Transcript Euro Weight Loss-2015 Frankfurt, Germany August 18

EURO WEIGHT LOSS-2015
FRANKFURT, GERMANY
AUGUST 18 – 20, 2015
Amalan Karthigeyan
THE USE OF PHARMACOTHERAPY IN THE
TREATMENT OF BINGE EATING DISORDER
Dr Amalan Karthigeyan
Euro Global Summit and Medicare Expo on Weight Loss
Euro Weight Loss 2015
Frankfurt
INTRODUCTION TO BINGE EATING DISORDER
Consumption of large amounts of food without
control and the use of purging behaviours.
 DSM-V – autonomous eating disorder.
Previously categorised as Eating Disorder not
Otherwise Specified.
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ANTIDEPRESSANTS
WHY ANTIDEPRESSANTS?
Shown to be effective in bulimia nervosa.
 Overlap with anxiety and
depression/depressive disorder.
 Dysfunction of serotonergic, noradrenergic and
dopaminergic systems in binge eating disorder.
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ANTIDEPRESSANTS USED IN BINGE EATING
DISORDER
Tricyclic antidepressants (desipramine,
imipramine)
 Selective serotonin reuptake inhibitors
(fluoxetine, fluvoxamine, sertraline, citalopram)
 Selective noradrenergic reuptake inhibitors
(atomoxetine, venlafaxine, sibutramine)
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Desipramine
• 12-week placebo control trial with 23 women with non-purging bulimia nervosa –
63% decrease in weekly binge eating frequency and mean weight loss of 3.5kg
compared to 16% frequency decrease and 1.2kg weight loss on placebo. (McCann
and Agras, 1990)
Imipramine
• 8-week placebo control trial - decreased binge eating demonstrated in 23 subjects
but placebo response also high. (Alger et al 1991)
• Demonstrated significant reduction in binge frequency and weight loss when used in
combination with adjunctive therapy compared to placebo which demonstrated
weight gain. (Laederach-Hofmann et al 1999)
Four placebo-control trials using SSRIs - ≥ 50% decrease in binge frequency
Fluoxetine
• Suppression of short-term food consumption and mean energy intake. However GI
symptoms are a side effect – may have contributed.
• 6 week placebo controlled trail of 60 patients – decreased binge eating frequency
and BMI (Arnold et al 2002)
Fluvoxamine
• Reduced binge eating frequency and subsequent weight loss demonstrated by
trials (Hudson et al).
Sertraline
• 6-week double blind placebo controlled trial of 34 patients – reduced binge eating
frequency and BMI (McElroy et al 2000)
• 8-week randomised control trial on 34 patients with night eating syndrome –
improvement in night eating symptoms (O’Reardon et al 2006)
Citalopram
• 6-week placebo controlled trial of 38 patients – significant reduction in binge
eating frequency and weight (McElroy et al 2003).
Atomoxetine
•10-week randomised placebo-controlled double blind trial of 40 patients – decreased
frequency of binge eating episodes (4 patients dropped out) (McElroy et al 2007b).
Venlafaxine
•Study of 35 patients treated over 120 days – decreased weekly frequency in binge
eating. (Malhort et al 2002).
Sibutramine
•Open trial on 10 obese patients over 12 weeks – 7/10 demonstrated decreases in
binge frequency and body weight (Appolinario et al 2002).
•12-week randomised double-blind placebo controlled trial on 60 subjects - decreased
binge frequency and weight (Appolinario et al 2003).
•Withdrawn in 2010 due to risks outweighing the benefits.
ANTICONVULSANTS
WHY ANTICONVULSANTS?
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Bipolar disorder reported to co-occur with binge eating disorder.
Anticonvulsants shown to be effective in either the manic
phase or depressive phase.
Proven effective for psychiatric conditions characterised with
impulsive behaviours or traits that co-occur with binge eating
disorder.
Some anticonvulsants associated with weight loss and anorexia
in epileptics.
Animal studies show that glutamate agonists e.g. kinate/AMPA
agonists stimulating the lateral hypothalamus induces
increased food intake.
ANTICONVULSANTS USED IN BINGE EATING
DISORDER
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Zonisamide - Decreased binge eating episode frequency, binge day
frequency, degree of hunger and BMI demonstrated by 12-week trial of
originally 15 patients decreased to 8 due to side effects of medication
(McElroy et al 2006).
