Medication Management for Binge Eating Disorder

Introduction to Medication Selection

Lisdexamfetamine is the only FDA-approved medication specifically for moderate-to-severe binge eating disorder and should be the first-line pharmacologic choice when medication is indicated, according to the American College of Cardiology 1, 2, 3

Pharmacotherapy should be considered after a trial of eating disorder-focused cognitive-behavioral therapy (CBT) or interpersonal therapy, as recommended by the American Psychiatric Association 1, 2
Medication should be considered when patients prefer medication over psychotherapy, as suggested by the National Institute of Mental Health 1, 2
Patients with comorbid obesity (BMI ≥30 kg/m² or BMI ≥27 kg/m² with weight-related comorbidities) should be considered for medication, according to the American Heart Association 1, 2

Lisdexamfetamine is recommended for moderate-to-severe BED, especially when weight management is a goal, with a strength of evidence rated as high by the American College of Cardiology 2
Topiramate (often as phentermine/topiramate ER combination) is an alternative option for patients with obesity as primary concern or as part of combination therapy, with substantial evidence for reducing binge eating behaviors and body weight, as reported by the Endocrine Society 1, 2
Naltrexone/Bupropion (Contrave) is recommended for patients with significant food cravings or addictive eating patterns, with demonstrated efficacy for weight management, as stated by the American Academy of Family Physicians 1, 2

Mirtazapine and tricyclic antidepressants should be avoided in BED patients with obesity due to weight gain potential, as warned by the American Diabetes Association 1, 2
Sympathomimetic agents (phentermine, phentermine/topiramate ER) should be avoided in patients with cardiovascular disease, as cautioned by the American Heart Association 4

Initial assessment should be done monthly for the first 3 months, with ongoing monitoring at least every 3 months thereafter, as recommended by the American Gastroenterological Association 4, 1
Discontinuation criteria include ≤5% weight loss at 12 weeks, at which point alternative medication or other treatments should be considered, as suggested by the National Institute of Diabetes and Digestive and Kidney Diseases 4

Patients with Type 2 Diabetes should be considered for GLP-1 analogues (e.g., liraglutide) that reduce hyperglycemia in addition to first-line metformin, as recommended by the American Diabetes Association 4