherapy, and medications. With regard to nutritional therapy, behavior weight loss has been clearly shown to be beneficial. A number of psychotherapies have been studied and shown to provide benefit, including cognitive behavioral therapy (CBT), interpersonal therapy, and dialectic behavior therapy. Other psychotherapies are under development. A wide number of medication trials have been completed. These began with trials of antidepressants (first tricyclic antidepressants, then more recently selective serotonin reuptake inhibitors [SSRIs] and other commonly used agents). One issue with the antidepressant and the psychotherapy trials is that weight loss is a commonly desired outcome of treatment, but very limited weight loss is usually observed, even with the cessation of binge eating during antidepressant or psychotherapy treatment. Partly for that reason, there has been increased interest in drugs with appetite suppression and weight loss as a main or side effect. This work has included medications previously used for obesity but now taken off the market: dexfenfluramine [3] and sibutramine [4, 5] and, more recently, weight loss agents such as orlistat and drugs with appetite-suppressant side effects, such as topiramate and zonisamide.

Because of the relatively late presentation of BED, relatively little is known about its treatment in adolescents.

Diet/lifestyle

  • Behavioral weight loss has been shown to diminish the frequency of binge eating and may lead directly to weight loss.

  • This impact on weight loss is of importance because most individuals seeking treatment for BED are obese, and of them, most are seeking both cessation of binge eating and reduction in weight.

  • The extent of behavioral weight loss is limited: a weight loss of 5–10 % is commonly observed, but maintenance of this weight loss has consistently proven very difficult.

  • In addition, it appears that this degree of weight loss falls well short of what most individuals are seeking.

Psychotherapy

  • Psychotherapy is an important intervention in the treatment of BED.

  • CBT, interpersonal therapy, and dialectic behavior therapy have all been studied, and show promise in the treatment of BED.

  • The interventions appear most effective for frequency of binge eating and perhaps eating disorder cognition (impact on weight is typically negligible, even in individuals who cease binge eating entirely).

  • Evidence suggests that combining psychotherapy and pharmacotherapy may lead to modest added benefit.

Pharmacologic treatment

Typically, up to three targets exist for treatment in BED: binge eating behavior, eating disorder cognitions, and weight loss. By and large, the same agents are used to address each of these symptoms.

Fluoxetine

Fluoxetine has been examined in combination with other interventions such as CBT [6, 7] and behavior modification [8]. In general, fluoxetine has shown little added benefit for binge eating, particularly when added to CBT, although there was benefit for weight in one study [8] and for depression in another [6].

Standard dosage :

Initial dosage is 20 mg/day; the typical treatment goal is 60–80 mg/day, based on previous work in bulimia nervosa (which is commonly extrapolated to BED), showing greater effect with a 60 mg dose than a 20 mg dose.

Contraindications :

None.

Main drug interactions :

Fluoxetine is a potent inhibitor of cytochrome P450 (CYP)-2D6, and thus the doses of other drugs metabolized by CYP2D6 should be diminished.

Main side effects :

Diminished libido, anorgasmia, insomnia, upset stomach.

Special points :

Fluoxetine is US Food and Drug Authority (FDA)-approved for bulimia nervosa, but not for BED.

Cost :

Low.

Fluvoxamine :

In a 9-week double-blind, placebo-controlled trial, fluvoxamine was more effective than placebo in reducing binge eating behavior [9]. Mean weight loss was also greater with fluvoxamine (2.7 vs. 0.3 lbs).

Standard dosage :

Initial dosage is 50 mg/day, with gradual titration to minimize nausea. The typical goal is 150–300 mg/day in a single daily dose.

Contraindications :

None.

Main drug interactions :

Fluvoxamine is a strong CYP1A2 and 2C9/19 inhibitor, so doses of drugs metabolized by that cytochrome should be diminished.

Main side effects :

Nausea, anorgasmia, diminished libido.

Special points :

None.

Cost :

Low.

Citalopram :

In a 6-week placebo-controlled, double-blind trial, citalopram (mean dose 57.9 mg) has been shown to diminish BED symptoms [10]. Among completers, weight loss was greater with citalopram than with placebo (4.7 vs. 0.4 lbs weight gain, respectively).

