________________________________________________________________________ Behavioral Addictions
Other SSRIs mostly fail to separate from placebo. Trials of fluvoxamine and escitalopram reported statistically significant differences in weight loss favoring the SSRI. With a mean BMI of 33–40, these patients had a mean weight loss of 2.7–3.52 pounds, which shows reports of statistically significant differ- ences can be clinically irrelevant [261]. Adding fluoxetine or fluvoxamine to CBT or other behavioral treatments did not enhance outcomes compared with either psychological therapy alone [261]. However, the pooled results of seven second-generation antidepressant trials (five SSRIs, one duloxetine, and one bupropion) found patients receiving second-generation antidepressants were 1.67 times more likely to achieve binge-eating abstinence than those receiving placebo. Second-generation antidepressants reduced weekly binge-eating episodes by roughly two-thirds and binge-eating days per week by roughly one day (vs. placebo) [81]. Other Antidepressants Duloxetine, a serotonin-norepinephrine reuptake inhibitor, was studied in 40 patients with binge eating disorder and comorbid depressive disorder. After 12 weeks, duloxetine (mean dose: 78.7 mg) significantly reduced weekly binge-eating days, binge-eating episodes, and severity ratings for binge eat- ing disorder and depressive disorders compared with placebo. However, it did not differ from placebo in BMI, eating pathol- ogy, depression, or anxiety [267]. Antiepileptic Medications In several randomized controlled trials, topiramate was sig- nificantly superior to placebo in more rapid reductions in binge eating, binge-eating remission, and weight loss. Binge- eating remissions in two topiramate studies were 64% and 58%. Adding topiramate (vs. placebo) to CBT significantly enhanced binge-eating remission rates and led to significantly and meaningfully greater weight loss [261]. Aside from lisdex- amfetamine, topiramate is the only medication to consistently demonstrate substantial weight loss in patients with binge eating disorder [81]. In one randomized, placebo-controlled trial, 18 patients were randomized to 12 weeks of either phentermine/topiramate or placebo. Eating disorder behaviors, mood, and side effects were measured. Outcome measures included objective binge- eating days/week and binge abstinence. Baseline objective binge-eating days/week decreased from 16.2 to 4.2 with phen- termine/topiramate versus 13.2 with placebo. Abstinence rates were 63.6% with phentermine/topiramate versus 9.1% with placebo. Other measured effects with the combination were minimal and similar to placebo [268]. The promising outcomes with topiramate are tempered by high rates of adverse events resulting in study dropout, includ- ing sympathetic nervous system arousal, headaches, sleep disturbances, and a collection of other symptoms including rash, high blood pressure, confusion, and taste aversion [81]. Dropout from topiramate is substantially reduced by adding CBT [261].
Other antiepileptics show less robust efficacy than topiramate [261]. Lamotrigine was not superior to placebo, and zonisamide was superior to placebo in more rapid binge-eating reduction and greater weight loss, but binge-eating remissions did not differ [261]. Anti-Obesity Medications While not a binge eating disorder criterion, obesity is strongly associated with binge eating disorder in epidemiologic studies and is nearly universal in participants in binge eating disorder studies. Orlistat is a peripherally acting drug that blocks fat absorption in the gut without CNS effects. Several trials found orlistat significantly superior to placebo in enhancing weight loss, with no difference in binge eating reductions. Orlistat added to CBT significantly enhanced weight-loss outcomes but not binge eating reductions (compared with placebo). Orlistat or placebo added to behavioral weight loss therapy enhanced weight losses in obese patients without binge eating disorder, but not among obese patients with binge eating disorder [261]. Naltrexone/bupropion and liraglutide have been added as new-generation anti-obesity drugs. Liraglutide is a glucagon-like peptide 1 (GLP-1) receptor agonist that decreases inappropri- ate glucagon secretion, slows gastric emptying, and decreases food intake. It is approved as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight man- agement in adults who are overweight or obese with one or more comorbidity [269]. The combination naltrexone 32 mg/ bupropion 360 mg is approved as an adjunct to a hypocaloric diet and increased physical activity for chronic weight manage- ment in adults with obesity or overweight and one or more weight-related comorbidity [270; 271]. Disulfiram A small 12-week trial of disulfiram 250 mg/day significantly decreased binge-eating episodes per week (7.9 pretreatment vs. 0.9 post-treatment), and 58.3% achieved binge-eating remis- sion. However, 25% dropped out from side effects, and the remaining subjects reported drowsiness, headache, dysgeusia, tachycardia, dizziness, and nausea [272]. Non-Invasive Brain Stimulation Therapy A small pilot study evaluated single-session transcranial direct current stimulation of the right dorsolateral PFC compared with sham therapy. Transcranial stimulation decreased craving for sweets, savory proteins, and food overall (with the strongest reductions in men), and significantly reduced desire to binge eat in men the day of active treatment. Greater reductions in craving and food intake correlated with less eating for reward motives and greater intent to restrict calories, respec- tively. Stimulation of the brain may recruit mechanisms that enhanced cognitive control and/or reduced the need for reward. Transcranial direct current stimulation in binge eating disorder was safe, and the results support evaluation of multi- session therapy [273].
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