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BULIMIA NERVOSA
Self-Conscious Socialite. . . . . . . . . . . . . . . . . . . . . . . . . . Level I
Laura F. Ruekert, PharmD, BCPP, CGP
CASE SUMMARY
A 21-year-old woman is being admitted to an acute care behavioral
health hospital needing management for a new diagnosis of bulimia
and depression with symptoms started 6 months ago after she was
cut from her college dance team. She meets DSM-5 criteria for severe
bulimia nervosa and presents with signs including mild parotid
gland enlargement, Russell’s sign, and QTc prolongation. QTc prolongation could be a result of current drug therapy (ziprasidone) or
from the bulimia; however, because ziprasidone must be taken with
food to ensure proper absorption in addition to the boxed warning concerning QTc prolongation, a change in therapy is justified.
Other drug therapy problems include questionable absorption due
to purging and current bupropion therapy in the setting of an eating
disorder. Achieving goals of therapy necessitates focusing on psychiatric comorbidities as well as the bulimic behaviors; therefore,
substance misuse and bipolar depression must be addressed. In
addition, addressing the bulimia, depression, and substance misuse
as well as providing dialectical behavioral therapy could initially
be adequate treatment to prevent further self-injurious behaviors.
Fluoxetine is an FDA-approved drug for bulimia nervosa which
may also provide coverage for bipolar depression symptoms. It is
appropriate to consider patient’s bipolar diagnosis and monitor
her mood while changing therapies. An FDA-approved drug for
acute bipolar depression, such as quetiapine or lurasidone, could be
considered as an alternative to ziprasidone for mood stabilization.
Purging implications include potentially insufficient absorption of
medications, an increased risk for electrolyte abnormalities, and
dehydration. Long-term consequences of repeated, untreated eating disorders are not only costly to manage, but they can also be
life-threatening. The reader is asked to consider appropriate pharmacologic and nonpharmacologic approaches to the management
of bulimia nervosa in a patient with psychiatric comorbidities of
depression associated with bipolar disorder, type II, and substance
misuse, taking into consideration the self-mutilating behaviors.
QUESTIONS
Problem Identification
1.a. Create a list of the patient’s drug therapy problems.
• Bulimia Nervosa (severe): The patient has been bingeing on
large quantities of food in a discrete period of time (usually
<2 hours) with subsequent purging. BN is characterized by
compulsive overeating, usually followed by some type of compensatory method of purging, and is often accompanied by
guilt and depression. This patient uses compensatory methods
of self-induced vomiting and laxatives; however, other methods
may include using diuretics, using other medications, fasting,
and excessive exercise. For diagnosis, binge eating and purging
must both occur at least once a week for 3 months and include
• Bipolar Depression: HAM-D score of 20 indicates severe
depression, not controlled on current therapy of bupropion,
escitalopram, and ziprasidone. Escitalopram has been used
for an adequate duration at the maximum dose. Fluoxetine,
an FDA-approved drug for bulimia, could be an alternative to
escitalopram. It would be prudent to evaluate ziprasidone use
in patients with eating disorders, because it needs to be taken
with a meal of about 500 calories for proper absorption. In
this case, the patient also has a prolonged QTc interval and
alternative therapy should be explored. Bupropion should
not be taken by people with eating disorders due to the dosedependent risk of seizures.
• Substance use disorder: High rates of impulsivity and
obsessive-compulsiveness are found in people with eating
disorders.2 People with eating disorders may also impulsively
use or misuse substances. This patient uses tobacco, laxatives,
alcohol, and cannabis. She notes a strong desire to use
these substances regardless of consequences. She has recently
dropped out of school and isolates herself. Substance use can
also contribute to her depression becoming worse over time
and negate the therapeutic effects of her medication regimen.
• Self-injurious behavior: Patient presents with superficial scars
and cuts. Self-injurious behavior is an inappropriate coping
mechanism that may be associated with the patient’s history of
showing cluster B personality disorder traits and is exacerbated
by her untreated eating disorder and/or current depression.
While there are data to show naltrexone might be useful in
decreasing the patient’s urges to cut herself, initial treatment
in this case will focus on pharmacotherapy for controlling
comorbid psychiatric disease states with the intent that the
self-injurious behavior would improve. Nonpharmacotherapy
should also target this behavior by providing insight and
teaching appropriate coping skills. Naltrexone, or necessity for
other pharmacotherapy, could be reassessed periodically prior
to discharging from the acute care hospital.
1.b. What signs, symptoms, and laboratory values indicate the
severity of the BN, any secondary complications from BN,
and depression?