Standard dosage :

Initial dosage is 20 mg/day; increased to 40 mg/day after 1 week. Doses above 40 mg/day are not typically used.

Contraindications :

None.

Main drug interactions :

As with other SSRIs, citalopram should be used with care in conjunction with triptans.

Main side effects :

Diminished libido, anorgasmia.

Special points :

Due to a recent FDA warning, doses above 40 mg/day are not typically used out of concern for interference with cardiac conduction and prolongation of the corrected QT interval (QTc).

Cost :

Low.

Sertraline

Sertraline (mean dose 187 mg) has been shown to be effective in the treatment of binge eating in a single 6-week double-blind, placebo-controlled, randomized study [11]. Reduction in body mass index (BMI) was greater in the sertraline group.

Standard dosage :

Initial dosage is 50 mg/day; dose is typically titrated to 100–200 mg/day in a single daily dose.

Contraindications :

Sertraline should be used with caution in individuals requiring triptans for migraine treatment.

Main drug interactions :

Sertraline is a modest inhibitor of CYP450 2D6.

Main side effects :

Diminished libido, anorgasmia, diarrhea, insomnia.

Special points :

Sertraline is more prone to causing diarrhea than other SSRIs.

Cost :

Low.

Topiramate

In three double-blind, placebo-controlled trials, topiramate was shown to be more effective than placebo in the treatment of BED [12, 13, 14••]. Durations varied from 14 to 21 weeks. Mean (or median) doses ranged from 208 to 300 mg per day. Additionally, topiramate conferred significantly more weight loss than placebo. Further, the first of these trials had an open-label extension for 12 months, which suggested that effects were maintained and that weight loss might progress after the first 6 months of treatment.

Standard dosage :

Initial dosage is 50 mg/day; titrate gradually over several weeks to 100–200 mg/day.

Contraindications :

Angle closure glaucoma, history of kidney stones.

Main drug interactions :

Co-administration with carbamazepine lowers topiramate levels by roughly 10 %. Co-administration with other carbonic anhydrase inhibitors (acetazolamide, zonisamide) increases risk for nephrolithiasis.

High-dose (>200 mg) topiramate treatment may diminish the effectiveness of oral contraceptives.

Main side effects :

Renal stones, sedation, memory loss/difficulties with word finding, paresthesias, change in taste.

Special points :

Problems recalling words or names are commonly encountered. The frequency of this side effect may be reduced by titrating gradually over a number of weeks.

Cost :

Low.

Zonisamide

One 16-week double-blind, placebo-controlled trial has shown that zonisamide (mean daily dose 436 mg) is effective in the treatment of BED [15]. Greater weight loss was observed in the zonisamide group (10.6 vs. 2.2 lbs).

Standard dosage :

200–600 mg/day in divided doses.

Contraindications :

Sensitivity to sulfonamides.

Main drug interactions :

CYP3A4 inhibitors may increase zonisamide serum concentrations. Co-administration with other carbonic anhydrase inhibitors (acetazolamide, topiramate) may increase nephrolithiasis risk.

Main side effects :

Sedation, dizziness, nausea, headache.

Special points :

As with topiramate, weight loss in this trial was somewhat more pronounced than in antidepressant trials.

Cost :

Low.

Lamotrigine

One 16-week placebo-controlled, double-blinded study suggests that lamotrigine (mean dose 236 mg) may diminish weight and improve metabolic parameters in BED [16]. However, response rates for binge eating did not, perhaps due to a high placebo response rate.

Standard dosage :

The initial dosage is 25 mg/day; increase as per rigorously standardized titration schedule to diminish risk of Stevens-Johnson syndrome to 100–200 mg/day in a single dose.

Contraindications :

History of Stevens-Johnson syndrome.

Main drug interactions :

The risk of Stevens-Johnson syndrome is increased in someone receiving other anticonvulsants, necessitating the use of a slower dose titration schedule.

Main side effects :

Sedation, Stevens-Johnson syndrome.

Special points :

Stevens-Johnson syndrome is a rare, serious side effect that can be associated with lamotrigine, but its frequency is diminished with careful adherence to the slow dose titration schedule for this drug.

Cost :

Low.

