Lisdexamfetamine in the treatment of moderate-to-severe binge eating disorder in adults: systematic review and exploratory meta-analysis of publicly available placebo-controlled, randomized clinical trials

Exploring bi-directional impacts of Lisdexamfetamine dimesylate on psychological comorbidities and quality of life in people with Binge Eating Disorder

BACKGROUND

Lisdexamfetamine dimesylate (LDX) has demonstrated safety and efficacy for treatment of Binge Eating Disorder (BED). However, to date, trials have not included participants with co-occurring psychiatric disorders. This study explores how LDX affects eating disorder psychopathology, symptoms of common psychiatric comorbidities of BED (ADHD, depression, anxiety), and psychological quality of life, in people with moderate to severe BED.

METHODS

These are secondary analyses of an open-label LDX trial conducted in 41 adults (18-40 years) over eight-weeks. Participants received LDX titrated to 50 or 70 mg. Clinical assessments and self-report questionnaires were conducted at baseline and 8-week follow-up.

RESULTS

Eating disorder psychopathology and psychological quality of life improved after 8-weeks of LDX. No significant group-level changes in depression, anxiety or ADHD severity scores were observed. However, the majority within the small subsets with elevated depression and ADHD symptoms experienced reduced depressive and inattentive symptom severity, respectively.

CONCLUSIONS

We provide proof-of-concept evidence that LDX may provide broader psychological benefits to individuals with BED, beyond reducing their BE frequency. Effects of LDX on anxiety should be monitored closely by clinicians. Early indications suggest that LDX may be effectively used in people with BED, with and without co-occurring psychiatric conditions, however tolerability may be lower in highly complex cases.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry (anzctr.org.au) #ACTRN12618000623291.

Knowledge and attitudes towards eating disorders: A survey of psychiatrists and psychiatry trainees in New South Wales

OBJECTIVE

To evaluate New South Wales (NSW) psychiatrists' and psychiatry trainees' knowledge and attitudes towards eating disorders (EDs).

METHOD

A total of 1781 psychiatrists and trainees in NSW were invited to complete an anonymous questionnaire assessing ED confidence, knowledge and attitudes.

RESULTS

A total of 51 doctors responded to the survey, with 38 completing all items. Significant knowledge gaps were revealed. Respondents expressed a desire for more ED training.

CONCLUSION

Enhanced ED training in psychiatry education and incorporating the lived experience voice to improve attitudes appear necessary.

Established and emerging treatments for eating disorders

Eating disorders (EDs) are common mental health conditions that carry exceedingly high morbidity and mortality rates. Evidence-based treatment options include a range of psychotherapies and some, mainly adjunctive, pharmacological interventions. However, around 20-30% of people fail to respond to the best available treatments and develop a persistent treatment-refractory illness. Novel treatments for these disorders are emerging, but their efficacy and clinical relevance need further investigation. In this review article, we first outline the evidence-base for the established treatments of the three 'classical' EDs [anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED)]. We then review research on some of the most promising emerging treatment modalities, discussing the questions and challenges that remain.

Outcomes in people with eating disorders: a transdiagnostic and disorder-specific systematic review, meta-analysis and multivariable meta-regression analysis

