Bulimia nervosa

Key NICE recommendations on management

People with an eating disorder (ED) should be treated by professionals competent to do so.

Consider psychiatric crisis or psychiatric inpatient care if there is acute mental health risk (e.g., significant suicide risk).

The impact of home, education, work and wider social environment (including internet/social media) on the person’s ED should be assessed and addressed throughout treatment.

• Be alert throughout assessment/treatment (especially in children and young people) to signs of bullying, teasing, abuse (e.g., emotional, physical, sexual) and neglect.

Do not offer:

• Medication as the sole treatment for bulimia nervosa

• A physical therapy (e.g., transcranial magnetic stimulation, acupuncture, weight training, yoga, warming therapy) as part of treatment for an ED.

Advice should be given to people with an ED who are:

• Vomiting to have regular dental/medical reviews, avoid highly acidic foods/drinks, and avoid brushing teeth immediately after vomiting (instead use non-acidic mouthwash)

• Misusing laxatives/diuretics that these do not reduce calorie absorption and therefore do not help with weight loss, and to gradually reduce and stop their use of these

• Exercising excessively to stop doing so.

See the NICE guideline section Conception and pregnancy for women with eating disorders for specific information on management of women who are pregnant, peri-/post-natal, or planning pregnancy.

Psychological treatment for bulimia nervosa

For adults with bulimia nervosa, bulimia-nervosa-focused guided self-help should be considered.

• If bulimia-nervosa-focused guided self-help is unacceptable, contraindicated, or ineffective after 4 weeks, individual eating-disorder-focused cognitive behavioural therapy (CBT-ED) should be considered.

For children and young people, bulimia-nervosa-focused family therapy should be offered.

• If bulimia-nervosa-focused family therapy is unacceptable, contraindicated or ineffective, individual CBT-ED should be considered.

All people should be advised that psychological treatments have a limited effect on weight.

Management and monitoring of physical health for eating disorders

Acute medical care (e.g., emergency admission) should be provided for severe electrolyte imbalance, severe malnutrition or dehydration, or signs of incipient organ failure.

• People with severely compromised physical health should be admitted for medical stabilisation and refeeding initiation (if unable to be done in an outpatient setting).

• Do not use an absolute weight or BMI threshold when deciding whether to admit.

• Inpatient care should not be used solely to provide psychological ED treatment.

If a person’s physical health is at serious risk due to their ED, they do not consent to treatment, and they can only be treated safely in an inpatient setting, follow the legal framework for compulsory treatment in the Mental Health Act 1983.

• If physical health is at serious risk in a child/young person that lacks capacity, and they do not consent to treatment, seek parental/carer consent and if necessary, use an appropriate legal framework for compulsory treatment (e.g., Mental Health Act 1983/2007, Children Act 1989).

Assess fluid/electrolyte balance if compensatory behaviours or water loading are suspected.

• If supplements are needed to restore electrolyte balance, these should be offered orally unless the electrolyte disturbance is severe or there are problems with gastrointestinal absorption.

• If there is continued unexplained electrolyte imbalance, assessment should take place to determine whether this could be caused by another condition.

Assess whether electrocardiogram monitoring is needed based on the following risk factors:

• Rapid weight loss

• Excessive exercise

• Severe purging behaviours (e.g., laxative/diuretic misuse, vomiting)

• Bradycardia or hypotension

• Excessive caffeine (e.g., from energy drinks)

• Prescribed or non-prescribed medications (monitoring should be offered if the person is taking medication that could compromise cardiac functioning, e.g., could cause electrolyte imbalance, bradycardia <40 bpm, hypokalaemia, prolonged QT interval)

• Muscular weakness

• Electrolyte imbalance

• Previous abnormal heart rhythm.

Identify, assess and manage overweight and obesity as appropriate.

Physical and mental health comorbidities

Eating disorder specialists and other teams (e.g., diabetes team, substance misuse service) should collaborate to support effective treatment of physical/mental health comorbidities.

• Be aware that diabetes control may become challenging and closer monitoring of diabetes may be needed during ED treatment. Insulin misuse may be present.

• See the NICE guideline section Physical and mental health comorbidities for more information on managing comorbidities (including diabetes) in people with an ED.

Seek specialist paediatric or endocrinology advice if there is delayed physical development or faltering growth in children and young people with an ED.

When prescribing medication for a person with an ED, consider:

• The possible impact of malnutrition/compensatory behaviours on medication effectiveness and the risk of side effects

• How the ED will affect adherence (e.g., to medications that can affect body weight)

• The risks of medication that can compromise physical health due to pre-existing medical complications.

© NICE (2020) All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England https://www.nice.org.uk/terms-and-conditions#notice-of-rights. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.