The Use of Duloxetine in Chronic Bulimia Nervosa—A Case Report

| August 26, 2009 | 0 Comments

by Richard C. Christensen, MD, MA, and Robert N. Averbuch, MD

Dr. Christensen is Professor and Chief of the Division of Public Psychiatry at the University of Florida College of Medicine. Dr. Averbuch is Assistant Professor in the Department of Psychiatry at the University of Florida College of Medicine.


Psychiatry (Edgemont) 2009;6(8):27–28

ABSTRACT

Selective serotonin reuptake inhibitors are routinely prescribed as off-label treatments for bulimia nervosa. There is, however, a paucity of literature addressing the efficacy of the serotonin norepinephrine reuptake inhibitors in the pharmacologic management of this disorder. This article describes a clinical situation in which duloxetine, a serotonin norepinephrine reuptake inhibitor, effectively treated a patient with long-standing bulimia nervosa, purging type, and comorbid generalized anxiety disorder.

KEY WORDS

bulimia nervosa, pharmacological management, serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, duloxetine

INTRODUCTION

A review of current literature on the treatment of eating disorders reveals a conspicuous absence of US Food and Drug Administration (FDA)-approved biological therapies. Indeed, only fluoxetine has been approved for bulimia nervosa (BN).[1] Consequently, clinicians routinely prescribe antidepressants, primarily selective serotonin reuptake inhibitors (SSRIs), as off-label treatments for BN. There is, however, a paucity of literature addressing the efficacy of the serotonin norepinephrine reuptake inhibitors (SNRIs) in the pharmacologic management of this disorder. We describe a case report in which duloxetine, an SNRI, effectively treated a patient with long-standing BN, purging type, and comorbid generalized anxiety disorder (GAD). Although there has been one published study examining the effects of duloxetine in the treatment of obese patients with binge eating disorder,[2] our clinical account appears to be only the second case report describing the efficacy of this agent in the management of treatment-refractory BN.[3]

CASE REPORT

Ms. D was a 35-year-old caucasian woman who experienced the onset of BN, purging type, in late adolescence when she began self-induced emesis following evening meals. During her early 20s, Ms. D’s illness escalated to several daily episodes of binge eating, routinely followed by purging. In her mid-20s, she underwent serial pharmacologic trials with SSRIs, including sertraline, paroxetine, escitalopram, and fluoxetine, all at therapeutic doses and for extended durations. Although she functioned at a fairly high level socially and vocationally as an adult, her disorder persisted. Ms. D achieved her best treatment response in her late 20s with a combination of cognitive behavioral therapy (CBT) and fluoxetine. For nearly two years she reduced her bingeing and purging episodes to approximately once per day. However, following the birth of her first child, the episodes increased to at least twice a day. Despite a gradual titration of fluoxetine to 60mg/day and continued psychotherapy, no improvement was noted over the course of several years. During this time, she became increasingly distraught and, after developing a severe gastritis, was referred to our clinic.

On initial examination, her physical health, apart from chronic gastritis, was good with a normal body mass index and no electrolyte abnormalities. There was no evidence of neurological deficits or disease. Other than GAD, she evidenced no other Axis I psychiatric comorbidities. There were, however, characterological traits consistent with an obsessive compulsive personality, including perfectionism, personal rigidity, and preoccupation with organization and order.

An initial trial of 50mg of topiramate was poorly tolerated and subsequently discontinued. Given her limited response to multiple SSRI trials, duloxetine was initiated at 30mg/day. Ms. D continued to receive biweekly CBT. Within three weeks, the number of binge/purging episodes had decreased to just once per day. Subjectively, the patient noted a decreased “drive” to binge. Duloxetine was optimized to 60mg/day and, following a 12-week trial, the patient reported just one binge/purging episode over an entire month. Due to complaints of jitteriness, we reduced her dosage 30mg/d, and there was no subsequent increase in binge/purge behaviors after four months of continued treatment. As an added benefit, GAD symptoms were also markedly reduced.

DISCUSSION

Several placebo-controlled studies investigating the use of SSRIs in the treatment of BN underscore some efficacy in their use.[3,4] Moreover, several case reports suggest the norepinephrine reuptake inhibitor (NRI), reboxetine, helps reduce aberrant eating behaviors in BN.[5,6] Assuming that both the serotonin and norepinephrine systems are implicated in the pathophysiology of BN, it is reasonable to believe that a dual agent, such as duloxetine, should produce a positive, perhaps synergistic, effect in the treatment of this debilitating eating disorder.[2] This brief case report provides some additional support for duloxetine’s role in the treatment of SSRI-refractory BN and highlights the need for further research.

REFERENCE
1. Ashih HW. Effective psychiatric medications for eating disorders. Carlat Psychiatry Rep. 2009;7(5):1–3.
2. Leombruni P, Lavagnino L, Gastaldi F, et al. Duloxetine in obese binge eater outpatients: preliminary results from a 12-week open trial. Hum Psychopharmacol. 2009; June 18 (Epub ahead of print).
3. Hazen E, Fava M. Successful treatment with duloxetine in a case of treatment refractory bulimia nervosa: a case report. J Psychopharmacol. 2006;20(5):723.
4. Milano W, Petrella C, Sabatino C, et al. Treatment of bulimia nervosa with sertraline: a randomized controlled trial. Adv Therapeutics. 2004;21(4):232–237.
5. Milano W, Siano C, Petrella C, et al. Treatment of bulimia nervosa with fluvoxamine: a randomized controlled trial. Adv Therapeutics. 2005;22(3):278–283.
6. Fassino S, Daga G, Boggion S, et al. Use of reboxetine in bulimia nervosa. J Psychopharmacol. 2004;18:423–428.

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Category: Case Report, Past Articles, Personality Disorders, Psychiatry

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