A 33-year-old woman comes to the office for "help losing weight." She says, "I'm really trying, but I haven't seen any results." The patient has been on restrictive diets that cut out various food groups but gained 5 pounds in the past month. She feels "defeated" and says, "Nothing I try works. I end up feeling sorry for myself, and before I know it, I've eaten an entire cake. Even though I feel disgusting afterward, I still do it a few times a week." She reports no difficulty with sleep, energy, or concentration. The patient has been avoiding meals with friends and family because of embarrassment about overeating. Medical history is insignificant. Mental status examination reveals an overweight woman wearing loose clothing. She is cooperative and has a reactive affect. Treatment options are discussed, and the patient prefers to start medication. Which of the following medications would be most appropriate for this patient?

Question

A 33-year-old woman comes to the office for "help losing weight."  She says, "I'm really trying, but I haven't seen any results."  The patient has been on restrictive diets that cut out various food groups but gained 5 pounds in the past month.  She feels "defeated" and says, "Nothing I try works.  I end up feeling sorry for myself, and before I know it, I've eaten an entire cake.  Even though I feel disgusting afterward, I still do it a few times a week."  She reports no difficulty with sleep, energy, or concentration.  The patient has been avoiding meals with friends and family because of embarrassment about overeating.  Medical history is insignificant.  Mental status examination reveals an overweight woman wearing loose clothing.  She is cooperative and has a reactive affect.  Treatment options are discussed, and the patient prefers to start medication.  Which of the following medications would be most appropriate for this patient?

Quizplus · Accepted Answer

11ec25c8_d778_d538_bc81_3184517972f3_MD0003_00 This patient's repeated episodes of eating an excessive quantity of food in a discrete period, associated with loss of control, physical discomfort, and distress, are consistent with binge eating disorder (BED). The most prevalent eating disorder in the United States, BED has negative repercussions for physical health, including increased risk for obesity, diabetes, hyperlipidemia, and hypertension, as well as comorbid psychiatric disorders such as depression, anxiety, and illicit drug use. It can be differentiated from bulimia nervosa by the absence of inappropriate compensatory behaviors (eg, vomiting, excessive exercise, starvation). Although patients with BED are more likely to be overweight or obese, it also occurs in those of normal weight. The mainstay of treatment for BED is psychotherapy. Cognitive-behavioral therapy has the most evidence of benefit. Medications can be considered in patients who do not have access to psychotherapy, prefer medications, or fail psychotherapy alone. Options include selective serotonin reuptake inhibitors such as sertraline, the stimulant lisdexamfetamine, and the antiepileptic agent topiramate. (Choice A) The antidepressant bupropion has the advantage of not causing weight gain and may be associated with weight loss in some patients. However, it lacks evidence for use in BED. SSRIs are considered first-line pharmacotherapy for BED. (Choice B) The antiepileptic agent topiramate has shown benefit in the treatment of BED. However, there is lack of evidence to recommend the use of lamotrigine. (Choice C) The antiobesity agent orlistat has not shown benefit in decreasing binge eating episodes and is not recommended for use in BED. (Choice D) The sympathomimetic weight loss agent, phentermine, is not recommended for use in BED because of a lack of evidence of efficacy and the potential for adverse effects, which include hypertension, tachycardia, and cardiac ischemia. Educational objective: Binge eating disorder is characterized by repeated episodes of excessive eating accompanied by a loss of control and subsequent distress. The most effective treatment is psychotherapy. Medication options include selective serotonin reuptake inhibitors (eg, sertraline), lisdexamfetamine, and topiramate. References: Binge eating disorder. (http://www.ncbi.nlm.nih.gov/pubmed/28477651) Psychological, pharmacological, and combined treatments for binge eating disorder: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/29942715) Pharmacological treatment of binge eating disorder: update review and synthesis. (http://www.ncbi.nlm.nih.gov/pubmed/26044518)

A 33-Year-Old Woman Comes to the Office for "Help Losing