Eating disorders (EDs) are known to be associated with high mortality and often chronic and severe course, but a recent comprehensive systematic review of their outcomes is currently missing. In the present systematic review and meta-analysis, we examined cohort studies and clinical trials published between 1980 and 2021 that reported, for DSM/ICD-defined EDs, overall ED outcomes (i.e., recovery, improvement and relapse, all-cause and ED-related hospitalization, and chronicity); the same outcomes related to purging, binge eating and body weight status; as well as mortality. We included 415 studies (N=88,372, mean age: 25.7±6.9 years, females: 72.4%, mean follow-up: 38.3±76.5 months), conducted in persons with anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), other specified feeding and eating disorders (OSFED), and/or mixed EDs, from all continents except Africa. In all EDs pooled together, overall recovery occurred in 46% of patients (95% CI: 44-49, n=283, mean follow-up: 44.9±62.8 months, no significant ED-group difference). The recovery rate was 42% at <2 years, 43% at 2 to <4 years, 54% at 4 to <6 years, 59% at 6 to <8 years, 64% at 8 to <10 years, and 67% at ≥10 years. Overall chronicity occurred in 25% of patients (95% CI: 23-29, n=170, mean follow-up: 59.3±71.2 months, no significant ED-group difference). The chronicity rate was 33% at <2 years, 40% at 2 to <4 years, 23% at 4 to <6 years, 25% at 6 to <8 years, 12% at 8 to <10 years, and 18% at ≥10 years. Mortality occurred in 0.4% of patients (95% CI: 0.2-0.7, n=214, mean follow-up: 72.2±117.7 months, no significant ED-group difference). Considering observational studies, the mortality rate was 5.2 deaths/1,000 person-years (95% CI: 4.4-6.1, n=167, mean follow-up: 88.7±120.5 months; significant difference among EDs: p<0.01, range: from 8.2 for mixed ED to 3.4 for BN). Hospitalization occurred in 26% of patients (95% CI: 18-36, n=18, mean follow-up: 43.2±41.6 months; significant difference among EDs: p<0.001, range: from 32% for AN to 4% for BN). Regarding diagnostic migration, 8% of patients with AN migrated to BN and 16% to OSFED; 2% of patients with BN migrated to AN, 5% to BED, and 19% to OSFED; 9% of patients with BED migrated to BN and 19% to OSFED; 7% of patients with OSFED migrated to AN and 10% to BN. Children/adolescents had more favorable outcomes across and within EDs than adults. Self-injurious behaviors were associated with lower recovery rates in pooled EDs. A higher socio-demographic index moderated lower recovery and higher chronicity in AN across countries. Specific treatments associated with higher recovery rates were family-based therapy, cognitive-behavioral therapy (CBT), psychodynamic therapy, and nutritional interventions for AN; self-help, CBT, dialectical behavioral therapy (DBT), psychodynamic therapy, nutritional and pharmacological treatments for BN; CBT, nutritional and pharmacological interventions, and DBT for BED; and CBT and psychodynamic therapy for OSFED. In AN, pharmacological treatment was associated with lower recovery, and waiting list with higher mortality. These results should inform future research, clinical practice and health service organization for persons with EDs.

Psychological and Medical Treatments for Binge-Eating Disorder: A Research Update

Binge-eating disorder (BED), characterized by recurrent binge eating in the absence of regular weight-compensatory behaviors, is the most common eating disorder, associated with pronounced mental and physical sequelae. An increasing body of research documents the efficacy of diverse approaches to the treatment of this disorder, summarized in meta-analyses. This research update narratively reviewed randomized-controlled trials (RCTs) on the psychological and medical treatment of BED published between January 2018 to November 2022, identified through a systematic literature search. A total of 16 new RCTs and 3 studies on previous RCTs providing efficacy- and safety-related data were included. Regarding psychotherapy, confirmatory evidence supported the use of integrative-cognitive therapy and, with lower effects, brief emotion regulation skills training for binge eating and associated psychopathology. Behavioral weight loss treatment was revealed to be efficacious for binge eating, weight loss, and psychopathology, but its combination with naltrexone-bupropion did not augment efficacy. New treatment approaches were explored, including e-mental-health and brain-directed treatments, mostly targeting emotion and self-regulation. Additionally, different therapeutic approaches were evaluated in complex stepped-care models. In light of these advances, future research is necessary to further optimize effects of evidence-based treatments for BED, through improvement of existing or development of new treatments, based on mechanistic and/or interventional research, and/or tailoring treatments to personal characteristics in a precision medicine approach.

