Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

nonpregnant adults

1st line – cognitive behavioral therapy (CBT)

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ACUTE
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nonpregnant adults
1st line – 

cognitive behavioral therapy (CBT)

Ideally, CBT (standard or guided self-help) is used first for isolated bulimia.[87] It may begin with CBT guided self-help (e.g., CBT self-help materials supplemented with 9 twenty-minute supportive sessions over 16 weeks). Switching to standard CBT after a 4-week trial is recommended if guided self-help is ineffective, unacceptable or contraindicated. A Cochrane review examined the evidence for the efficacy of CBT in treating bulimia. The conclusion was that, while there is evidence to support the use of CBT, the quality of trials is variable and sample sizes are often small.[89][90]

There is some evidence to support internet use of CBT.[91][101][102]

Plus – nutritional and meal support

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ACUTE
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nonpregnant adults
Plus – 

nutritional and meal support

Treatment recommended for ALL patients in selected patient group

Nutrition counseling is an essential part of treatment for bulimia nervosa. It should be supervised by a trained and experienced dietitian. Meal support means that a therapist actively supports the patient at mealtimes regarding their concerns, feelings, habits, and beliefs about eating. In some cases, ongoing meal support may be helpful as part of maintenance.

Consider – selective serotonin-reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI)

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ACUTE
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nonpregnant adults
Consider – 

selective serotonin-reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI)

Treatment recommended for SOME patients in selected patient group

These are used to temporarily reduce the frequency of binge eating and purging. They should be taken at a time of day when, by history, they are not likely to be purged.

They should be considered when there will be a significant benefit in a reduction of binge eating or purging. This may occur while waiting for psychological treatment or when psychological treatment is underway but ineffective. The chance of overdose and the history of medication or substance misuse must be assessed. Only 1 to 2 weeks of medication should be prescribed.

Fluoxetine should be tried first, based on lower dropout rates than with other antidepressants in bulimia.[106] Fluoxetine is unlikely to be of benefit if it does not cause a 60% decrease in binge eating or vomiting by week 3.[107]

Sertraline is an alternative SSRI for those who cannot tolerate fluoxetine. It has fewer adverse effects and less withdrawal than venlafaxine.

Venlafaxine has a more rapid onset of action (within days) at relatively lower doses compared with fluoxetine or sertraline, but is equal in its effect at reduction of binge eating and purging.

Other SSRI/SNRIs can be prescribed based on the patient's presentation.

Primary options

fluoxetine: 20 mg orally once daily initially, increase by 20 mg/day increments every 1-2 weeks according to response, maximum 60 mg/day

Secondary options

sertraline: 25 mg orally once daily initially, increase by 25 mg/day increments at weekly intervals according to response, maximum 200 mg/day

Tertiary options

venlafaxine: 37.5 mg orally (extended-release) once daily initially, increase by 75 mg/day increments every 2-4 weeks according to response, maximum 225 mg/day

Consider – other types of psychological therapies

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ACUTE
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nonpregnant adults
Consider – 

other types of psychological therapies

Treatment recommended for SOME patients in selected patient group

There is evidence to suggest that interpersonal psychotherapy is effective in reducing binge-eating episodes.[73] Psychoanalytic psychotherapy has shown efficacy, though a randomized trial reported that CBT was more effective in relieving binge eating and purging symptoms as it is generally faster in obtaining results and requires fewer sessions.[93] The most appropriate therapy depends on availability, the comfort of the patient and therapist with the therapy, and comorbidities, such as personality disorder, that may also require treatment.

Providers should encourage understanding of the condition and motivation to normalize eating behavior.

Core dysfunctional thoughts, attitudes, motives, conflicts, and feelings should be addressed.

Family support should be enlisted.[99]

Self-help groups may be useful. However, the benefit depends on the underlying philosophy of the group and the group leader(s). Therefore, the clinician should ask about the groups in follow-up.

2nd line – SSRI or SNRI (without CBT)

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ACUTE
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nonpregnant adults
2nd line – 

SSRI or SNRI (without CBT)

Ideally, CBT is used first for isolated bulimia. However, treatment is often unavailable. Initial SSRI treatment is an acceptable alternative, as comorbid disease (i.e. depression or post-traumatic stress disorder) commonly afflicts patients and is treated as well.[108]

Medications should be taken at a time of day when by history they are not likely to be purged.

The chance of overdose and the history of medication or substance misuse must be assessed. Only 1-2 weeks of medication should be prescribed.

Fluoxetine should be tried first, based on lower dropout rates than with other antidepressants in bulimia.[106] Fluoxetine is unlikely to be of benefit if it does not cause a 60% decrease in binge eating or vomiting by week 3.[107]

Sertraline is an alternative SSRI for those who cannot tolerate fluoxetine. It has fewer adverse effects and less withdrawal than venlafaxine.

Venlafaxine has a more rapid onset of action (within days) at relatively lower doses compared with fluoxetine or sertraline, but is equal in its effect at reduction of binge eating and purging.

Other SSRI/SNRIs can be prescribed based on the patient's presentation.

