# Bulimia Nervosa - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: NICE Guideline NG69: Eating disorders: recognition and treatment 2017 (updated 2020) · Fluoxetine 20 mg Capsules SmPC section 4.2 (eMC product 11909) · LUSTRAL ® 50 mg film coated tablets SmPC section 4.2 Posology and method of administration (eMC product 1070) - Verified date: 2026-08 ## Verified against - Fluoxetine 20 mg Capsules SmPC section 4.2 (eMC product 11909) - LUSTRAL ® 50 mg film coated tablets SmPC section 4.2 Posology and method of administration (eMC product 1070) - Bulimia Nervosa - disease-level clinical article (bulimia-nervosa-full.txt) - Bulimia Nervosa - disease-level clinical article (bulimia-nervosa-clinical.txt) ## Treatment metadata - Fluoxetine — 20 mg — oral.solid - Referral & safety-netting (no drug therapy) - Sertraline — 50 mg — oral.solid ## Complete treatment card ```text BULIMIA NERVOSA Sources: NICE Guideline NG69: Eating disorders: recognition and treatment 2017 (updated 2020) · Fluoxetine 20 mg Capsules SmPC section 4.2 (eMC product 11909) · LUSTRAL ® 50 mg film coated tablets SmPC section 4.2 Posology and method of administration (eMC product 1070) Review status: REVIEWED against Fluoxetine 20 mg Capsules SmPC section 4.2 (eMC product 11909), LUSTRAL ® 50 mg film coated tablets SmPC section 4.2 Posology and method of administration (eMC product 1070), Bulimia Nervosa - disease-level clinical article (bulimia-nervosa-full.txt), Bulimia Nervosa - disease-level clinical article (bulimia-nervosa- clinical.txt) (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (1) - History often reveals sore throat, irregular periods, and constipation, plus headache, fatigue, and lethargy, as well as abdominal pain and bloating [abdominal distension · abdominal pain · abnormal uterine bleeding · constipation · fatigue · headache · irregular periods · lethargy · sore throat] SIGNS - what you find (5) - Exam findings can include low blood pressure, dry skin, swollen parotid glands, and dental erosion [dry skin · hypotension · parotid swelling] - Calluses on the back of the hand, known as Russell's sign, come from self-induced vomiting [vomiting] - Hair loss, fluid retention, and nosebleeds can also be associated with bulimia nervosa [hair loss · nosebleed · oedema] - Orthostatic blood pressure, height, weight, and vital signs are checked, along with skin, mouth, and abdominal exam - An exam for neurologic disease is done first, so vomiting or weight loss is not wrongly labeled as bulimia [vomiting · weight loss] TESTS (6) - A metabolic panel checks electrolytes, liver function, BUN, creatinine, and calcium - A complete blood count with differential is obtained, and a vitamin B12 level may be considered - If disease is severe, serum magnesium, phosphorus, and an ECG are also obtained - Female patients get a pregnancy test, and those with secondary amenorrhea are tested for LH, prolactin, beta-hCG, and FSH - A positive laxative screen in stool or urine is not required to make the diagnosis - Typical lab abnormalities include low potassium with alkalosis, low sodium, and elevated liver enzymes IF NOT THIS - what else fits (8) - Biliary disease causes nausea and vomiting with abnormal transaminases or bilirubin - Irritable bowel syndrome increases bowel frequency but is not usually tied to binge eating - Prader-Willi syndrome causes excess appetite and obesity, with intellectual disability and hypogonadism, but no purging - Kleine-Levin syndrome affects adolescent males with increased appetite, excess sleepiness, and behavior change, without purging - Diabetes mellitus is a recognized cause of excess hunger and should be checked with a blood glucose - Anorexia nervosa differs because it requires a BMI under 18, which is not required for bulimia - Binge eating disorder lacks the purging and between-binge dietary restriction seen in bulimia - Major depressive disorder and borderline personality disorder can involve overeating and suicidal ideation but lack bulimia's compensatory purging Source StatPearls "Bulimia Nervosa" - disease-level clinical article Status traced to the source above 1. FLUOXETINE [1st line] Adult 60 mg once daily - Review at 3 months. The label is explicit that long-term efficacy beyond 3 months has not been demonstrated