Identify the eating-disorder phenotype #
Establish restriction, loss-of-control eating, binge episodes, compensatory behaviours and the role of weight/shape concerns. Document frequency, duration, distress and functional impact. Low intake driven by sensory aversion or fear of adverse consequences requires consideration of ARFID rather than assuming weight/shape psychopathology.
Medical and psychiatric assessment #
Measure weight and its trajectory, pulse, blood pressure including orthostatic change, temperature and hydration. Ask explicitly about vomiting, laxatives, diuretics, excessive exercise and medication misuse. Assess depression, obsessive symptoms, substance use and self-harm, and determine whether outpatient nutrition and monitoring are feasible.
Separate presentations #
| Presentation | Treatment implication |
|---|---|
| Anorexia nervosa | Restore nutrition and weight while addressing restrictive psychopathology. |
| Bulimia nervosa | Target the binge–compensation cycle with eating-disorder psychotherapy; fluoxetine may be an adjunct. |
| Binge-eating disorder | Target binge episodes and distress; do not equate treatment with rapid weight loss. |
| Medical cause of weight loss or vomiting | Investigate the relevant endocrine, gastrointestinal or systemic symptoms. |
Tests and clinical purpose #
| Test | Reason and interpretation |
|---|---|
| CBC, electrolytes, glucose, renal and liver profile | Assess systemic effects, dehydration and complications of restriction/purging. |
| Magnesium and phosphate | Important in malnutrition and refeeding assessment; arrange repeat testing according to the medical plan. |
| ECG | Assess rhythm/QTc particularly with restriction, substantial purging, cardiac symptoms or QT-prolonging medicines. |
| Thyroid or gastrointestinal investigations | Use the history to investigate alternative causes. |
| Bone-health assessment | Consider consequences of prolonged malnutrition/amenorrhoea; specialist assessment may include DXA. |
Condition-specific treatment #
For adult anorexia, use coordinated nutritional rehabilitation and a specialist psychological approach such as CBT-ED, MANTRA or specialist supportive clinical management. Medical compromise or unsafe refeeding needs a supervised setting.
For bulimia and binge-eating disorder, guided self-help can be followed by CBT-ED when unsuitable or ineffective. Establish regular eating and identify binge triggers. Medication alone is not an adequate treatment programme.
Doses & prescribing #
Each prescribing record identifies its population and source jurisdiction; international labeling does not establish Indian approval. The clinician selects treatment after assessment.
Fluoxetine
Adult bulimia nervosa; adjunct to comprehensive care
Adults · Conventional tablet/capsule; not weekly delayed-release product · Oral · US fluoxetine label; not a statement of Indian indication approval
- Starting dose
- Label-recommended dose is 60 mg each morning; some patients require gradual titration to it.
- Titration
- Individualize gradual introduction for tolerability; the cited label does not specify a universal incremental schedule for bulimia.
- Treatment range / target
- 60 mg/day is the evidence-supported target.
- Maximum / limits
- Doses above 60 mg/day have not been systematically studied for bulimia; do not import the depression maximum.
- Trial & duration
- Reassess acute response and periodically review continued benefit during maintenance.
- Monitoring
- Binge/purge frequency, activation, suicidality, sodium when indicated, bleeding and interactions.
- Population & organ-function adjustments
- Use a lower or less frequent dose in hepatic impairment and selected medically complex patients.
- Important cautions
- MAOIs and interacting serotonergic medicines; long persistence matters when switching. Assess electrolyte/cardiac vulnerability from purging.
Check the treatment actually delivered #
Review engagement, eating-pattern change, continued purging, physical deterioration and barriers to attending treatment. Escalate the level of medical care when outpatient monitoring is insufficient. Revisit the formulation when symptoms or weight change do not fit the presumed diagnosis.
Relapse prevention #
Track recurrence of restrictive rules, compensatory behaviour and binge cues. Agree how worsening intake or physical symptoms will trigger reassessment. Continue to address body-image concerns and everyday function rather than treating a single weight measurement as recovery.
Medical complexity #
Malnutrition, dehydration and electrolyte disturbance can change medication tolerability. Pregnancy, diabetes and other conditions affecting nutrition require coordinated specialist care. Do not extrapolate the adult fluoxetine table to children, severe malnutrition or pregnancy without the relevant assessment.
Follow the behaviour and physical state #
Record binge and compensatory-behaviour frequency, nutritional intake, weight trajectory and physical findings. Repeat abnormal investigations and reassess changes in symptoms or medicines. Normal baseline laboratory results do not exclude serious eating-disorder pathology.
Medication pitfalls #
Fluoxetine’s bulimia evidence is for reduction of binge/purge behaviour, not weight restoration in anorexia. In the pivotal trial, 60 mg/day was studied over 8 weeks; benefit is not a reason to omit nutritional or psychological care. Do not use an antidepressant depression maximum as a bulimia-specific target.
Assessment tools #
Choose the instrument for its intended purpose; interpretation accompanies the linked tool.
Patient discussion #
Open a plain-language explanation
Eating difficulties can affect physical health at any body size. Care addresses both the body’s needs and the thoughts and feelings maintaining the problem.
References · 5
- NICE NG69: Eating disorders recommendations · United Kingdom · Checked 2026-10-26 · Supports: Separate presentations; Condition-specific treatment; Check the treatment actually delivered; Relapse prevention; Medical complexity
- APA: Practice Assessment Tool for Care of Patients With Eating Disorders, 2024 · United States · Checked 2026-10-26 · Supports: Identify the eating-disorder phenotype; Medical and psychiatric assessment; Tests and clinical purpose; Follow the behaviour and physical state
- NEDA: Eating disorders evaluation and diagnostic investigations · United States · Checked 2026-10-26 · Supports: Separate presentations; Tests and clinical purpose; Check the treatment actually delivered; Follow the behaviour and physical state
- DailyMed: Fluoxetine—bulimia dosing and prescribing precautions · United States label · Checked 2026-10-26 · Supports: Medical complexity; Medication pitfalls; Fluoxetine — Adult bulimia nervosa; adjunct to comprehensive care (Conventional tablet/capsule; not weekly delayed-release product)
- Fluoxetine Bulimia Nervosa Collaborative Study Group: randomized trial · Original clinical trial · Checked 2026-10-26 · Supports: Medication pitfalls