Genetics and neurobiology of eating disorders

Eating disorders (anorexia nervosa, bulimia nervosa and binge-eating disorder) are a heterogeneous class of complex illnesses marked by weight and appetite dysregulation coupled with distinctive behavioral and psychological features. Our understanding of their genetics and neurobiology is evolving thanks to global cooperation on genome-wide association studies, neuroimaging, and animal models. Until now, however, these approaches have advanced the field in parallel, with inadequate cross-talk. This review covers overlapping advances in these key domains and encourages greater integration of hypotheses and findings to create a more unified science of eating disorders. We highlight ongoing and future work designed to identify implicated biological pathways that will inform staging models based on biology as well as targeted prevention and tailored intervention, and will galvanize interest in the development of pharmacologic agents that target the core biology of the illnesses, for which we currently have few effective pharmacotherapeutics.

Lisdexamfetamine and binge-eating disorder: A systematic review and meta-analysis of the preclinical and clinical data with a focus on mechanism of drug action in treating the disorder

Binge-Eating Disorder (BED) is the most common eating disorder in the United States. Lisdexamfetamine (LDX) was approved in 2015 by the FDA for treatment of BED and is the only drug approved for treating the disorder. There has been no systematic evaluation of the published clinical and preclinical evidence for efficacy of LDX in treating BED and the mechanisms responsible for the therapeutic action of the drug. To address this gap, we conducted a systematic review and meta-analysis using PRISMA guidelines. Fourteen clinical and seven preclinical articles were included. There is consistent evidence from clinical studies that LDX is an effective treatment for BED and that the drug reduces the BED symptoms and body weight of patients with the disorder. There is also consistent evidence from preclinical studies that LDX reduces food intake but no consistent evidence for a preferential reduction of palatable food consumption by the drug in rodents. The evidence on mechanism of action is more limited and suggests LDX may reduce binge eating by a combination of effects on appetite/satiety, reward, and cognitive processes, including attention and impulsivity/inhibition, that are mediated by catecholamine and serotonin mechanisms in the brain. There is an urgent need for adequately powered, placebo-controlled, behavioural and neuroimaging studies with LDX (recruiting patients and/or individuals with subclinical BED symptoms) to further investigate the mechanism of action of the drug in treating BED. An improved understanding of the behavioural and neurochemical mechanisms of action of LDX could lead to the development of improved drug therapies to treat BED.

An open-label trial on the efficacy and tolerability of naltrexone/bupropion SR for treating altered eating behaviours and weight loss in binge eating disorder

PURPOSE

Binge eating disorder (BED) has a considerable clinical relevance by virtue of its high numerous psychiatric and medical comorbidities; among the latter, the most frequent is obesity. Available treatments for BED have shown frequent relapse of binges or weight regain in the long term. The new combination of naltrexone and bupropion sustained release (NB) has proved to be effective for weight loss among obese patients. As NB acts on hypothalamic and reward circuits, that seem involved in the pathogenesis and maintenance of BED symptoms, this study aims to evaluate the efficacy of NB in improving pathological eating behavior and losing weight in BED patients.

METHODS

In this preliminary study, 23 obese-BED patients and a control group of 20 obese non-BED patients (respectively, Groups 1 and 2) who had previously undergone at least 5 unsuccessful weight-loss programs were treated with NB in addition to modified life style. Evaluation at t0 and after 16 weeks of treatment (t1) included anthropometric measurement, eating behavior assessment and psychopathological questionnaires (EDE-Q, BES, YFAS, BDI and STAI).

RESULTS

A significant and similar weight loss (ΔBMI% ≈ 8%) was evident for both groups. Pathological eating behavior (i.e., binge, grazing, emotional eating, craving for carbohydrates, and post-dinner eating), BES score and YFAS severity significantly improved, especially among BED. NB was well tolerated and drop-out rate was low.

CONCLUSION

Treatment with NB, in addition to a reduced-calorie diet and increased physical activity, seems an effective and well-tolerated option for improving pathological eating behavior and losing weight in obese-BED patients.

LEVEL OF EVIDENCE

Level III case-control study.

