Medication for Treating Eating Disorders

The Psychiatrist's Role And Medication

continued

Binge Eating Disorder (BED) and Medication

As has been previously stated, the research on BED (including drug studies) is minimal but growing. However, several investigators believe that binge eating is less a matter of willpower than brain chemistry. In some cases, clinicians and researchers are using SSRIs with binge eating disorder for the same reasons they use it for bulimia. Serotonin helps us feel full, so it is theorized that people with binge eating disorders like bulimia nervosa may want to eat all the time because they have too little of the neurotransmitter serotonin and thus never feel satisfied (satiated).

Guidelines for When to Use Medications

• After nutritional rehabilitation has begun

• After full patient history and medical evaluation are complete

• After full family history and evaluation

• After review of valid, reliable, published data-based trials

• After psychoeducation and initiation of psychotherapy

• When medication-responsive coexisting conditions are clearly identified, particularly when they predate the onset of the eating disorder

Psychotropic Medications Commonly Used in Eating Disorders

Antidepressants

Selective Serotonin Reuptake Inhibitors (SSRIs): Used for obsessive-compulsive behaviors, depression, and anxiety disorders like panic, social phobia, and post-traumatic stress disorder. Have been shown to decrease binge/purge behavior when used in higher doses (e.g., 60 mg Prozac). May diminish obsessive, rigid thinking and ritualistic behavior traits. Fluoxetine (Prozac) trials have shown that administering the drug after weight restoration in anorexia nervosa may prevent relapse. Low risk of suicidal overdoses with these medications.

Cautions: These medications may not be used in pregnancy, particularly first trimester, unless absolutely necessary. This class of medications is not addicting, but there may be side effects with abrupt withdrawal of Paxil, Zoloft, and Luvox. A gradual tapering off is recommended. Drug interactions do occur. It is important for the prescribing doctor to know about all drugs being taken, including over-the-counter drugs and herbs or homeopathics. Monoamine oxidase inhibitors (MAOIs) cannot be used within two weeks of beginning to take SSRIs. MAOIs cannot be started until five to eight weeks after discontinuation of Prozac.

Most common side effects: anxiety, nervousness, insomnia, agitation, gastric irritation, fatigue, drowsiness, sweating, tremor, anorexia (loss of appetite), diarrhea, dizziness, lightheadedness, sexual dysfunction, decreased libido.

Examples of general dosing:

Prozac (fluoxetine) 10–80 mg a day
Zoloft (sertraline) 25–200 mg a day
Paxil (paroxetine) 10–50 mg a day
Luvox (fluvoxamine) 50–300 mg a day
Celexa (citalopram) 10–60 mg a day

Norepinephrine-Dopamine Reuptake Inhibitor (NDRI): Wellbutrin (Bupropion). According to the Food and Drug Administration (FDA), this medication should not be used in patients with active eating disorders because of the higher risk of seizures.

Serotonin-Norepinephrine Reuptake Inhibitor (SNRI): This new antidepressant has not yet been studied in eating disorders, but theoretically it should be helpful. This medication is used for depression and anxiety disorders, including generalized anxiety disorders. Weight gain or loss may occur, with corresponding alteration in appetite.

There is no clear advantage over SSRIs in terms of side effects. It may have a more stimulating effect and has been known to cause nausea. Overall, however, this drug does tend to have fewer side effects than the tricyclics. There is a lower suicide potential for overdose with this drug than there is with tricyclics, but the potential may be higher than that with SSRIs.

Most common side effects: Nausea and increased blood pressure (hypertension).

Examples of general dosing:

Effexor (Venlafaxine) 37.5 mg two times a day to 300 mg total (given in two doses) a day

Serotonin Antagonist Reuptake Inhibitors (SARIs): This is another new class of antidepressant not yet studied in eating disorders but used in depression and anxiety disorders. Compared to the SSRIs, the SARIs have the advantage of not causing or increasing anxiety, insomnia, or sexual dysfunction.

Most common side effects: Sedation and nausea.

