Because of the dearth of FDA –approved medications for eating disorders, psychotherapy has gradually become the treatment of choice. Nonetheless, clinical trials of off-label uses of various medications have yielded a few impressive results, particularly for bulimia and binge eating disorder. Here’s a quick run down of various meds that may be worth a try.

Anorexia Nervosa (AN)

Antidepressants. Both amitriptyline and fluoxetine have been studied in double-blind placebo-controlled trials, and neither has been shown to be more effective than placebo for either weight gain or weight maintenance. Nonetheless, fluoxetine did decrease both depression and anxiety in anorectic patients in one study (Kaye et al., Biol Psych 2001; 49:644-52). In a different study, amitriptyline was found ineffective for depressive symptoms in patients with AN (Biederman et al., J Clin Psychopharm 1985; 5:10-16).

Cyproheptadine (Periactin). Cyproheptadine is a potent histamine & serotonin antagonist. Most often used to treat migraines, it has been shown to be an effective appetite stimulant in cystic fibrosis (Homnick et al., Ped Pulm 2004; 38(2):129-34). In a double-blind study of 81 anorectic females, a subgroup of patients (those who had experienced complications at birth) gained approximately 5 kg on cyproheptadine vs. less than 2 kg on placebo (Goldberg et al., Brit J Psych 1979, 134: 67-70). In another double-blind study of 72 patients, cypropheptadine significantly reduced the number of days to reach normal weight in anorectic patients when compared to amitriptyline or placebo (Halmi et al.,
Arch Gen Psych 1986; 43(2): 177-81). Because of its relatively safe side-effect profile, cyproheptadine dosed at 2 mg QID and titrated up to 10 mg QID (max 40 mg daily – as per Halmi et al’s protocol), seems a reasonable option during the
weight-restoration phase of treatment.

Olanzapine (Zyprexa). In an attempt to use olanzapine’s weight gain side effect to clinical advantage, researchers funded by Eli Lilly randomly assigned 34 anorectic patients to either olanzapine (final mean dose, 6.6 mg/day) or placebo. Both groups reached their target weight by the end of the study period, although the olanzapine group got there sooner (8 weeks vs. 10 weeks). Both groups improved similarly on depression and anxiety scales, but olanzapine was more effective than placebo for obsessive symptoms. Unfortunately, because of an enormous overall dropout rate (only 14 of the original 34 remained in the study at the 10 week end point), it is hard to draw clear conclusions from the results (Bissada et al., Am J Psychiatry 2008;165: 1281-1288).

Bulimia Nervosa (BN) / Binge Eating Disorder (BED)

SSRIs. Fluoxetine (Prozac) is the only FDA-approved SSRI for bulimia; few other SSRIs have been studied for this indication. While two small placebo-controlled studies have endorsed the effectiveness of fluvoxamine (Luvox) 200 mg/day for BN (Milano et al., Adv Ther 2005; 22:278-83; Fichter et al., J Clin Psychopharm 1996; 16: 9-18), a large double-blind study of 267 patients found fluvoxamine up to 300mg/day to be no better than placebo (Schmidt et al., J Clini Psychopharm 2004; 24: 549-552). Most SSRIs appear effective for binge eating disorder (BED), including fluoxetine at 40-80 mg/day (Arnold et al., J Clin Psych 2002; 63: 1028-1033), fluvoxamine at 260 mg/day (Hudson et al., Am J Psychiatry 1998; 155: 1756-62), citalopram at 60 mg/day (McElroy et al., J Clin Psych 2003; 64: 807-813), and sertraline at 100-200 mg/day (Leombruni et al., Hum Psychopharm 2006; 21: 181-188). Of note, escitalopram (Lexapro) at 26.5 mg/day was the only SSRI that was not associated with reduced binge-eating episodes when compared to placebo, though a statistically significant weight loss of 1 kg (vs. wt gain of 0.5 kg on placebo) was noted (Guerdjikova et al., Hum Psychopharm 2008; 23: 1-11).

Tricyclics. Imipramine (Pope et al., Am J Psych 1983; 140: 554-558) & desipramine (Barlow et al., Can J Psych 1988; 33:129-133) have both been shown to be effective for BN, at average doses of 150-200 mg/day. However, one study of 32 women found no superiority of amitriptyline (150 mg/day) over placebo (Mitchell et al., J Clin Psychopharm 1984;4:186-193).

Topiramate (Topamax). Several placebo-controlled trials have endorsed the effectiveness of topiramate 250-300 mg/day for both BN and BED. The most common side effects were parasthesias, taste perversion, and difficulty with concentration/attention (Nickel et al., Int J Eat Disord 2005; 38: 295-300; McElroy et al., Biol Psych 2007; 61: 1039 - 48)

Naltrexone (Revia). Naltrexone, an opiate antagonist used to treat alcoholism, may also be effective for BN, though the evidence is mixed. One double-blind, placebo-controlled cross-over trial reported that it reduced binge-purge episodes for 18 of 19 outpatients (Marrazzi et al., Int Clin Psychopharm 1995; 10: 163-172), but a similarly designed study of 16 bulimic women showed no clinically significant improvement (Mitchel et al., J Clin Psychopharm 1989; 9: 94-97). A single study of naltrexone for BED found no advantage over placebo (Alger et al., Am J Clin Nutr 1991; 53: 865-71).

Sibutramine (Meridia). Sibutramine, an FDA-approved weight loss agent, appears to be effective for the treatment of BED. In a recent study (Wilfley et al., Am J Psych 2008; 165: 51-58), 304 patients with BED were randomized to sibutramine 15 mg/day or placebo. At 24 weeks, patients on active treatment had a greater reduction in binge eating (2.7 fewer episodes per week vs. 2.0 fewer on placebo) and greater weight loss (4.3 kg vs. 0.8 kg on placebo) than patients on placebo.