1. Binge Eating Disorder: 3. Pharmacotherapy
James E Mitchell, M.D.
Feel free to re-title and remove Penn specific stuff

2. Pharmacotherapy OF BED
Target BE?
Target Weight?
Target Both?
Target Comorbidity?
Target All Three?

3. Disclosure:
I was a paid consultant to the pharmaceutical firm that makes LDX in 2016

5. Pharmacotherapy for Binge Eating Disorder
Class
Drug
Tricyclics
eg. Imipramine
SSRIs
eg. Citalopram
SNRIs/NRIs
eg. Atomoxetine
Lipase Inhibitor
Orlistat
Amphetamine Pro-drug
Lisdexamfetamine
Anti-Epileptics
eg. Topiramate
Other Classes
eg. Na Oxybate
Combinations
eg. Topiramate + Phentermine

6. Class
Drug
Effect on Binge Eating
Effect on Weight
Tricyclics
Imipramine ++
+/-
Desipramine
SSRIs
Citalopram
Escitaloprm
Fluvoxamine
Sertraline
Fluoxetine
SNRIs/NRIs
Atomoxetine +
Venlafaxine
Duloxetine

9. Decreased Fat Absorption: An Inventive Vocabulary
Oily spotting
Flatus with discharge
Fecal urgency
Fatty/oily stool
Oily evacuation
Increased defecation
Fecal incontinence
Diarrhea

10. Fat-Soluble Vitamins and Carotenoids
Vitamin A
Vitamin D
Vitamin E
Vitamin K (prothrombin time)
Beta-carotene

11. Anti-epileptic Medications
and Lisdexamfetamine
Medication
Effect on Binge Eating
Effect on Weight
Topiramate ++
Zonisamide
Lisdexamfetamine*
(*Only FDA approved agent: Indicated for the treatment of Moderate to Severe Binge Eating Disorder (BED) in adults)

12. Prior Medications for Obesity
Past
Various Amphetamines
Sibutramine
Fenfluramine/phentermine (Fen/Phen)
CB1 antagonists

13. Amphetamines Racemic amphetamine Dextroamphetamine
Introduced in the treatment of narcolepsy by Prinzmetal and Bloomberg in 1935
Dextroamphetamine
Introduced for calming hyperexcitable-hyperactive children, by Bradley, in 1937
Also tried in the treatment of depression, but with little success

19. Class Effect on Binge Eating Effect on Weight
Drug
Effect on Binge Eating
Effect on Weight
Other Classes
Na Oxybate
Inadequate
Data
Baclofen
Lamotrigine
Acamprosate

20. Drugs/Combinations with Weight Loss Effects in BED
Topiramate (+ Phentermine or Bupropion) Zonisamide (+ Phentermine or Bupropion) Bupropion (+ Naltrexone) Lisdexamfetamine

21. Drugs/Combinations for Weight Loss in BED with DM
Topiramate (+ Phentermine or Bupropion)
Zonisamide (+ Phentermine or Bupropion)
Bupropion (+ Naltrexone)
Lisdexamfetamine Metformin Incretin (GLP-1) Mimetics DPP-4 Inhibitors (+/-)

22. Phentermine + Topiramate
Synergy for weight loss
Lower doses can be used

23. Phentermine + Topiramate
Anorexigenic agent
52 year history of use
Most widely prescribed weight loss drug in U.S.
Topiramate
Anticonvulsant agent

24. Phentermine +Topiramate
Mechanism of Action
Phentermine
Sympathomimetic amine
Topiramate
Block neuronal voltage-dependent Na+ channels
Antagonize AMPA/kainite glutamate receptors
Enhance GABA-A activity

25. Phentermine + Topiramate
Mechanism of weight loss
Phentermine
appetite reduction
Topiramate
increased satiety
increased energy expenditure

26. Phentermine + Topiramate
Common adverse events in clinical trials
Paresthesia
Dry mouth
Constipation
Upper respiratory tract infection
Nasopharyngitis
Headache

27. Phentermine + Topiramate
Cognitive side effects
Disturbance in attention/memory/word finding
Poor insight into problem
Minimize if start Topiramate at 25 mg, increase by 25 mg/week, maximum 200 mg
Cognitive disturbances resolves after drug discontinuation.

28. Bupropion + Naltrexone
Antidepressant with Weight loss effects
NE and DA reuptake inhibition
Mechanism of decreased appetite involves POMC effects
Naltexone
Long acting narcotic antagonist
Opioid blockade enhances effects at POMC

29. Bupropion + Naltrexone
Side-effects
seizure activity
dry mouth, nausea
headache, dizziness, ringing in ears
vision changes
sore throat
muscle pain
nausea, vomiting
stomach pain or cramping.
nervousness
irritability .

30. Lisdexamfetamine (LDX)
Red Blood Cells

33. LDX Side-effects Decreased appetite Headache Irritability Insomnia
Not to be used with substance abuse history

35. Questions/Comments?