Treatment of Eating Disorders in Adults Versus Adolescents: Similarities and Differences

FINDINGS

Although several individual psychotherapies for adults with eating disorders are empirically supported, with family-based treatment (FBT) being the leading recommended empiric treatment in adolescents, patients with eating disorders are still difficult to treat, and outcomes are often poor. In some countries, the clinical services for adolescents and adults are separate, and it is common for patients to receive treatments that differ in terms of both theory and content when they are switched from adolescent to adult services. Changes in the nature of treatment also often occur when patients move from less intensive types of care to more intensive treatment, and vice versa. These transitions may create a discontinuity in the care pathway and disorient patients and their significant others about the strategies and procedures used for addressing eating problems. However, the observation that younger and older patients essentially share the same eating-disorder psychopathology has led to evidence-based enhanced cognitive-behavioral therapy (CBT-E) being adapted for use in adolescents. Originally an evidence-based treatment for adults with eating disorders, CBT-E has yielded promising results in trials in cohorts of adolescent outpatients and inpatients, and is recommended as an alternative to FBT in adolescent patients.

IMPLICATIONS

With a unified treatment such as CBT-E, several issues that plague conventional eating-disorder services could be partially overcome, as patients can move seamlessly from adolescence to adulthood and through different levels of care, with no change in the nature of the treatment itself. Future randomized, controlled trials should compare FBT to CBT-E to better clarify the specific therapeutic needs of subgroups of adolescents and adult patients with eating disorders.

Eating disorders

Eating disorders are disabling, deadly, and costly mental disorders that considerably impair physical health and disrupt psychosocial functioning. Disturbed attitudes towards weight, body shape, and eating play a key role in the origin and maintenance of eating disorders. Eating disorders have been increasing over the past 50 years and changes in the food environment have been implicated. All health-care providers should routinely enquire about eating habits as a component of overall health assessment. Six main feeding and eating disorders are now recognised in diagnostic systems: anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant-restrictive food intake disorder, pica, and rumination disorder. The presentation form of eating disorders might vary for men versus women, for example. As eating disorders are under-researched, there is a great deal of uncertainty as to their pathophysiology, treatment, and management. Future challenges, emerging treatments, and outstanding research questions are addressed.

Systematic review and exploratory meta-analysis of the efficacy, safety, and biological effects of psychostimulants and atomoxetine in patients with schizophrenia or schizoaffective disorder

OBJECTIVE

Our aim was to summarize the efficacy and safety of atomoxetine, amphetamines, and methylphenidate in schizophrenia.

METHODS

We undertook a systematic review, searching PubMed/Scopus/Clinicaltrials.gov for double-blind, randomized, placebo-controlled studies of psychostimulants or atomoxetine in schizophrenia published up to 1 January 2017. A meta-analysis of outcomes reported in two or more studies is presented.

RESULTS

We included 22 studies investigating therapeutic effects of stimulants (k=14) or measuring symptomatic worsening/relapse prediction after stimulant challenge (k=6). Six studies of these two groups plus one additional study investigated biological effects of psychostimulants or atomoxetine. No effect resulted from interventional studies on weight loss (k=1), smoking cessation (k=1), and positive symptoms (k=12), and no improvement was reported with atomoxetine (k=3) for negative symptoms, with equivocal findings for negative (k=6) and mood symptoms (k=2) with amphetamines. Attention, processing speed, working memory, problem solving, and executive functions, among others, showed from no to some improvement with atomoxetine (k=3) or amphetamines (k=6). Meta-analysis did not confirm any effect of stimulants in any symptom domain, including negative symptoms, apart from atomoxetine improving problem solving (k=2, standardized mean difference (SMD)=0.73, 95% CI=0.10-1.36, p=0.02, I2=0%), and trending toward significant improvement in executive functions with amphetamines (k=2, SMD=0.80, 95% CI=-1.68 to +0.08, p=0.08, I2=66%). In challenge studies, amphetamines (k=1) did not worsen symptoms, and methylphenidate (k=5) consistently worsened or predicted relapse. Biological effects of atomoxetine (k=1) and amphetamines (k=1) were cortical activation, without change in β-endorphin (k=1), improved response to antipsychotics after amphetamine challenge (k=2), and an increase of growth hormone-mediated psychosis with methylphenidate (k=2). No major side effects were reported (k=6).

