Guideline sources The following summarized guidelines for the evaluation and management of bulimia nervosa (BN) are prepared by our editorial team based on guidelines from the American Psychiatric Association (APA 2023), the The Scottish Intercollegiate Guidelines Network (SIGN 2022), the U.S. Preventive Services Task Force (USPSTF 2022), the Canadian Practice Guidelines (CPG 2021; 2020), the American Academy of Child and Adolescent Psychiatry (AACAP 2015), the American Association of Family Physicians (AAFP 2015), the Royal Australian and New Zealand College of Psychiatrists (RANZCP 2014), and the American College of Gastroenterology (ACG 2013). 1 2 3 4 5 6 7 8 9 Guidelines 1. Screening and diagnosis Indications for screening: As per APA 2023 guidelines, screen for the presence of an eating disorder as part of an initial psychiatric evaluation. B As per SIGN 2022 guidelines: https://web.pathway.md/diseases/rec6qHyJqfYNfNum4 1/7 6/29/23, 3:21 AM Bulimia nervosa Pathway Consider screening for the presence of eating disorders as part of the routine review of patients with T1DM. C Elicit history of current or past history of eating disorders in females during pregnancy and postnatal period, recognizing the potential barriers for disclosure. A As per USPSTF 2022 guidelines, insufficient evidence to assess the balance of benefits and harms of screening for eating disorders in adolescents and adults. I As per AACAP 2015 guidelines, screen all pediatric and adolescent patients for eating disorders seen by a mental health clinician, followed by a comprehensive diagnostic evaluation (including laboratory tests and imaging studies as indicated) if positive. B As per ACG 2013 guidelines, consider assessing for the presence of eating disorders (including BN) when evaluating a patient for gastroparesis. B 2. Diagnostic investigations Initial evaluation: As per APA 2023 guidelines, assess the following during the initial evaluation of patients with a possible eating disorder: height and weight history (maximum and minimum weight, recent weight changes) presence of, patterns in, and changes in restrictive eating, food avoidance, binge eating, and other eating-related behaviors (rumination, regurgitation, chewing, and spitting) patterns and changes in food repertoire (breadth of food variety, narrowing or elimination of food groups) presence of, patterns in, and changes in compensatory and other weight control behaviors, including dietary restriction, compulsive or driven exercise, purging behaviors (laxative use, self-induced vomiting), and use of medication to manipulate weight percentage of time preoccupied with food, weight, and body shape prior treatment and response to treatment for an eating disorder psychosocial impairment secondary to eating or body image concerns or behaviors family history of eating disorders, other psychiatric illnesses, and other medical conditions (obesity, IBD, diabetes mellitus). B Show 2 more As per RANZCP 2014 guidelines, include the following in the assessment of adult patients with possible BN: elicit history enquiring into any binge eating, dietary restriction and/or fasting, compulsive or driven exercise, or additional weight control behaviors assess for cognitions of weight and/or shape overvaluation, and body image and eating preoccupations assess for any past history of eating disorders or other psychiatric comorbidities perform a physical examination, including measurement of weight, height, BMI calculation, pulse rate, and BP https://web.pathway.md/diseases/rec6qHyJqfYNfNum4 2/7 6/29/23, 3:21 AM Bulimia nervosa Pathway consider obtaining cardiovascular evaluation and an ECG as clinically indicated consider obtaining serum biochemistry and random glucose as clinically indicated consider involving a general practitioner and/or dentist as appropriate. B Electrocardiogram: obtain an ECG in patients with a restrictive eating disorder, severe purging behavior, or taking medications known to prolong the QTc interval. B Laboratory tests: obtain a CBC and a comprehensive metabolic panel including electrolytes, liver enzymes, and renal function tests in the laboratory assessment of patients with a possible eating disorder. B Screening for comorbidities: As per AAFP 2015 guidelines, assess for psychiatric comorbidities, including depression and suicide risk, anxiety disorders, and substance use disorders, in patients with an eating disorder. B As per RANZCP 2014 guidelines, assess for any past history of eating disorders or other psychiatric comorbidities in patients with BN. B Screening for comobidities: as per APA 2023 guidelines, assess for co-occurring health conditions, including psychiatric disorders, in the initial psychiatric evaluation of patients with a possible eating disorder. B 3. Medical management Multidisciplinary care: As per APA 2023 guidelines, provide a documented, comprehensive, culturally appropriate, and person-centered treatment plan incorporating medical, psychiatric, psychological, and nutritional expertise, commonly via a coordinated multidisciplinary team, in patients with an eating disorder. B As per AACAP 2015 guidelines, ensure a multidisciplinary team approach (developmentally aware, sensitive, and skilled in the care of pediatric and adolescent patients with eating disorders) for the treatment of eating disorders in young patients. B As per AAFP 2015 guidelines, ensure an interdisciplinary team approach, often including a family physician, a psychotherapist or psychiatrist, a dietitian, an eating disorder specialist, and school personnel, for the treatment of patients with BN. B Setting of care: As per AACAP 2015 guidelines: Offer outpatient psychosocial interventions as the initial treatment of choice in pediatric and adolescent patients with an eating disorder. B Consider offering psychiatric hospitalization, day programs, partial hospitalization programs, and residential