Primary options

fluoxetine: 20 mg orally once daily initially, increase by 20 mg/day increments every 1-2 weeks according to response, maximum 60 mg/day

Secondary options

sertraline: 25 mg orally once daily initially, increase by 25 mg/day increments at weekly intervals according to response, maximum 200 mg/day

Tertiary options

venlafaxine: 37.5 mg orally (extended-release) once daily initially, increase by 75 mg/day increments every 2-4 weeks according to response, maximum 225 mg/day

Plus – nutritional and meal support

Back
ACUTE
|
nonpregnant adults
Plus – 

nutritional and meal support

Treatment recommended for ALL patients in selected patient group

Nutrition counseling is an essential part of treatment for bulimia nervosa. It should be supervised by a trained and experienced dietitian. Meal support means that a therapist actively supports the patient at mealtimes regarding their concerns, feelings, habits, and beliefs about eating. In some cases, ongoing meal support may be helpful as part of maintenance.

Consider – other types of psychological therapies

Back
ACUTE
|
nonpregnant adults
Consider – 

other types of psychological therapies

Treatment recommended for SOME patients in selected patient group

There is evidence to suggest that interpersonal psychotherapy is effective in reducing binge-eating episodes.[73] Psychoanalytic psychotherapy has shown efficacy, though a randomized trial reported that CBT was more effective in relieving binge eating and purging symptoms as it is generally faster in obtaining results and requires fewer sessions.[93] The most appropriate therapy depends on availability, the comfort of the patient and therapist with the therapy, and comorbidities, such as personality disorder, that may also require treatment.

Providers should encourage understanding of the condition and motivation to normalize eating behavior.

Core dysfunctional thoughts, attitudes, motives, conflicts, and feelings should be addressed.

Family support should be enlisted.[99]

Self-help groups may be useful. However, the benefit depends on the underlying philosophy of the group and the group leader(s). Therefore, the clinician should ask about the groups in follow-up.

Plus – immediate referral for specialist evaluation or emergency department assessment

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ACUTE
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nonpregnant adults
|
with suicidality, diabetes mellitus, or physical symptoms such as loss of consciousness, syncope, or seizures
Plus – 

immediate referral for specialist evaluation or emergency department assessment

Treatment recommended for ALL patients in selected patient group

The presence of suicidality indicates the need for immediate psychiatric evaluation.

If the patient presents with physical symptoms such as loss of consciousness, syncope, and seizures, referral for emergency department assessment is advised.

If the patient has diabetes, referral to an endocrinologist is recommended.

Alcohol-use disorder or other substance misuse, borderline personality disorder, or ongoing self-injurious behavior also indicates the need for immediate specialized psychiatric or psychological referral.

Otherwise, treatment can progress as an outpatient.

Consider – glycemic control

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ACUTE
|
nonpregnant adults
|
with suicidality, diabetes mellitus, or physical symptoms such as loss of consciousness, syncope, or seizures
Consider – 

glycemic control

Treatment recommended for SOME patients in selected patient group

Patients with bulimia and type 1 diabetes require special attention with respect to their glycemic control and insulin management. Fluctuations in glycemic control necessitate close monitoring of hyperglycemia and - importantly - hypoglycemia; the latter could be life-threatening if severe.

Patients with bulimia and type 2 diabetes often have significant fluctuations in body weight and glycemic control. Counseling for weight management aids improvement of glycemic control. Fluoxetine at high dose may be particularly beneficial in inducing weight loss and preventing weight gain in overweight and obese patients with bulimia.

Diabetic patients with bulimia often endure dangerous conditions due to poor blood sugar control, erratic insulin or oral hypoglycemic use, and binge-eating and purging behaviors. Admittance to a hospital may be necessary. Referral to an endocrinologist is recommended for optimal glucose control.[103]

children and adolescents

1st line – cognitive behavioral therapy (CBT) or family-based therapy (FBT)

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ACUTE
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children and adolescents
1st line – 

cognitive behavioral therapy (CBT) or family-based therapy (FBT)

There is moderate evidence for the effectiveness of CBT in children and adolescents with bulimia.[86]

One randomized trial found that FBT may be more effective than CBT in the short term for adolescent patients with bulimia nervosa; however, there was no difference between groups at 1-year follow-up.[86][92]

Plus – nutritional and meal support

Back
ACUTE
|
children and adolescents
Plus – 

nutritional and meal support

Treatment recommended for ALL patients in selected patient group

Nutrition counseling is an essential part of treatment for bulimia nervosa. It should be supervised by a trained and experienced dietitian. Meal support means that a therapist actively supports the patient at mealtimes regarding their concerns, feelings, habits, and beliefs about eating.[86] In some cases, ongoing meal support may be helpful as part of maintenance.​

Consider – fluoxetine

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ACUTE
|
children and adolescents
Consider – 

fluoxetine

Treatment recommended for SOME patients in selected patient group

There is very little evidence for pharmacologic treatments for children and adolescents with bulimia nervosa. Fluoxetine is not approved for pediatric bulimia nervosa; however, it is approved for child and adolescent depression and obsessive-compulsive disorder, so it could be considered if medication is required.[86]

