Treatment

The vast majority of patients can be managed as outpatients.

In patients with bulimia nervosa, psychological treatment and antidepressants do not differ in remission rates, but dropout rates are lower with psychological treatment. A combination of antidepressants and psychological treatment is the best for increasing remission (1).

NICE suggests:

• psychological interventions for bulimia nervosa
  • as a possible first step, patients with bulimia nervosa should be encouraged to follow an evidence-based self-help programme
    • healthcare professionals should consider providing direct encouragement and support to patients undertaking an evidence-based self-help programme as this may improve outcomes. This may be sufficient treatment for a limited subset of patients
  • bulimia-nervosa-focused guided self-help should be considered for adults with bulimia nervosa (2):
    • bulimia-nervosa-focused guided self-help programmes for adults with bulimia nervosa should: use cognitive behavioural self-help materials for eating disorders supplement the self-help programme with brief supportive sessions (for example 4 to 9 sessions lasting 20 minutes each over 16 weeks, running weekly at first)
    • if bulimia-nervosa-focused guided self-help is unacceptable, contraindicated, or ineffective after 4 weeks of treatment, consider individual eating-disorder focused cognitive behavioural therapy (CBT-ED)
    • explain to all people with bulimia nervosa that psychological treatments have a limited effect on body weight (2)
      
• pharmacological interventions for bulimia nervosa
  • do not offer medication as the sole treatment for binge eating disorder (2)
  • the NICE committee (2) highlighted that there are risks associated with prescribing medication to people with bulimia nervosa and a comorbidity because of potential physical problems
    • depending on the severity and duration of the eating disorder, they may also have cardiovascular and renal problems, gastrointestinal disturbance, fluid and electrolyte abnormalities and dental abnormalities. For this reason, the committee wanted to emphasise that caution should be exercised when prescribing or discontinuing antidepressants such as SSRIs
    • antidepressant drugs can reduce the frequency of binge eating and purging, but the long-term effects are unknown. Any beneficial effects will be rapidly apparent. However prescription of an antidepressant must be only part of a multifaceted management strategy; and also should only be employed with consideration of cautions detailed above
      • selective serotonin reuptake inhibitors (SSRIs) (specifically fluoxetine) are the drugs of first choice for the treatment of bulimia nervosa in terms of acceptability, tolerability and reduction of symptoms (2,3)
        • adults and the elderly: A dose of 60 mg/day is recommended. Long-term efficacy (more than 3 months) has not been demonstrated in bulimia nervosa (3)
• management of physical aspects of bulimia nervosa
  • patients with bulimia nervosa who are vomiting frequently or taking large quantities of laxatives (especially if they are also underweight) should have their fluid and electrolyte balance assessed
  • when electrolyte disturbance is detected, it is usually sufficient to focus on eliminating the behaviour responsible. In the small proportion of cases where supplementation is required to restore electrolyte balance, oral rather than intravenous administration is recommended, unless there are problems with gastrointestinal absorption

If the patient is vomiting, advise the individual to use a non-acid mouthwash and to avoid brushing the teeth after vomiting. Reducing acidic food intake may help lower the acidity of the oral environment. Advise the patients to gradually reduce laxative abuse if present. Educate them that laxatives do not significantly reduce calorie absorption (2).

Notes (2):

• medication risk management
  • when prescribing medication for people with an eating disorder and comorbid mental or physical health conditions, take into account the impact malnutrition and compensatory behaviours can have on medication effectiveness and the risk of side effects
  • when prescribing for people with an eating disorder and a comorbidity, assess how the eating disorder will affect medication adherence (for example, for medication that can affect body weight)
  • when prescribing for people with an eating disorder, take into account the risks of medication that can compromise physical health due to pre-existing medical complications
  • offer ECG monitoring for people with an eating disorder who are taking medication that could compromise cardiac functioning (including medication that could cause electrolyte imbalance, bradycardia below 40 beats per minute, hypokalaemia, or a prolonged QT interval)
    
• Physical health assessment and monitoring for all eating disorders
  • assess fluid and electrolyte balance in people with an eating disorder who are believed to be engaging in compensatory behaviours, such as vomiting, taking laxatives or diuretics, or water loading
    • assess whether ECG monitoring is needed in people with an eating disorder, based on the following risk factors:
    • rapid weight loss
    • excessive exercise
    • severe purging behaviours, such as laxative or diuretic use or vomiting
    • bradycardia
    • hypotension
    • excessive caffeine (including from energy drinks)
    • prescribed or non-prescribed medications
    • muscular weakness
    • electrolyte imbalance
    • previous abnormal heart rhythm.

Reference:

1. Baccaltchuk J et al (2001). Antidepressants versus psychological treatments and their combination for bulimia nervosa. Cochrane Database Syst Rev, CD003385 (latest version 13 Aug 2001
2. NICE (May 2017). Eating disorders: recognition and treatment
3. EMC. SPC - fluoxetine (Accessed 01/10/23)