CONCLUSIONS

No efficacy for stimulants or atomoxetine on negative symptoms is proven. Atomoxetine or amphetamines may improve cognitive symptoms, while methylphenidate should be avoided in patients with schizophrenia. Insufficient evidence is available to draw firm conclusions.

A Phase 3, Multicenter, Open-Label, 12-Month Extension Safety and Tolerability Trial of Lisdexamfetamine Dimesylate in Adults With Binge Eating Disorder

BACKGROUND

A 12-month, open-label extension study assessed the long-term safety and tolerability of lisdexamfetamine dimesylate (LDX) in adults with binge eating disorder (BED).

METHODS

Adults (aged 18-55 y) with BED who completed 1 of 3 antecedent studies were enrolled in a 52-week, open-label extension study (dose optimization, 4 weeks [initial titration dose, 30-mg LDX; target doses, 50- or 70-mg LDX]; dose maintenance, 48 weeks). Safety evaluations included the occurrence of treatment-emergent adverse events (TEAEs), vital sign and weight assessments, and Columbia-Suicide Severity Rating Scale responses.

RESULTS

Of the 604 enrolled participants, 599 (521 women and 78 men) comprised the safety analysis set, and 369 completed the study. Mean (SD) LDX exposure was 284.3 (118.84) days; cumulative LDX exposure duration was 12 months or longer in 344 participants (57.4%). A total of 506 participants (84.5%) reported TEAEs (TEAEs leading to treatment discontinuation, 54 [9.0%]; severe TEAEs, 42 [7.0%]; serious TEAEs, 17 [2.8%]). Treatment-emergent adverse events reported in greater than or equal to 10% of participants were dry mouth (27.2%), headache (13.2%), insomnia (12.4%), and upper respiratory tract infection (11.4%). Mean (SD) changes from antecedent study baseline in systolic and diastolic blood pressure, pulse, and weight at week 52/early termination (n = 597) were 2.19 (11.043) and 1.77 (7.848) mm Hg, 6.58 (10.572) beats per minute, and -7.04 (7.534) kg, respectively. On the Columbia-Suicide Severity Rating Scale, there were 2 positive responses for any active suicidal ideations; there were no positive responses for suicidal behavior or completed suicides.

CONCLUSIONS

In this 12-month, open-label, extension study, the long-term safety and tolerability of LDX in adults with BED were generally consistent with its established profile for attention-deficit/hyperactivity disorder.

Meta-analysis of the effectiveness of psychological and medical treatments for binge-eating disorder (MetaBED): study protocol

INTRODUCTION

Binge-eating disorder (BED) was included as its own diagnostic entity in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). An increasing number of treatment studies have been published, but an up-to-date comprehensive meta-analysis on diverse treatment approaches for BED is lacking. In an updated and extension of a previous meta-analysis, the goals of this study are to assess the short-term and long-term effectiveness of psychological and medical treatments for BED.

METHODS AND ANALYSIS

We will search bibliographic databases and study registries, including manual searches for studies published before January 2016. The search strategy will include terms relating to binge eating and diverse forms of psychological and medical interventions. Language will be restricted to English. The studies included will be treatment studies, that is, randomised-controlled trials, and non-randomised and non-controlled studies, for individuals with BED (DSM-IV or DSM-5), and studies that provided a pre-treatment and at least one post-treatment or follow-up assessment of binge eating. The primary outcomes will be the number of binge-eating episodes, abstinence from binge eating and diagnosis of BED at post-treatment and/or follow-up(s), and changes from pre-treatment to post-treatment and/or follow-up(s). Likewise, as secondary outcomes, eating disorder and general psychopathology, quality of life, and body weight will be analysed and adverse events and treatment drop-out will be examined. Study search, selection and data extraction, including risk of bias assessment, will be independently performed by 2 reviewers and consensus will be sought. Moderator analyses will be conducted, and equity aspects will be considered. Sensitivity analyses will be conducted to determine the robustness of the results.