programs for eating disorders in pediatric and adolescent patients only when outpatient interventions have been unsuccessful or are unavailable. C https://web.pathway.md/diseases/rec6qHyJqfYNfNum4 3/7 6/29/23, 3:21 AM Bulimia nervosa Pathway As per AAFP 2015 guidelines, assess medical stability and the need for hospitalization in the initial evaluation of patients with eating disorders. B As per RANZCP 2014 guidelines, consider admitting patients to an inpatient or day program unit if there is an increased risk of non-response to outpatient/community-based care. C Pharmacotherapy, general principles: As per AACAP 2015 guidelines, reserve medications, including complementary and alternative medications, for comorbid conditions and refractory cases. B As per RANZCP 2014 guidelines: Consider offering pharmacotherapy as an adjunctive treatment for an additive benefit. B Offer pharmacological treatment where psychological therapy is not available. A Pharmacotherapy, antidepressants: As per APA 2023 guidelines, offer SSRIs (such as fluoxetine 60 mg/day), either initially or in case of minimal or no response to psychotherapy alone by 6 weeks, in adult patients with BN. B As per SIGN 2022 guidelines, consider offering antidepressants as a short-term treatment in patients with BN or as an adjunct to psychological treatments. C Show 2 more As per AAFP 2015 guidelines, consider offering elective serotonin reuptake inhibitors for the treatment of patients with BN. C As per RANZCP 2014 guidelines: Offer high-dose fluoxetine or other SSRIs in patients with BN. A Monitor adverse effects of antidepressants and modify use as required. B Pharmacotherapy (antipsychotics): avoid using antipsychotics for the treatment of patients with BN. D Pharmacotherapy (obesity medications): consider offering topiramate or orlistat for weight loss in patients with comorbid obesity. C 4. Nonpharmacologic interventions Psychotherapy: As per APA 2023 guidelines: Offer eating disorder-focused CBT in adult patients with BN. B Offer eating disorder-focused family-based treatment in adolescent and emerging adult patients with BN having an involved caregiver. B As per SIGN 2022 guidelines, offer CBT, preferably in the specially adapted format for eating disorders or BN, as first-line therapy in adult patients with BN. Consider offering other treatment options, such as interpersonal therapy, integrative cognitive-affective therapy, or schema therapy, if CBT is ineffective, unsuitable, or unacceptable. A https://web.pathway.md/diseases/rec6qHyJqfYNfNum4 4/7 6/29/23, 3:21 AM Bulimia nervosa Pathway Show 3 more As per CPG 2020 guidelines: Offer family-based treatment in all pediatric and adolescent patients with BN, especially with a duration of illness < 3 years. A Consider CBT in pediatric and adolescent patients with BN. C As per AAFP 2015 guidelines, consider offering psychotherapy, such as CBT, for the treatment of patients with BN. C As per RANZCP 2014 guidelines, offer individual psychological therapy (therapist-led CBT or enhanced CBT; alternatively, CBT adapted for internet delivery or in guided self-help form) as first-line therapy in adult patients with BN. A Technology-based interventions: As per SIGN 2022 guidelines, consider offering psychological assessments and treatment via videoconferencing as an adjunct or alternative to in-person sessions when there are barriers to accessing in-person sessions. C As per CPG 2021 guidelines, offer internet CBT-based guided self-help in emerging adult patients with BN. A Show 6 more Yoga: advise practicing, yoga in addition to standard treatments, in medically stable young patients with anorexia nervosa. B 5. Specific circumstances Pregnant patients: elicit history of current or past history of eating disorders in females during pregnancy and postnatal period, recognizing the potential barriers for disclosure. A Show 13 more Clinical findings Symptoms Past medical history Amenorrhea AUD Anxiety Attention deficit hyperactivity disorder Binge eating Binge eating disorder Body image dissatisfaction Depression Fainting Iron deficiency anemia Fatigue Obesity Lightheadedness Personality disorders Mood changes Substance use disorder Purging behavior Vitamin B12 deficiency Self-induced vomiting Vitamin D deficiency Suicidal ideation https://web.pathway.md/diseases/rec6qHyJqfYNfNum4 5/7 6/29/23, 3:21 AM Bulimia nervosa Pathway Social history Medication history Dietary restrictions Diuretics Overexercising Laxatives Head and neck exam Vascular exam Angular cheilitis Peripheral edema Bilateral parotid gland enlargement Dental exam Dental erosions Gynecologic exam Anovulation Integument exam Dehydration Lab findings Russell's sign Hypocalcemia Hypochloremia Hypokalemia Hypomagnesemia Hyponatremia Hypophosphatemia Metabolic acidosis Metabolic alkalosis Zinc deficiency References 1. 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J Eat Disord. 2021 Apr 16;9 1 46. Open 5. Scottish Intercollegiate Guidelines Network. SIGN 164 Eating disorders. SIGN. 2022 Aug. Open 6. Brian C Harrington, Michelle Jimerson, Christina Haxton et al. Initial Evaluation, Diagnosis, and Treatment of Anorexia Nervosa and Bulimia Nervosa. Am Fam Physician. 2015 Jan 1;91 1 46 52. Open https://web.pathway.md/diseases/rec6qHyJqfYNfNum4 6/7 6/29/23, 3:21 AM Bulimia nervosa Pathway 7. US Preventive Services Task Force, Karina W Davidson, Michael J Barry et al. Screening for Eating Disorders in Adolescents and Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2022 Mar 15;327 11 1061 1067. Open 8. Jennifer Couturier, Leanna Isserlin, Mark Norris et al. Canadian practice guidelines for the treatment of children and adolescents with eating disorders. J Eat Disord. 2020 Feb 1;8 4. Open 9. Camilleri M, Parkman HP, Shafi MA et al. Clinical guideline: management of gastroparesis. Am J Gastroenterol. 2013 Jan;108 1 18 37. 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