Aripiprazole Shows Promise for Some Chronic Eating Disorders

Reprinted from Eating Disorders Review
March/April 2010 Volume 21, Number 2
©2010 Gürze Books

Some patients with chronic eating disorders may benefit from long-term treatment with a newer atypical antipsychotic, aripiprazole, according to the results of a small study (Int J Eat Disord. 2010: released online before publication). There has been increased interest in the atypical antipsychotics after case reports and open trials have described some efficacy for other members of this group, including olanzepine, quetiapine, and risperdone.

Unlike first-generation antipsychotics such as thorazine or haloperidol, which can cause neurological side effects such as extrapyramidal symptoms and, in some cases tardive dyskinesia after prolonged use, the newer products help control psychotic thinking and may have mood-stabilizing, anti-anxiety, and antidepressant properties. However, the newer generation of atypical antipsychotic medications is associated with other adverse effects, including excessive weight gain, insulin resistance leading to diabetes mellitus, and hypercholesterolemia in some patients. Although not free of these adverse effects, apiprazole has generally been less frequently associated with them than olanzapine, quetiapine or risperidone have been.

Mary Ellen Trunko, MD, and colleagues at the University of California-San Diego Medical School treated eight patients with aripiprazole for periods ranging from 4 months to more than 3 years. Five had anorexia nervosa (AN) and three had bulimia nervosa (BN). The authors note that this may be the first report of any response to an antipsychotic agent among patients with BN, and that the drug was well tolerated in all 8 patients.

Two chronic cases

Two cases show the chronic nature of the patients’ symptoms and the effects of aripiprazole. In the first, a 52-year-old woman had a history of vacillations between low-weight BN and AN-purging type since adolescence, and had substance abuse, social phobia, and laxative abuse. Her usual BMI (body mass index, kg/m2) was 17 to 19, with a low of 12. For many years, this patient had taken 50 to 200 over-the-counter laxative tablets daily. She had been on a regimen including quetiapine, 300 mg/night for 6 months, and was taking other drugs daily, including venlafaxine XR, 225 mg; clonazepam, 1.5 mg; buspirone, 30 mg; and trazodone, 250 mg. Several months after discontinuing laxatives, the patient was switched from quetiapine to aripiprazole, 5 mg/day. After a week, she noticed an increased sense of calm, and when the drug was titrated to 10 mg/day, the change in her affect was marked. She returned to eating three meals per day with increasing food choices and was no longer driven to exercise. She has been on the medication for 40 months.

A second patient was a 33-year-old female accountant with a history of BN, major depressive disorder, and obsessive-compulsive traits. She had carefully maintained a BMI of 20 while binge-eating and purging four to five times a week over the past 10 years. While she was in an intensive outpatient eating disorders treatment program, she was treated with escitalopram, 20 mg/day, combined with lamotrigine, 200 mg/day, but remained chronically depressed with daily suicidal ideation and no change in her eating behaviors. With the addition of aripiprazole, 7.5 mg/day, she reported less anxiety, an improved mood, and her binge/purge episodes were reduced to less than one per month. Also, for the first time she reported feeling less rigid thoughts and fears. She got a new job and planned her first true vacation. She maintained her first significant intimate relationship. After about 18 months, lamotrigine was discontinued, and no change in status occurred. She had been treated with aripiprazole for 41 months, with lasting benefits. She had a mild weight gain at first but has been stable at a BMI of 21. A slight increase in binge eating with occasional purging occurred about three years into the program, but topiramate, 75 mg per day was added, and she subsequently had full remission of binge-purge symptoms.

The authors note that these are the first case reports suggesting that aripiprazole may have long-term efficacy and safety in some patients with chronic eating disorders, The medication was well tolerated even at moderately high doses—all 8 patients reported a notable reduction in eating-specific anxiety, and all had a substantial decrease in obsessional thoughts about food, weight, and body image. Three of the AN patients gained weight to normal-range BMIs, and the two others reached partially restored weight. Two underweight BN patients also gained weight to more normal ranges. All reported better tolerance to weight gain than they had experienced with other medications. One hopeful finding was a degree of change in the underlying traits of rigidity and harm avoidance that may be significant, since such traits often remain after recovery.

Further studies are needed

The authors noted that since all patients were taking other medications, it was unclear whether the response was due to aripiprazole alone or to the combined treatment. Also, of the 35 patients the authors have thus far treated with aripiprazole, perhaps half have had a positive response, including reduction of depression, anxiety, and eating-disordered signs and symptoms. About a fourth of all patients have discontinued the drug because of side effects or a change of mind about treatment with medications. And, although many AN patients refuse medication, especially if weight gain is involved, the authors have found that AN patients were more willing to try aripiprazole—perhaps because of the well-publicized fact that weight gain is a less common adverse effect with this drug than with others in its class.

Finally, Dr. Trunko and colleagues write that controlled trials are needed of aripiprazole as monotherapy and as augmentation for antidepressants, to prove whether this drug is truly efficacious for treating patients with eating disorders.

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