Children and adolescents prescribed fluoxetine should be monitored closely for clinical worsening and suicide risk, especially with new treatment or changes in dose. The Food and Drug Administration issued a black box warning on suicidality associated with the pediatric use of antidepressants in 2004.[109] However, the increased risk of suicidal ideation is relatively small, 3% to 4% with antidepressant use compared to 2% with placebo.[110]

Primary options

fluoxetine: consult specialist for guidance on dose

Plus – immediate referral for specialist evaluation or emergency department assessment

Back
ACUTE
|
children and adolescents
|
with suicidality, diabetes mellitus, or physical symptoms such as loss of consciousness, syncope, or seizures
Plus – 

immediate referral for specialist evaluation or emergency department assessment

Treatment recommended for ALL patients in selected patient group

The presence of suicidality indicates the need for immediate psychiatric evaluation.

If the patient presents with physical symptoms such as loss of consciousness, syncope, and seizures, referral for emergency department assessment is advised.

If the patient has diabetes, referral to an endocrinologist is recommended.

Substance misuse, borderline personality disorder, or ongoing self-injurious behavior also indicates the need for immediate specialized psychiatric or psychological referral.

Otherwise, treatment can progress as an outpatient.

Consider – glycemic control

Back
ACUTE
|
children and adolescents
|
with suicidality, diabetes mellitus, or physical symptoms such as loss of consciousness, syncope, or seizures
Consider – 

glycemic control

Treatment recommended for SOME patients in selected patient group

Patients with bulimia and type 1 diabetes require special attention with respect to their glycemic control and insulin management. Fluctuations in glycemic control necessitate close monitoring of hyperglycemia and - importantly - hypoglycemia; the latter could be life-threatening if severe.

Patients with bulimia and type 2 diabetes often have significant fluctuations in body weight and glycemic control. Counseling for weight management aids improvement of glycemic control.

Diabetic patients with bulimia often endure dangerous conditions due to poor blood sugar control, erratic insulin or oral hypoglycemic use, and binge-eating and purging behaviors. Admittance to a hospital may be necessary. Referral to an endocrinologist is recommended for optimal glucose control.[103]

pregnant

1st line – specialist referral + cognitive behavioral therapy (CBT)

Back
ACUTE
|
pregnant
1st line – 

specialist referral + cognitive behavioral therapy (CBT)

It is recommended that pregnant patients should be assessed for follow-up as a high-risk pregnancy. Therefore, referral to an obstetrician and psychiatrist is advised.

Ideally, CBT is used first for isolated bulimia. However, CBT is often not available. A Cochrane review examined the evidence for the efficacy of CBT in treating bulimia. The conclusion was that, while there is evidence to support the use of CBT, the quality of trials is variable and sample sizes are often small.[89][90]

Plus – nutritional and meal support

Back
ACUTE
|
pregnant
Plus – 

nutritional and meal support

Treatment recommended for ALL patients in selected patient group

Nutrition counseling is an essential part of treatment for bulimia nervosa. It should be supervised by a trained and experienced dietitian. Meal support means that a therapist actively supports the patient at mealtimes regarding their concerns, feelings, habits, and beliefs about eating. In some cases, ongoing meal support may be helpful as part of maintenance.

In pregnancy, a dietitian should be consulted to prepare the patient for the increase in caloric intake required and the associated weight gain and edema. During pregnancy, proper nutrition is essential for the developing fetus. The mother is often able to abstain from binge eating and purging. Deficiencies of vitamins and minerals should be corrected as soon as pregnancy is diagnosed.

Consider – other types of psychological therapies

Back
ACUTE
|
pregnant
Consider – 

other types of psychological therapies

Treatment recommended for SOME patients in selected patient group

There is evidence to suggest that interpersonal psychotherapy can be effective in reducing binge-eating episodes.[73] Psychoanalytic psychotherapy has shown efficacy, though a randomized trial reported that CBT was more effective in relieving binge eating and purging symptoms as it is generally faster in obtaining results and requires fewer sessions.[93] The most appropriate therapy depends on availability, the comfort of the patient and therapist with the therapy, and comorbidities, such as personality disorder, that may also require treatment.

Providers should encourage understanding of the condition and motivation to normalize eating behavior.

Core dysfunctional thoughts, attitudes, motives, conflicts, and feelings should be addressed.

Family support should be enlisted. Family therapy can be useful in adolescents with bulimia nervosa.[86][92][97][98][99]

Self-help groups may be useful. However, the benefit depends on the underlying philosophy of the group and the group leader(s). Therefore, the clinician should ask about the groups in follow-up.

Consider – glycemic control

Back
ACUTE
|
pregnant
Consider – 

glycemic control

Treatment recommended for SOME patients in selected patient group

Pregnant patients with comorbid diabetes should be referred to an endocrinologist for optimal glucose control. Diabetic patients with bulimia often endure dangerous conditions due to poor blood sugar control, erratic insulin or oral hypoglycemic use, and binge-eating and purging behaviors. Admittance to a hospital may be necessary.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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