Topiramate – trial of 13 patients: 9 demonstrated reduction in binge eating
and weight (Shapira et al 2000). Trial on 8 obese patients: 4 out of 6 who
completed the trial showed reduction in binge frequency and weight
(Appolinario et al 2002). Same findings in a placebo-controlled trial of 61
patients which showed 64% of patients on topiramate stopped binge eating
compared to 30% on placebo and there was an average weight loss of
5.9kg compared to 1.2kg on placebo. However there was a high dropout
rate due to side effects (McElroy et al 2003).
Lamotrigine – Only one randomised placebo-controlled trial (51 patients
over 16 weeks) which demonstrated no difference in binge frequency
compared to placebo but greater difference in weight loss (Guerdjikova et al
2009).
ANTI-OBESITY AGENTS
EVIDENCE SUPPORTING USE OF ANTI-OBESITY
AGENTS
 Binge eating consists of an increased appetite
and reduced satiety.
 Binge eating disorder consists of obesity.
 Some anti-obesity agents have been shown to
reduce appetite and increase satiety.
ANTI-OBESITY AGENTS USED
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D-Fenfluramine – Investigated because of its serotonergic action. Found to suppress
binge eating but no evidence of reduction in body weight (Stunkard et al 1996).
However has been withdrawn in 1997 due to associations with cardiac valve lesions
and pulmonary hypertension.
Orlistat – gastrointestinal lipase inhibitor. 7.4% weight reduction vs 2.3% for placebo
(Golay et al 2005).
Phentermine – sympathomimetic amine. Believed to supress appetite by promoting
release of norepinephrine. No studies of phentermine as monotherapy. Phentermine
and fenfluramine shown to improve binge eating and weight loss (Alger et al 1999).
Phentermine and fluoxetine in a 20 week study – 95% decrease in weekly binge
frequency and decreased body weight.
NEW EMERGING TREATMENTS
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Atomoxetine identified as a new agent.
Acamprosate – glutamate receptor modulator. Used to maintain abstinence in
alcohol dependence. Suggested that decreased glutamate function decreases binge
eating by preclinical and clinical trials. 10-week placebo controlled trial of 40
patients – secondary endpoint analysis demonstrated improvement in binge day
frequency, slight decrease in weight with acamprosate and increase with placebo
(McElory et al 2011).
Baclofen – Also shown to be effective in alcohol dependence. 10-week trial on 7
women – 5/7 showed reduced binge frequency by 50% and 3/7 free from binge
eating (Broft et al 2007). Double-blind placebo-controlled trial on 12 patients – binge
eating significantly decreased in both baclofen and placebo.
SUMMARY
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Antidepressants have been effective in bulimia nervosa. They
are used because of overlaps of anxiety and depression with
BED and has effect on serotonergic, noradrenergic and
dopaminergic systems which demonstrate dysfunction in BED.
Anticonvulsants have been effective in manic or depressive
phase in bipolar disorder and other behaviours or traits which
co-occurs with BED. They have been associated with weight
loss and anorexia.
There are anti-obesity agents being used.
Numerous trials have been conducted demonstrating the
effectiveness of these medications.
New treatments for BED are being found.
REFERENCES
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Pharmacological Approaches in the Treatment of Binge Eating Disorder, Appolinario
and McElroy, Current Drug Targets, 2004, 5, 301-307.
Latest advancements in the pharmacological treatment of binge eating disorder,
Marazziti et al, European Review for Medical and Pharmacological Sciences, 2012;
16: 2102-2107.
The Pharmacological Options in the Treatment of Eating Disorders, Milano et al,
ISRN Pharmacology, Volume 2013, Article ID 352865
World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the
Pharmacological Treatment of Eating Disorders, Aigner et al, The World Journal of
Biological Psychiatry, 2011; 12: 400-443
Pharmacotherapy of Binge Eating Disorder: A Review, Goracci et al, J Addict Med
2015; 9: 1-19
Binge Eating Disorder diagnosis and treatment: a recap in front of DSM-5, Amianto
et al, BMC Psychiatry (2015) 15: 70
Pharmacological management of binge eating disorder: current and emerging
treatment options, McElroy et al, Therapeutics and Clinical Risk Management 2012;
8, 219-241
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