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Sodium Oxybate in the Treatment of Binge Eating Disorder: an Open-Label, Prospective Study

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Sodium Oxybate in the Treatment of Binge Eating Disorder: an Open-Label, Prospective Study REGULAR ARTICLE Sodium Oxybate in the Treatment of Binge Eating Disorder: An Open-Label, Prospective Study Susan L. McElroy, MD1,2 ABSTRACT verity, eating pathology, obsessive-com- Objective: To assess preliminarily the pulsive symptoms, food cravings, body Anna I. Guerdjikova, PhD, effectiveness of sodium oxybate in binge mass index, and body weight. Nine par- 1,2 MSW * eating disorder. ticipants had remission of binge eating 1,2 and five lost 5% of their baseline Erin L. Winstanley, PhD Method: This was an open-label, pro- 1 weight; all five of the latter participants Anne M. O’Melia, MD spective, 16-week, flexible dose study of had remission of binge eating. Nicole Mori, CNP1,2 sodium oxybate in binge eating disorder. Paul E. Keck Jr., MD1,2 The primary outcome was binge eating Discussion: In this open-label trial, so- James I. Hudson, MD, ScD3 episode frequency. dium oxybate was effective in binge eat- ing disorder, but associated with high a Results: Twelve individuals received so- discontinuation rate. VC 2010 by Wiley dium oxybate, 10 completed at least one Periodicals, Inc. postbaseline evaluation, and five com- pleted the study. Mean dose at endpoint Keywords: binge eating disorder; was 7.1 (2.0) g/day. Sodium oxybate was pharmacotherapy; sodium oxybate associated with significant reductions in frequency of binge days and binge epi- sodes, as well as measures of clinical se- (Int J Eat Disord 2010; 00:000–000) Introduction the associated obesity. The antiepileptics topira- mate and zonisamide,8–10 the selective norepineph- Binge eating disorder is characterized by recurrent, rine reuptake inhibitor atomoxetine,11 and the distressing episodes of binge eating without the selective serotonin norepinephrine reuptake inhib- inappropriate compensatory weight loss behaviors itor (SNRI) sibutramine12,13 have been shown to of bulimia nervosa.1 It has a lifetime prevalence of decrease both binge eating and excessive body about 2–3%, is often chronic, and is associated with weight, but are associated with problematic psychopathology (mood, anxiety, and substance adverse events and/or low levels of persistent use disorders), obesity, reduced quality of life, and use.5,14,15 Novel treatments that reduce both binge 2–4 disability. eating and body weight and that are well tolerated Despite growing awareness of the significance of are therefore needed for binge eating disorder. binge eating disorder as a public health problem, it Gamma-hydroxybutyrate (GHB) is a unique has no pharmacological treatment approved by the compound that is an endogenous molecule [a 5 Food and Drug Administration (FDA). Several psy- short-chain fatty acid synthesized within the cen- chological interventions and selective serotonin tral nervous system (CNS)], a drug of abuse (illicit reuptake inhibitors (SSRIs) reduce binge eating, GHB), and a therapeutic drug marketed for the 6,7 but not all patients respond adequately. In addi- treatment of excessive daytime sleepiness and cata- tion, these treatments are generally ineffective for plexy in patients with narcolepsy (sodium oxybate; 1 Xyrem ).16–18 Sodium oxybate is also currently Accepted 20 November 2009 being evaluated as a treatment for fibromyalgia, Supported by Jazz Pharmaceuticals. and preliminary trials indicate efficacy and good *Correspondence to: Anna I. Guerdjikova, PhD, MSW, Lindner 19,20 Center of HOPE and Department of Psychiatry, University of Cin- tolerability for this indication. Because of cinnati College of Medicine, 4075 Old Western Row Road Mason, GHB’s association with abuse and severe central Ohio 45040. E-mail: [email protected] nervous system (CNS) depressant effects, including 1 Research Institute, Lindner Center of HOPE, Mason, Ohio 2 respiratory depression, coma, and death when Department of Psychiatry, University of Cincinnati College of 21–23 Medicine, Cincinnati, Ohio taken in overdose, sodium oxybate was 3 Department of Psychiatry, Harvard Medical School and Biologi- approved by the FDA as a Schedule III drug with a cal Psychiatry Laboratory, McLean Hospital, Belmont, Massachu- black box warning stating it is a ‘‘central nervous setts system depressant with abuse potential’’ that Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/eat.20798 ‘‘should not be used with alcohol or other CNS 24 VC 2010 Wiley Periodicals, Inc. depressants.’’ It is presently available only International Journal of Eating Disorders 00:0 000–000 2010 1 McELROY ET AL. through a centralized pharmacy, the Xyrem Success Finally, sodium oxybate is well tolerated when Program,25 which provides educational materials to taken as prescribed.16,17,24 Compared with the anti- both prescriber and patient explaining the risks depressants, antiepileptics, and antiobesity agents and proper use of sodium oxybate, along with the presently used in binge eating disorder, sodium required prescription form. Preliminary experience oxybate is associated with lower rates of sexual dys- with the Success Program has found very little function, cognitive impairment, and hypertension, abuse of sodium oxybate when prescribed in this respectively. 