• BN:
✓Parotid gland enlargement
✓Russell’s sign on right hand
✓Slightly distended abdomen
Copyright © 2017 by McGraw-Hill Education. All rights reserved.
Bulimia Nervosa
Cheen T. Lum, BSc, PharmD, BCPP
CHAPTER 74
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self-evaluation unduly influenced by body shape and weight.
This patient is considered severe with an average of about
eight episodes per week using compensatory behaviors (mild
1–3 episodes, moderate 4–7 episodes, and extreme 14 or more
episodes per week).1 The 12-month prevalence among young
females is 1–1.5%.1 The peak onset typically ranges from 13 to
20 years of age. Females are disproportionately affected by the
disorder (male:female ratio is 1:10). Thirty to seventy percent
of patients with BN also are noted to suffer from comorbid
substance abuse. Certain occupations which place an emphasis
on body image, such as dance, may be a predisposing risk factor
(in combination with other social, environmental, and genetic
factors) for eating disorders. Other psychiatric disorders, such
as kleptomania and depression (~80%), are also common
comorbidities. Unlike anorexia nervosa (AN), patients with
BN may often be within a normal weight range. Similar to AN,
patients with BN often fear gaining weight and are unhappy
with their body self-image. Behaviors associated with BN are
often performed privately, because patients affected by the disorder are ashamed of or disgusted with their actions.
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✓Course, brittle hair
SECTION 7
✓Hypotension, bradycardia, and QTc interval prolongation
✓Other symptoms can include bloating, fullness, lethargy,
GERD, abdominal pain; sore throat, dental enamel erosion; hypochloremia, hypokalemia, or metabolic acidosis;
increased salivary amylase; and low voltage EKG/prolonged
QTc interval, cardiomegaly.
• Complications secondary to BN:
Psychiatric Disorders
✓With the exception of a prolonged QTc interval, there are
no serious complications secondary to BN noted in this
patient. Examples of such medical complications include
cardiac complications (decreased cardiac output, arrhythmia), metabolic complications (alkalosis, acidosis), electrolyte abnormalities (hypokalemia, hypomagnesemia, and
hypocalcemia), hormonal changes, brain atrophy, dental
complications, gastrointestinal complications (parotid gland
enlargement, gastric dilation, gastric rupture, and esophagitis), osteoporosis, seizures, coma, and death.
• Bipolar Depression:
✓Patient reports the medication is not effective. Also, medication absorption is questionable due to purging.
✓History of depression associated with type II bipolar disorder: Patient also currently reports feelings of hopelessness,
frustration, fatigue, and low energy. She was tearful upon
admission and expressed suicidal ideations with a plan.
Lifestyle changes have included isolation and dropping out
of school.
✓The HAM-D score indicates her symptoms are severe.
✓Contributive family history.
✓ Patient currently has substance use issues which may exacerbate depression and/or destabilize her mood.
• Substance use disorder:
✓ Patient reported a social history of tobacco use (1PPD), laxative misuse, cannabis use daily, and binge drinking alcohol.
Patient’s UDS was positive for THC.
Desired Outcome
2.What are the goals of therapy for this patient?
• Provide a comprehensive management approach for the
patient by employing a multidisciplinary team of dietitians,
physicians, and psychiatrists as well as family involvement and
support.
✓Improve distorted self-image and restore healthy body
image. (Note: Weight restoration is usually not a goal for
bulimic patients. Healthy body weight is considered to be
within 90% ideal body weight.)
• Establish normal eating patterns and nonbinge meals.
• Improve associated psychological and physical outcomes.
• Cease compensatory behavior associated with binging.
• Improve symptoms of bipolar depression and promote adherence to medication regimen.
• Provide appropriate referrals, programs, and other nonpharmacologic interventions for substance use disorder.
Therapeutic Alternatives
3.a. What nonpharmacologic treatment strategies would be beneficial for this patient?
• It is important to note that multidisciplinary, nonpharmacologic treatment strategies are essential to support resolution of
Copyright © 2017 by McGraw-Hill Education. All rights reserved.
eating disorders. Cognitive behavioral therapy is recommended
as the most effective and best studied intervention in bulimia.1
Various psychotherapy techniques (provided as either group
or individualized sessions), healthy eating behaviors, and positive self-image have shown some beneficial results in BN/AN
patients and are recommended. Therapies using workbooks,
online modules, planned visits, telemedicine, e-mails, and
family-based treatments used in various combinations may
help enhance outcomes.3 Counseling should also address
substance-use issues and self-injurious behaviors.
