CPG for Eating Disorders

D 9.9.2.1.4. Amongst SSRI antidepressants, fluoxetine is the first-choice drug fortreatment of BN, in terms of acceptability, tolerability and symptomreduction. (Adopted from recommendation 7.3.6.3. of the NICE guide).9.9.2.2. What is the safety of antidepressants in patients withBN?The answer is based on the NICE CPG (2004) 30 , which describes the results obtainedfrom RCTs, on the high-quality SRSE (1++) elaborated by the AHRQ of the US (2006) 31 and ona more recently published one by Shapiro, et al. (2007) 211 . The updated search has not identifiedany new evidence. The studies are briefly described in question 9.9.2.1.Scientific EvidenceThere is limited evidence to suggest that antidepressant treatment (fluoxetine,desipramine, imipramine, phenelzine [withdrawn from the Spanish market], trazodone,mianserine, moclobemide) is superior to placebo in treatment discontinuation due toadverse effects (9 RCTs; N=1.078; Pope, 1983 293 , 1989 290 ; Mitchell, 1990 243 ; Walsh,1991 286 ; 1987 288 ; Kanerva, 1994 285 ; Goldstein, 1995 287 ; Fluoxetine Bulimia NervosaCollaborative Study Group, 1992 292 ; Carruba, 2001 291 ; RR: 1.90; 95% CI: 1.20 to 2.99;NNH: 20; 95% CI: 13 to 50).There is insufficient evidence to suggest which types of antidepressants (fluoxetine,desipramine, imipramine, phenelzine [withdrawn from the Spanish market], trazodone,mianserine, moclobemide, brupopion) are well or poorly tolerated by patients with BN(13 RCTs; Pope, 1983 293 , 1989 290 ; Mitchell, 1990 243 , 2001 258 ; Walsh, 1991 286 , 1987 288 ,2004 225 ; Kanerva, 1994 285 ; Goldstein, 1995 287 ; Fluoxetine Bulimia Nervosa CollaborativeStudy Group, 1992 292 ; Carruba, 2001 292 ; McCann, 1990 262 ; Sabine, 1983 299 ; Horne, 1988 289 ;N=1.336; random effects model RR: 0.91; 95% CI:0.72 to 1.16).RCT1++RCT1++There is limited evidence suggesting that treatment with antidepressants (fluoxetine,desipramine) vs. placebo favours treatment acceptability (5 RCTs Mitchell, 2001 258 ;Walsh, 1991 286 , 2004 233 ; Kanerva, 1994 285 ; Goldstein, 1995 287 , Fluoxetine BulimiaNervosa Collaborative Study Group, 1992 292 ; N=803; RR:0.79; 95% CI: 0.67 to 0.95).There is insufficient evidence suggesting that there are significant differences betweenSSRI antidepressants (fluoxetine) and placebo in the number of patients who discontinuetreatment due to adverse effects (3 RCTs Kanerva, 1994 285 ; Goldstein, 1995 287 ,Fluoxetine Bulimia Nervosa Collaborative Study Group, 1992 292 ; N=706; RR: 1.59; 95%CI: 0.88 to 2.88).There is strong evidence to determine that the dropout rate is greater in the placebogroup than in the group receiving tricyclic antidepressants (imipramine, desipramine) (4RCTs; N=217; Pope, 1983 293 , Mitchell, 1990 243 ; Walsh, 1991 286 ; McCann, 1990 262 ; RR:2.03; 95% CI: 1.18 to 3.49; NNT: 7; 95% CI: 4 to 20).RCT1++RCT1++RCT1++145CLINICAL PRACTICE GUIDELINE FOR EATING DISORDERS