Orlistat Misuse in Bulimia Nervosa

Ms. A was a 49-year-old woman who came to our weight management program for extreme obesity (287 lb; body mass index=45 kg/m²). At this assessment, she met DSM-IV criteria for bulimia nervosa, purging type, and major depressive disorder, diagnosed by means of structured interview.

Ms. A’s binge eating started at age 9 years; she weighed 140 lb at age 10. She continued binge eating and gaining weight throughout high school and college. At age 25, she was bingeing one or two times per day and weighed 206 lb. She took laxatives to relieve fullness one or two times a month but had no regular compensatory weight-loss behaviors.

Ms. A had tried nine weight-loss programs and two over-the-counter appetite suppressants in the past. One year before coming to our program, she began using orlistat, 120 mg t.i.d., as prescribed by her internist. Although she continued to binge four or five times per week, she lost 45 lb after 6 months. However, she stopped taking the drug because of financial difficulties and subsequently regained all of the weight within 4 months. Ms. A then began ordering orlistat through the Internet. To save money, she used the drug only during binges. When she came to our program 2 months later, she had lost 5 lb. However, Ms A was bingeing four to seven times a week, using orlistat during every binge, having four to eight bowel movements per day with moderate to severe fecal urgency, experiencing oily rectal spotting, and having flatulence after every binge. She avoided most social situations because of the side effects. We suggested that the orlistat might be reinforcing Ms. A’s binge eating and that it should be discontinued, but she responded that the drug had been helpful in preventing weight gain, and she was therefore reluctant to stop taking it.