3.b. What pharmacologic treatment strategies are available for
the treatment of BN/AN?
• Antidepressants: The rationale to treat BN with antidepressants includes evidence of dysfunction in the serotonergic
and noradrenergic systems as well as the comorbidity of and
psychopathological overlap with anxiety disorders, substance
abuse/misuse, obsessive compulsive spectrum disorders, and
depression.4
• Selective serotonin reuptake inhibitors (SSRIs), in general, have
the most supportive evidence for use in eating disorders.3
SSRIs have not proven to be helpful with weight restoration
during inpatient management of patients with AN; however,
beneficial effects on concomitant psychiatric conditions are
possible. SSRIs have demonstrated efficacy as one component
of the initial treatment program for most patients with BN.3
Fluoxetine, specifically, is FDA-approved for the treatment of
BN and does not carry an indication in the treatment of AN.
Fluoxetine showed efficacy over placebo in providing beneficial
effects and bulimic symptom reduction in several randomized,
controlled trials (RCTs) and has efficacy data for decreasing
depressive and anxious feelings, reducing binge-eating and
purging behavior, reducing chance of relapse, and improving
eating attitudes/habits.4 The target dose is 60 mg. To ensure
tolerability of the drug, starting at the lower end of the dosing range would be appropriate, and then the drug could be
titrated until the desired response is achieved. In addition to
fluoxetine, other SSRIs, such as citalopram, fluvoxamine, and
sertraline, have been studied in the treatment of BN. While
one RCT showed no clear efficacy of citalopram over placebo
for BN, other data from open trials suggest improvement
for symptoms such as impulsivity and depression.4,5 Fluvoxamine has demonstrated efficacy over placebo against bulimic
behavior in two out of three RCTs.4 Sertraline was shown to
be superior to placebo in the treatment of bulimic behavior
(specifically a reduction on bingeing) in one RCT, and two
smaller trials found a significant reduction in the number of
binges and purges per week.4,5
• Bupropion has demonstrated efficacy over placebo in reducing BN associated psychopathology and behavior in one RCT.
However, bupropion use should be avoided in patients with
eating disorders due to an increased risk of seizures.5
• Tricyclic antidepressants (TCAs)—imipramine, desipramine,
and amitriptyline—have been studied for mood, but none
are approved for use in eating disorders. There are four RCTs
for imipramine in reducing bulimic behavior, six RCTs for
desipramine with efficacy in reducing bulimic behavior, and
one RCT for amitriptyline, which showed no clear evidence
over placebo for BN; however, a subgroup with depression did
show a significant benefit compared to placebo.4 TCAs should
be used with caution in dehydrated, malnourished patients
due to higher risk of cardiac side effects. TCAs should also be
used cautiously, especially in underweight patients due to the
lethal consequences associated with accidental or intentional
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✓Bisphosphonate therapy would additionally present significant cost burden to the patient.
• Other antidepressant: Double-blind controlled studies are
needed to confirm the usefulness of other antidepressants such
as SNRIs and mirtazapine. Trazodone was significantly superior to placebo in reducing frequency of binging and purging
in one RCT.5
• Nutrition (usually reserved for AN; the malnourished or
underweight)
• Antipsychotics: Atypical antipsychotics have limited and conflicting evidence for treating BN/AN. Their mechanism may
decrease obsessive thinking and any delusional component
associated with denial3 or a distorted body image. Their place
in therapy may be more beneficial when treating comorbidities.
• Miscellaneous agents:
✓Topiramate (dose range of 25–400 mg) showed efficacy in
two RCTs in reducing BN associated psychopathology and
behavior with grade A evidence and a moderate risk-benefit
ratio.4,5 A reduction in the frequency of binge/purging and
improvement in quality of life were also noted by one
author.5
✓Naltrexone has inconsistent evidence supporting its use in
BN.4
✓Metoclopramide 10 mg 30 minutes prior to each meal may
be helpful if GI transit is prolonged; it may relieve bloating
and abdominal pain.
✓Ondansetron displayed efficacy over placebo in one trial for
reducing BN-associated behavior, but use should be cautioned due to potentially serious side effects.4
✓Carbamazepine may have benefit for patients with BN and
comorbid bipolar disorder. Two cases exploring oxcarbazepine use in patients with BN and comorbid self-mutilating
behaviors showed the self-mutilating behaviors disappeared,
but not purging.5
• Vitamin supplementation:
✓Calcium and vitamin D supplementation may be beneficial
in patients with eating disorders.3 Doses of calcium 1500 mg
daily (and vitamin D 400 IU daily) have been suggested
in patients who might be unwilling to consume dairy
products.6
✓A daily multivitamin can be administered to patients with
eating disorders.