Example of general dosing:

Serzone (Nefazodone) 100–600 mg a day

Tricyclics: Reduce depression and panic attacks and may diminish bingeing and purging behaviors. Generally cause increased appetite and weight gain. Generally cause more sedation than SSRIs. Much lower threshold for successful suicide, as they signif- icantly affect heart function in higher doses; commonly used in overdose attempts. Rapidly absorbed from the stomach. Have more side effects than SSRIs. Certain medications may increase blood levels without an actual increase in dose. This may place the person taking the medication at increased risk for side effects or inadvertent overdose. Can see side effects with abrupt discontinuation. Tapering is recommended, just as with SSRIs. Don't use with MAOIs. Thera-peutic blood levels can be beneficial.

Common side effects: Constipation, blurry vision, urinary hesitancy, possible affect on cardiac function, weight gain, increased appetite, possible decrease in libido.

Examples of general dosing:

Desipramine 100–300 mg a day
Imipramine 100–300 mg a day
Notriptyline 50–150 mg a day

Mood Stabilizers

Used primarily for mood stabilization in bipolar (manic-depressive) disorder or mood swings. May help stabilize mood instability in persons with borderline personality organization and various disorders of brain function. Can sometimes be used as augmentors in individuals who are not responding to antidepressants.

Depakote/valproic acid derivatives: Primary use is as anticonvulsant. May cause liver failure as more severe side effect. Can be fatal. General dosage range 500–2,000 mg. Causes less weight gain than lithium, but more than Tegretol. Blood serum levels must be checked. Gastrointestinal side effects may occur. Toxic levels can be fatal.

Carbamazepine (Tegretol): Anticonvulsant and mood stabilizer. Worse side effect aplastic anemia. Can be fatal, but rare (1 in 50,000). Gastrointestinal side effects do occur. Blood levels must be checked. Causes less weight gain than lithium and Depakote. Toxic levels can be fatal. Dose range 200–2,000 mg.

Lithium salt: May cause weight gain, acne, retention of water, hypothyroidism, excessive secretion of urine, excessive thirst. Replacement of water loss is essential, or toxicity will occur. Toxic levels will kill and are more likely with decreased potassium. Patients generally will not use if aware of risk of weight gain. Dose range 600–3,000 mg in eating disordered clients. Probably should be avoided in eating disorders due to lithium toxicity associated with low potassium and dehydration.

Lamictal (lamotragine): A newer anticonvulsant showing promise as a mood stabilizer. No blood levels necessary.

Antianxiety Medications

Generally benign in regard to side effects, but have significant effects in overdose. Most important concern is addiction potential. Short-term use is acceptable and long-term use sometimes necessary in severe anxiety disorders not responsive to SSRIs. In order of most to least addicting: Ativan, Klonopin (most commonly used for long-term treatment).

Examples of general dosing:

Ativan 009;.5–2.0 mg two to four times per day Klonopin .25–1.0 mg two to four times per day

Buspirone (Buspar): A new nonaddictive antianxiety drug that works differently than the benzodiazepines (e.g., Xanax, Valium). Used in generalized anxiety and as an adjunct to antidepressants for refractory depression and obsessive-compulsive disorder.

This chapter has been devoted mainly to the use of psychotropic medications. Eating disordered individuals have coexisting medical conditions and symptoms that also benefit from medication.

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The use of other types of medication in the treatment of eating disorders is certainly indicated for various medical complications that arise, but proper precautions must be taken. For example, prescribing hormone replacement therapy for an anorexic who has stopped menstruating may be a viable choice, with the precaution that there is no proof that the medication will prevent osteoporosis and taking it might even foster a false sense of security by masking the return of normal menstrual function.

Another example would be prescribing laxatives for a bulimic complaining of constipation. On the one hand, this might be contraindicated, but with another individual it may be necessary, particularly if the person has become laxative dependent and requires a slow and gradual weaning. The following chapter discusses these and other topics in the medical management of eating disorders, particularly anorexia and bulimia.

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By Carolyn Costin, MA, M.Ed., MFCC - Medical Reference from "The Eating Disorders Sourcebook"

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