People with BN often use other compensatory behaviors in addition to medications, including purging by self-induced vomiting, fasting, and excessive exercise (1). This article will briefly describe some of these medications, their mechanism of action, and how they negatively impact the body.
Weight-loss medications are generally ineffective at producing sustained, long-term weight loss. (13) They are designed to work in the body by increasing metabolism, reducing appetite, or changing how the body absorbs or processes calories. Many are prescription with some being sold over-the-counter (OTC). Most weight-loss medications are designed to be used for a short period of time, usually three months, as some can lead to dependency and addiction.
While laxatives may help with occasional constipation, individuals struggling with bulimia nervosa and other eating disorders may use them with the false belief they are away to lose weight or have a sense of control over their disorder. There are four main types of laxatives (2,3):
- Osmotic Laxatives. They draw water into the intestinal tract (lumen) which helps to hydrate, soften, and gently propel fecal matter along the tract. When abused, they can cause uncomfortable diarrhea, bloating, and in some cases, significant water loss and dehydration.
- Stimulant Laxatives. This category tends to be the most commonly abused type of laxatives due to their rapid onset of action and addictive nature. They stimulate nerve bundles within the intestinal tract to forcibly propel fecal matter. Long-term abuse causes permanent anatomical damage, called cathartic colon. They can cause considerable abdominal pain, cramps, nausea, and vomiting. (12)
- Bulk-forming Laxatives. These agents help to retain fluid in the stool and increase stool weight and consistency. Overdose symptoms include bloating, pain, nausea, vomiting, and even a bowel obstruction (where stool becomes completely impacted).
- Stool Softeners. They act by lowering the surface tension at the oil-water interface of feces, which allows water and fats (lipids) to better penetrate the stool and mix. This softens fecal matter, making defecation easier. Overdose symptoms include abdominal pain, bloating, nausea, vomiting, and diarrhea.
Diuretics are a type of prescription medication that are intended to be used under the guidance of a physician for conditions like heart and renal disease. Abuse of diuretics can quickly lead to life-threatening dehydration, electrolyte abnormalities, and kidney damage. When used for extended amounts of time, diuretic abuse can result in hormonal changes, such as hyperaldosteronism (excessive levels of the hormone aldosterone in the blood). End stages of abuse typically result in the patient being admitted to the hospital for aggressive intravascular (IV) hydration. In the setting of diuretic abuse, however, because of the longstanding hormonal changes, rapid rehydration causes dangerous levels of sodium retention and significant swelling (edema) (4,5).
Weaning off diuretic abuse must be done carefully, slowly, and under the supervision of a physician. Abruptly stopping them can cause life-threatening side effects. There are four classes of diuretics that each have a slightly different mechanism of action (6):
- Carbonic Anhydrase inhibitors. Overdose can cause fatigue, abdominal pain, nausea, vomiting, loss of sex drive, tinnitus, taste alteration, depression, skin rash, and black stool (7).
- Loop diuretics. Overdose results in life-threatening electrolyte imbalances, acid/base disturbance, dehydration, and low blood pressure (8).
- Potassium-sparing diuretics. Overdose causes high levels of potassium that lead to heart arrhythmias (9).
- Thiazide diuretics. Overdose symptoms include fainting, coma, weakness, arrhythmia, fever, and slowed breathing, to name a few (10).
Emetics are substances that induce vomiting. Historically, Ipecac syrup was a household remedy to give to children to induce vomiting if they consumed something poisonous. Ipecac syrup is dangerous and its recommendation has long been withdrawn in the medical community, as ipecac syrup is largely ineffective at its intended purpose. (14) Although it is more regulated than it once was, people with bulimia nervosa may use it to induce vomiting. Overdose symptoms include (11):
- Increased or irregular heart rate.
- Nausea and vomiting.
- Abdominal pain.
- Difficulty breathing.
- Fatigue and weakness.
- Stiff and achy muscles.
An enema is a solution used to clear out the colon in the setting of constipation, prior to surgery or a colonoscopy, prior to anal sex, or to deliver medication. They can be bought over the counter and when used in the appropriate setting, are safe to use. Those with bulimia nervosa may misuse enemas, much like laxatives, as a compensatory behavior. Unsafe, homemade enemas contain things like coffee, herbs, minerals, Epsom salts, soap, and acidic solutions that can be harmful to the colon. Overusing enemas can cause the following negative effects (12):
- Disrupts the guts of natural flora.
- Electrolyte disturbance.
- Severe dehydration.
- Rectal burns, inflammation, anal tears, and infection.
- Internal bleeding.
- GI spasms and anal pain.
- DSM5, 5th edition, 2013. American Psychiatric Association.
- Bashir A, Sizar O. Laxatives. [Updated 2021 Nov 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537246/
- PDR Search. Colace Capsules (docusate sodium) dose, indications, adverse effects, interactions… from PDR.net. (n.d.). Retrieved June 27, 2022, from https://www.pdr.net/drug-summary/Colace-Capsules-docusate-sodium-1023
- Pomeroy C, Mitchell JE, Seim HC, Seppala M. Prescription diuretic abuse in patients with bulimia nervosa. J Fam Pract. 1988 Nov;27(5):493-6. PMID: 3193066.
- Mascolo M, Chu ES, Mehler PS. Abuse and clinical value of diuretics in eating disorders therapeutic applications. Int J Eat Disord. 2011 Apr;44(3):200-2. doi: 10.1002/eat.20814. PMID: 20186716.
- List of common diuretics + uses & side effects. Drugs.com. (n.d.). Retrieved June 27, 2022, from https://www.drugs.com/drug-class/diuretics.html
- Farzam K, Abdullah M. Acetazolamide. [Updated 2021 Dec 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532282/
- Huxel C, Raja A, Ollivierre-Lawrence MD. Loop Diuretics. [Updated 2021 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK546656/
- Cherney, K. (2019, March 27). Potassium. Healthline. Retrieved June 27, 2022, from https://www.healthline.com/health/potassium#overdose
- U.S. National Library of Medicine. (n.d.). Thiazide overdose: Medlineplus medical encyclopedia. MedlinePlus. Retrieved June 27, 2022, from https://medlineplus.gov/ency/article/002577.htm
- Mayo Foundation for Medical Education and Research. (2022, February 1). Ipecac syrup (oral route) side effects. Mayo Clinic. Retrieved June 27, 2022, from https://www.mayoclinic.org/drugs-supplements/ipecac-syrup-oral-route/side-effects/drg-20064363
- Tresca, A. J. (2022, February 24). How enemas can make constipation worse. Verywell Health. Retrieved June 27, 2022, from https://www.verywellhealth.com/can-using-enemas-harm-your-intestines-1942580
- Tak, Y. J., & Lee, S. Y. (2021). Long-term efficacy and safety of anti-obesity treatment: Where do we stand? Current Obesity Reports, 10(1), 14–30. https://doi.org/10.1007/s13679-020-00422-w
- Position statement: Ipecac syrup<. Taylor & Francis. (n.d.). Retrieved June 27, 2022, from https://www.tandfonline.com/doi/abs/10.3109/15563659709162567