• Hormone therapy: Hormone therapy has not proven to be beneficial in improving bone mineral density (BMD) in patients
with eating disorders (particularly AN).3,7 Estrogen therapy
may be considered in patients with signs of estrogen deficiency
such as breast atrophy and dry skin. Combination estrogen
and progestogen therapy for AN patients with amenorrhea
may be considered.3,7
• Bisphosphonates:
✓Bisphosphonates do not have a standard role in the management of bone loss associated with eating disorders, and more
studies need to be conducted to help assess benefit-to-harm
ratio.3,7
✓Careful monitoring is essential during caloric supplementation to minimize risk of refeeding syndrome.
✓Inpatient weight gain should average approximately 0.9–
1.4 kg (2–3 lbs) weekly. Outpatient goal is 0.2–0.5 kg
(0.5–1 lb) per week.3
✓No specific nutritional regimen has been proven to be superior in the refeeding of AN patients. Parenteral nutrition and
nasogastric feeding should only be implemented in rare or
severe cases.3
Optimal Plan
4.a. What drug, dosage form, route, schedule, and duration of
therapy are best for comprehensive management of this
patient?
• Discontinue escitalopram, bupropion, and ziprasidone.
• A daily multivitamin would support maintenance of proper
nutrition in this patient.
• Fluoxetine 20 mg by mouth daily should be initiated to help
maintain a healthy weight and improve symptoms of depression and titrated to the target dose of 60 mg or as tolerated.
• Quetiapine extended release 300 mg nightly, titrated until
response range 400–800 mg daily, may be used as an alternative for ziprasidone for bipolar disorder.
4.b.What pharmacologic alternatives would be appropriate if
initial treatment interventions fail or are insufficient to
achieve desired outcomes?
• If there is no response after the fluoxetine dose is maximized, a different antidepressant should be initiated. SSRIs,
SNRIs, TCAs, and MAOIs have all been studied; however,
guidelines indicate a trial of a different SSRI is preferred due
to tolerability issues. Dosing could remain consistent with
antidepressant doses. There is a growing body of evidence for
topiramate, and it may be considered as an off-label option. In
addition, if the patient has extreme anxiety related to eating,
a benzodiazepine, such as lorazepam, could be initiated prior
to mealtime. Additional monitoring should be implemented
(and may include urine toxicology monitoring, random pill
counts, limiting supply, and observing for signs of misuse) if
using benzodiazepines in this patient case, due to the history
of substance misuse issues.
Outcome Evaluation
5.What clinical and laboratory parameters are necessary to
evaluate the therapy for achievement of the desired therapeutic
outcome and to detect or prevent adverse effects?
• Perform physical examination and assess appearance, nutritional status (including I/Os), and vitals daily.
• Monitor for drug adverse events including, but not limited to,
allergic reaction, extreme changes in mood, changes in sleep,
dizziness, nausea, vomiting diarrhea, signs or symptoms of
serotonin syndrome, and extrapyramidal side effects daily
while inpatient.
Copyright © 2017 by McGraw-Hill Education. All rights reserved.
Bulimia Nervosa
• Anxiolytics: Benzodiazepines have been used to reduce anticipatory anxiety associated with eating and around mealtimes;
however, there is insufficient supportive evidence to recommend their routine use for patients with eating disorders. In
addition, considerations should be given to the high rate of
comorbid substance use/misuse associated with eating disorder
diagnoses, and the risks of addiction and abuse associated with
benzodiazepines. Benzodiazepines would not be appropriate
for this patient at this time due to substance use issues.
✓ Oral refeeding of about 1000–1500 kcal per day (20–25 kcal/kg
of body weight) should be started initially for patients who
are malnourished (typically AN).3,7 Caloric intake for females
should be gradually increased by about 500 kcal every 4 days
to 3500 kcal daily (70–100 kcal/kg per day).3
CHAPTER 74
overdose. TCA use is contraindicated in patients with QTc
prolongation.