22,25 manner. Because of these observations, we conducted an Several lines of evidence suggested that sodium open-label trial of sodium oxybate in 12 patients oxybate might be a useful treatment for binge eat- with binge eating disorder. ing disorder. First, present in human brain as a metabolite of gaba-aminobutyric acid (GABA), and with at least two identified receptors, GHB modu- lates a number of neurotransmitters involved in the Method regulation of feeding behavior, including GABA, do- pamine, serotonin, opioids, and glutamate.17 Thus, Study Design chronic GHB administration has been shown to This was an open-label, 22-week, prospective, flexible- decrease food-maintained behavior in baboons,26 dose, single-center study conducted at the University of and the GHB analogue GET73 has been shown to Cincinnati Medical Center and the Lindner Center of reduce preference for palatable food in rats.27 Sec- HOPE. After a 1–4 week screening period, qualified par- ond, sodium oxybate treatment has been associ- ticipants entered a 16-week treatment period during ated with weight loss in patients with narcolepsy.28 which they received open-label sodium oxybate. Sodium Most agents associated with weight loss studied oxybate was discontinued at the last visit of the treatment thus far in binge eating disorder have been shown period. This visit was followed by a 2-week post-treat- effective for both binge eating and body weight ment assessment period. 15 reduction. Moreover, growing research has sug- During the treatment period, study visits were con- gested that binge eating disorder and narcolepsy ducted weekly for the first 6 weeks and then every 2 weeks may be pathophysiologically related. Like binge for the remaining 10 weeks. Sodium oxybate was dis- eating disorder, narcolepsy co-occurs with obe- pensed in 180 mL bottles containing 500 mg/mL sodium 29–32 sity, and conversely disturbed eating behaviors, oxybate. Participants were instructed to take 4.5 g/night, 32–35 including binge eating, co-occurs with narco- divided into two equal doses of 2.25 g, for the first lepsy. For example, in a case control study, 23% of 2 weeks, following which the dose could be increased by 60 patients with narcolepsy and cataplexy met cri- 1.5 g/night every 2 weeks as tolerated to a maximum teria for a clinical eating disorder as opposed to dose of 9 g/night. The minimum dose allowed was 3.0 g/ 35 none of 120 healthy controls. The majority of night. In the last 4 weeks of the treatment period, the patients experienced eating disorder symptoms, dosage was not altered unless side effects required a dos- with an irresistible craving for food and binge age reduction. eating being the most prominent features. Indeed, it has been hypothesized that binge eating may Participant Selection Criteria mediate the relationship between narcolepsy and Study participants were individuals recruited from 34 obesity. advertisements for a medication trial for persons with A third line of evidence suggesting sodium oxybate binge eating. They were eligible for the study if they met may be a useful treatment for binge eating disorder is DSM-IV-TR criteria for binge eating disorder1; had a that GHB has been shown effective in suppressing body mass index (BMI) 18 kg/m2 or 40 kg/m2; and craving for alcohol and reducing alcohol consump- were 21 through 65 years of age. Participants were tion in patients with alcohol use disorders in random- excluded if they met any of the following criteria: (1) had 36–40 ized, controlled trials. Preclinical, phenomeno- a lifetime history of a DSM-IV-TR diagnosis of a sub- logic, and comorbidity data suggest binge eating dis- stance abuse or dependence disorder, except for nicotine order and substance use disorders are related2,41,42 or caffeine abuse or dependence (as determined by psy- and growing research shows that medications that chiatric history, Structured Clinical Interview for DSM- reduce craving and consumption of drugs of abuse43 IV-TR,46 and urine toxicology); (2) had a history of a may also reduce binge eating.8,9,15,44,45 Indeed, one personality disorder (e.g., schizotypal, borderline, or anti- such drug, baclofen, shares a common mechanism social) which might interfere with assessment or compli- with sodium oxybate-agonism of centrally active ance with study procedures; (3) were displaying current GABA-B receptors.45 clinically significant depressive symptoms, defined as a 2 International Journal of Eating Disorders 00:0 000–000 2010 SODIUM OXYBATE IN BINGE EATING DISORDER major depressive episode by DSM-IV-TR criteria or a interval between visits (total number of binges in the Montgomery Asberg depression rating scale (MADRS)47 interval, divided by number of days in the interval, and score [24; (4) had clinically significant suicidality or multiplied by 7). Binge episodes were defined using homicidality, had made 1 lifetime suicide attempts, or DSM-IV-TR criteria1 and assessed via clinical interview had a MADRS suicide item score 2; (5) had a lifetime and review of take-home diaries.
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