ETHICS AND DISSEMINATION

Ethical approval is not required for this meta-analysis. Published in a peer-reviewed journal and disseminated electronically and in print, this meta-analysis will form the basis of the renewal of the German evidence-based S3 Guidelines of Diagnosis and Treatment of Eating Disorders, specifically BED.

TRIAL REGISTRATION NUMBER

CRD42016043604.

Aggressive clinical approach to obesity improves metabolic and clinical outcomes and can prevent bariatric surgery: a single center experience

BACKGROUND

The number of bariatric procedures has exponentially increased in the past decade, as a result of the lack of successful clinical weight-loss interventions. The main reasons for the failure of clinical obesity management are: (1) anti-obesity medications are administered as monotherapies (or pre-combined drugs); (2) lack of combination between pharmacotherapy and non-pharmacological modalities; (3) short duration of pharmacotherapy for obesity; (4) lack of weight-loss maintenance strategies; (5) misunderstanding of the complex pathophysiology of obesity; and (6) underprescription of anti-obesity medications. We developed a protocol that can potentially overcome the drawbacks that may lead to the failure of clinical therapy for obesity. The aim of this study is therefore to report the clinical and metabolic effects of our proposed obesity-management protocol over a 2-year period, and to determine whether this more intensive approach to obesity management is feasible and a possible alternative to bariatric surgery in patients with moderate-to-severe obesity.

METHODS

This retrospective study involved 43 patients in whom bariatric surgery was indicated. Patients underwent an intensive anti-obesity protocol that included pharmacotherapy with multiple drugs; intense surveillance with monthly body analysis by air-displacement plethysmography, electrical bioimpedance, and 3D body scans; weekly psychotherapy; diet planning with a dietician every 2 months; and exercises at least 3 times a week with exercises prescribed by a personal trainer at least once a month. Body weight (BW), total weight excess (TWE), obesity class, body mass index, fat weight, muscle weight, waist circumference, and visceral fat were analyzed. Markers of lipid and glucose metabolism, liver function, and inflammation were also evaluated. Therapeutic success was defined as >20% BW loss or >50% decrease in TWE after 1 year.

RESULTS

Significant improvements were observed in all clinical and metabolic parameters. Thirty-eight (88.4%) patients achieved 10% BW loss, and 32 (74.4%) achieved 20% BW loss. TWE decreased by >50% in 35 (81.4%) patients. Forty (93.0%) patients were able to avoid bariatric surgery.

CONCLUSION

An intensive clinical approach to obesity management can be an effective alternative to bariatric surgery, although further randomized controlled studies are necessary to validate our findings.

The Obesity-Impulsivity Axis: Potential Metabolic Interventions in Chronic Psychiatric Patients

Pathological impulsivity is encountered in a broad range of psychiatric conditions and is thought to be a risk factor for aggression directed against oneself or others. Recently, a strong association was found between impulsivity and obesity which may explain the high prevalence of metabolic disorders in individuals with mental illness even in the absence of exposure to psychotropic drugs. As the overlapping neurobiology of impulsivity and obesity is being unraveled, the question asked louder and louder is whether they should be treated concomitantly. The treatment of obesity and metabolic dysregulations in chronic psychiatric patients is currently underutilized and often initiated late, making correction more difficult to achieve. Addressing obesity and metabolic dysfunction in a preventive manner may not only lower morbidity and mortality but also the excessive impulsivity, decreasing the risk for aggression. In this review, we take a look beyond psychopharmacological interventions and discuss dietary and physical therapy approaches.