in bulimia Peds Children and adolescents <18 years require specialist child/adolescent eating disorder service referral; fluoxetine 60 mg/day efficacy is unestablished in under-18 bulimia (BNFC 2024). Source Fluoxetine 20 mg Capsules SmPC section 4.2 (eMC product 11909) Why 60 mg a day is the licensed bulimia dose and it beat placebo on bingeing, vomiting and purging in trials under 16 weeks. Beyond three months no conclusion can be drawn, and no source supports a '6-12 months minimum'. Caution Evidence-based eating disorder psychological therapy (CBT-ED) is the primary first-line treatment; pharmacotherapy is an adjunct or alternative. Check baseline and periodic serum electrolytes (potassium, sodium, magnesium) and ECG due to risk of hypokalemic metabolic alkalosis and QT prolongation from vomiting/laxative abuse. Increased risk of suicidal ideation in young adults (<25 years) during initial weeks of therapy. Bupropion is strictly contraindicated in bulimia nervosa due to severe risk of drug- induced seizures. NICE NG69 does not name a drug or a dose for bulimia. Its only medication recommendation is not to offer medication as the sole treatment - the treatment is guided self-help or CBT-ED, and this sits alongside it. Fluoxetine is contra-indicated in combination with irreversible, non-selective monoamine oxidase inhibitors (e.g. iproniazid). Fluoxetine is contra-indicated in combination with metoprolol used in cardiac failure. Egypt FLOROSIN 20MG 10 CAPS. UP PHARMA 11.00 EGP (1.10/unit) PHILOZAC 20MG 10 CAPS. AMOUN 11.00 EGP (1.10/unit) FLUOXETINE 20 MG 10 CAPS. MISR 18.60 EGP (1.86/unit) ELEVAMOOD 20 MG 28 CAPS. UNIPHARMA 56.00 EGP (2.00/unit) OCTOZAC 20MG 10 CAPS. OCTOBER PHARMA 21.60 EGP (2.16/unit) PHILOZAC 20MG 30 CAPS. AMOUN 75.00 EGP (2.50/unit) PROZAC 20MG 14 CAPS. ELI LILLY 118.00 EGP (8.43/unit) FLUOXETINE 20 MG H.G.CAPS. SIGMA 8.00 EGP 2. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult Source Bulimia Nervosa - disease-level clinical article (bulimia-nervosa-full.txt) Why Carries the referral criteria and warning signs for this condition, which apply whichever treatment is chosen. Caution RED FLAG - Perform an initial medical evaluation to determine medical stability and whether hospitalization is needed. RED FLAG - A cardiology consult is needed for severe or symptomatic cardiac complications from electrolyte derangement. RED FLAG - Screen for suicidality and comorbid psychiatric illness. 3. SERTRALINE [2nd line] Adult 50 mg once daily in morning, titrate by 50 mg weekly to target 100-200 mg daily Peds Specialist eating disorder service referral required. Source LUSTRAL ® 50 mg film coated tablets SmPC section 4.2 Posology and method of administration (eMC product 1070) Why Off-label SSRI alternative when fluoxetine is not tolerated or contraindicated. Fluoxetine's own SmPC (eMC 11909) licenses it specifically for bulimia nervosa at 60 mg/day ("Fluoxetine is indicated as a complement of psychotherapy for the reduction of binge-eating and purging activity"); no cached document licenses sertraline for this indication, and NG69 does not name a drug for bulimia at all. Caution Monitor for GI side effects, hyponatremia, and serotonin syndrome. Electrolyte screening mandatory prior to initiation. Do not abruptly stop therapy due to SSRI discontinuation syndrome. Off-label and not in NG69, which does not mention sertraline at all. It is here for the patient who cannot take fluoxetine; there is no bulimia-specific licensed dose behind it. Concomitant treatment with irreversible monoamine oxidase inhibitors (MAOIs) is contraindicated due to the risk of serotonin syndrome with symptoms such as agitation, tremor and hyperthermia. Concomitant intake of pimozide is contraindicated (see section 4.5). Egypt OPIRALINE 50 MG 20 F.C. TABS. EL-OBOUR 29.00 EGP (1.45/unit) AGRELOCIT 50 MG 20 TAB. MEMPHIS > ATM... 34.80 EGP (1.74/unit) DEPR-STAT 50MG 10 CAPS. MEMPHIS 21.60 EGP (2.16/unit) SESERINE 50MG 30 TAB. ADWIA 75.00 EGP (2.50/unit) SERPASS 50MG 30 F.C.TAB. GLOBAL NAPI P... 102.00 EGP (3.40/unit) SIRTO 50MG 10 F.C. TABS. HI-PHARM 34.00 EGP (3.40/unit) MOODAPEX 50 MG 30 F.C.TAB. MULTI-APEX 111.00 EGP (3.70/unit) LUSTRAL 50 MG 20 F.C.TABS. VIATRIS 136.00 EGP (6.80/unit) Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)