Acamprosate

Acamprosate (666 mg three times daily) was shown in one placebo-controlled, double-blind trial to be potentially useful in the treatment of BED [17•]. Binge day frequency and eating disorder cognitions were substantially better in acamprosate-treated patients than in those treated with placebo.

Standard dosage :

666 mg three times daily.

Contraindications :

Severe renal impairment.

Main drug interactions :

Naltrexone increased acamprosate levels.

Main side effects :

Diarrhea, flatulence, headache, fatigue.

Special points :

Acamprosate has been shown to be effective for reducing alcohol use in people with alcohol dependence.

Cost :

Medium.

Orlistat

Orlistat (120 mg three times daily), which blocks absorption of ingested fat in the bowel via inhibition of pancreatic lipase, was shown in one placebo-controlled, double-blinded study to produce greater weight loss than placebo in the treatment of BED, but it did not result in a greater decrease in binge eating [18]. In a second study using orlistat or placebo plus guided self-help, orlistat was associated with greater reduction in binge eating at the end of treatment but not at longer-term (3-month) follow-up [19].

Standard dosage :

120 mg three times daily.

Contraindications :

Co-administration with cyclosporine.

Main drug interactions :

Orlistat can diminish absorption of cyclosporine and warfarin.

Main side effects :

Oily stools, malabsorption symptoms, diarrhea, flatus.

Special points :

Orlistat is available in a lower dose over the counter (60 mg), but this dose has not been studied in BED.

Cost :

Low.

Escitalopram

Escitalopram (mean dose 26.5 mg per day) was examined in one double-blind, placebo-controlled trial for BED [20]. In this trial, escitalopram was not more effective than placebo in reducing specific binge eating symptoms, but greater weight loss and greater diminishment in overall severity of illness was seen with the active drug.

Standard dosage :

20–40 mg per day.

Contraindications :

Concurrent use of monoamine oxidase inhibitors.

Main drug interactions :

Risk of serotonin with triptans.

Main side effects :

Diminished libido, anorgasmia, insomnia, sedation, headache, nausea.

Special points :

Escitalopram is the stereoisomer of citalopram.

Cost :

Low.

Atomoxetine

In one 10-week, randomized, double-blind, placebo-controlled trial, atomoxetine (mean dose 106 mg per day) was shown to be effective in reducing binge eating frequency, weight, and overall severity of illness and eating disorder cognitions as compared with placebo [21].

Standard dosage :

40–120 mg per day.

Contraindications :

Narrow-angle glaucoma, pheochromocytoma.

Main drug interactions :

Atomoxetine metabolism is inhibited by potent CYP2D6 inhibitors.

Main side effects :

Nausea, low appetite, tiredness, constipation, dry mouth.

Special points :

Atomoxetine has been FDA approved for the treatment of attention-deficit hyperactivity disorder.

Cost :

Moderate.

Duloxetine

Duloxetine (mean dose 78.7 mg per day) was examined in a 12-week, double-blind, placebo-controlled trial for treatment of BED along with comorbid major depressive disorder [22•]. In this trial, duloxetine had greater impact on frequency of binge eating and overall severity of illness ratings. However, differences were not seen in either BMI, depression, or anxiety.

Standard dosage :

60–120 mg per day.

Contraindications :

Narrow-angle glaucoma.

Main drug interactions :

CYP2D6 inhibitors raise serum duloxetine levels.

Main side effects :

Nausea (minimized by slow titration), sexual side effects, withdrawal syndrome.

Special points :

Duloxetine has been shown to be useful in treating some pain conditions.

Cost :

Moderate.

Pediatric considerations

Little, if any, work has directly addressed treatment interventions for BED in the pediatric population. This is perhaps because BED is most often encountered in the clinical setting well beyond adolescence, even though it typically begins in that time frame.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

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Conflict of Interest

Scott Crow has received grants from Shire for a BED study.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

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Correspondence to Scott Crow MD.

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Crow, S. Treatment of Binge Eating Disorder. Curr Treat Options Psych 1, 307–314 (2014). https://doi.org/10.1007/s40501-014-0023-4

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Keywords

  • Binge eating disorder
  • Binge eating
  • Eating disorder
  • Obesity
  • Anti-depressants
  • Weight loss
  • Cognitive behavioral therapy
  • Behavioral weight loss