A 36-year-old woman comes to the office due to difficulty losing weight over the past several months. The patient says, "I typically lose 1 or 2 pounds in the first week of dieting, but by the second week I lose control and start eating bags of cookies and potato chips." These episodes are followed by a few days of fasting and exercising excessively. The patient is upset about her weight and appearance but has no persistent sadness. She enjoys her work and socializing with friends and family. The patient has no medical conditions, but her menstrual cycle is irregular. Weight is 67 kg (147.7 lb) and height is 160 cm (5 ft 3 in). BMI is 26.2 kg/m². Blood pressure is 100/70 mm Hg and pulse is 86/min. Physical examination shows dry skin but is otherwise unremarkable. The patient has a full range of affect and no suicidal ideation. Laboratory results are as follows: The diagnosis is discussed, and the patient asks if any medications are available for treatment. Which of the following is the most appropriate recommendation?

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11ec25c8_d772_e1c3_bc81_e9f2228f5d49_MD0003_00 This patient's history of recurrent binge eating, preoccupation with weight and appearance, and compensatory behaviors (ie, fasting, excessive exercise) is suggestive of bulimia nervosa. The laboratory finding of hypokalemia is consistent with self-induced vomiting. Other typical findings in bulimia nervosa include dry skin, hypotension, tachycardia, menstrual irregularities, erosion of dental enamel, enlarged parotid glands, and metabolic alkalosis. Selective serotonin reuptake inhibitors are first-line pharmacotherapy for bulimia nervosa. Fluoxetine has the best evidence for reducing the frequency of bingeing and purging episodes. Although fluoxetine can be used alone, it is most effective as part of a multimodal therapy that includes nutritional rehabilitation (ie, establishing a structured and consistent meal pattern) and cognitive-behavioral therapy. (Choice A) The antidepressant bupropion is contraindicated in patients with active symptoms of bulimia nervosa due to an increased risk of seizures. (Choice C) Methylphenidate is a stimulant used primarily in the treatment of attention deficit hyperactivity disorder and narcolepsy. Decreased appetite is a common side effect. (Choice D) Fluoxetine is an evidence-based treatment for bulimia nervosa and should be considered in this patient. In contrast, there is little evidence to support the use of pharmacotherapy as a first-line treatment in anorexia nervosa (which requires BMI <18.5 kg/m² for diagnosis). (Choice E) The antipsychotic olanzapine typically causes weight gain. It has been used as an adjunct treatment in anorexia nervosa but is not indicated in bulimia nervosa. (Choice F) Orlistat, a weight-loss drug that inhibits pancreatic lipases, is used in the treatment of obesity (eg, BMI ≥30 kg/m²). Educational objective: Fluoxetine is first-line pharmacotherapy for bulimia nervosa. Best results are achieved as part of a multimodal therapy that includes cognitive-behavioral therapy and nutritional rehabilitation. References: Psychopharmacological advances in eating disorders. (http://www.ncbi.nlm.nih.gov/pubmed/28933969) Psychopharmacologic treatment of eating disorders: emerging findings. (http://www.ncbi.nlm.nih.gov/pubmed/25796197)

A 36-Year-Old Woman Comes to the Office Due to Difficulty