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SECTION 7
Psychiatric Disorders
• Outpatient monitoring may include: Checking BMD and labs,
such as BMP and a CBC, and performing a physical examination (at least) annually.3 Periodic evaluations of physicals and
lab work including vitals, weight, nutritional status, CBC,
CMP, and toxicology screens might be necessary. Check a
urinalysis to assess specific gravity (1.003–1.03) since young
women may water-load to falsely elevate weight. Perform a
dental examination annually. Assess for symptoms of depression at each follow-up visit. Examples of scales include the
HAM-D or Beck Depression Inventory. Additionally, monitor mood, sign/symptoms of hypomania/mania changes in
behavior, frequency of crying, energy level, and participation
in healthy social activities. Ask about alcohol consumption,
tobacco use, and cannabis use during follow-up visits. Toxicology screening might also be appropriate.
• Assessment scales recommended by the American Psychiatric
Association include:
✓Clinician-administered measures: Eating Disorder Examination, Yale–Brown–Cornell Eating Disorder Scale
✓ Self-report measures: Diagnostic Survey for Eating Disorders
(DSED), Bulimia Test—Revised (BULIT-R), Eating Attitudes
Test (EAT), Eating Disorder Examination–Questionnaire
(EDE-Q), Eating Disorders Inventory–2 (EDI-2), and Questionnaire on Eating and Weight Patterns (QEWP)
Patient Education
6.What information should be provided to the patient to
enhance adherence, ensure successful therapy, and minimize
adverse effects of BN treatment?
• We are going to start you on an antidepressant, fluoxetine.
This medication will help improve the symptoms and behaviors associated with your eating disorder and provide relief
from depression. It is important to take it every day for
maximum efficacy, and you should not purge after taking the
medication. We will start one 20-mg capsule by mouth daily,
and then assess if we will need to increase the dose at your
scheduled follow-up visits.
• Take the fluoxetine every morning to avoid insomnia. Other
potential side effects associated with fluoxetine include nausea,
vomiting, diarrhea, constipation, headache, dizziness, anxiety,
and sexual dysfunction. You probably will not notice drastic
improvements with symptoms within the first couple of weeks
of treatment, but with continued treatment with fluoxetine,
you should notice an improvement in bulimic tendencies as
well as depression symptoms after 4–6 weeks. If at any time
you notice a worsening of depressive or suicidal thoughts, call
your doctor immediately.
Copyright © 2017 by McGraw-Hill Education. All rights reserved.
• The ziprasidone is being replaced with quetiapine extendedrelease to help with the symptoms of bipolar depression. You
should take it once a day at bedtime as one potential side effect
is sedation. Other potential side effects include headache, constipation, dizziness, dry mouth, and increases in cholesterol
and weight. It is important you keep all doctor appointments,
so that these side effects can be monitored.
• A multivitamin with zinc is also recommended once per day
for nutritional supplementation. Some people report an upset
stomach, and this can be minimized by taking your vitamin
with a meal.
• The above medications may be taken with or without food.
You should also take your other medications as prescribed as
keeping all your symptoms controlled will provide the best
quality of life. It is important to avoid purging in order to
allow the medications to be properly absorbed in your body
to optimize their efficacy. You should avoid alcohol and other
illegal substances while you are taking your medications. Do
not abruptly stop your medications. It is very important to
keep regular follow-up visits with your therapist and complete
any assignments or work you may be assigned as well as with
your doctor to have your symptoms, disease states, and medications monitored.
REFERENCES
1. American Psychiatric Association. Diagnostic and Statistical Manual of
Mental Disorders, 5th ed.. Washington, DC, 2013.
2. Finzi-Dottan R, Zubery E. The role of depression and anxiety in impulsive and obsessive–compulsive behaviors among anorexic and bulimic
patients. Eat Disord 2009;17:162–182.
3. American Psychiatric Association (APA). Practice Guidelines for the
Treatment of Patients with Eating Disorders, 3rd ed. Washington, DC,
American Psychiatric Association (APA), 2006.
4. Aigner M, Treasure J, Kaye W, Kasper S; WFSBP Task Force on Eating Disorders. World Federation of Societies of Biological Psychiatry
(WFSBP) guidelines for the pharmacological treatment of eating disorders. World J Biol Psychiatry 2011;12:400–443.
5. Tortorella A, Fabrazzo M, Monteleone AM, Steardo L, Monteleone P.
The role of drug therapies in the treatment of anorexia and bulimia
nervosa: a review of the literature. J Psychopathol 2014;20:50–65.
6. Setnick J. Micronutrient deficiencies and supplementation in anorexia
and bulimia nervosa: a review of the literature. Nutr Clin Pract
2010;25:137–142.
7. Yager J, Devlin MJ, Halmi KA, et al. Guideline Watch (August 2012):
Practice Guideline for the Treatment of Patients with Eating Disorders.
3rd ed. American Psychiatric Association, 2012.