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Orlistat Misuse as Purging in a Patient With Binge-Eating Disorder

TO THE EDITOR:  Orlistat, sold as Alli,^TM is a recently FDA-approved, over-the-counter weight-loss aid for overweight adults. It works via prevention of dietary fat digestion and absorption, and the subsequent passage of such fat via bowel movements (www.myAlli.com). Proper use of orlistat incorporates compliance with label directions, eating smaller portions, limiting fat intake to an average of 15 g per meal, being physically active, and meeting the minimum weight specification before beginning the program. Side effects of eating too much fat in a meal, referred to as "treatment effects" (see http://www.myalli.com/howdoesitwork.aspx), include bowel-function changes such as gas with oily spotting, loose stools, and more-frequent stools that may be hard to control.

Case Report
"Mrs. L," a 45-year-old, Caucasian married woman who self-referred for binge eating, met Diagnostic and Statistical Manual of Mental Disorders (DSM–IV)¹ criteria for Binge-Eating Disorder (BED), and she endorsed orlistat misuse. Mrs. L’s orlistat use was categorized as misuse and purging because it did not follow orlistat’s recommendations, and her rationale for taking it was to compensate for calories and fat ingested during binge episodes.

Mrs. L violated orlistat’s recommended use in various ways. First, she endorsed purposefully not following orlistat label directions by taking it more frequently, and often in larger doses (e.g., double) than indicated. Second, Mrs. L did not eat smaller portions nor limit fat to 15 g per meal. Rather, when she took orlistat before a binge, she purposefully ate large amounts of foods high in fat and caloric density. Last, she was not physically active and weighed less than Alli^TM’s minimum weight requirement (i.e., a body mass index [BMI] 27) before beginning the program.

Mrs. L believed that orlistat would compensate for a binge by disposing of excess fat and calories in oily spotting side effects that made her "feel less guilty" about bingeing. She simultaneously acknowledged that orlistat 1) named such side effects as treatment effects resulting from eating more fat than recommended; and 2) specifically forewarned users about such side effects to promote adherence to label directions (e.g., eating a low-fat diet). Although Mrs. L had experienced uncomfortable treatment effects, and cramping and soreness upon excretion at various times from Alli^TM misuse, she denied severe medical complications (e.g., hemorrhoids, bloody stool).

Mrs. L received five sessions of cognitive-behavioral therapy (CBT) before she was lost to follow-up for unknown reasons. By Session 3, Mrs. L had discontinued orlistat, and she attributed the cessation to therapeutic efforts to 1) label the misuse as "purging" and dysfunctional; and 2) highlight purging’s role in perpetuating the binge-and-purge cycle. By Session 5, Mrs. L decreased her binge episode frequency by approximately half. This intervention was Mrs. L’s first attempt at overcoming her eating disorder.

Discussion
There are noteworthy similarities between Mrs. L’s justification of her orlistat misuse and bulimia nervosa (BN) patients’ characteristic description of their use of more traditional purging methods (i.e., vomiting, laxatives, diuretics). Similarities include use of a compensatory method 1) to rid oneself of fat and calories consumed during a binge; 2) to decrease physical sensations of bloatedness and distention post-binge, despite uncomfortable side effects; 3) for purposes and in amounts contrary to product recommendations; 4) to decrease guilt about bingeing; 5) to deal with post-purge feelings of guilt and shame; and, finally 6) purposefully hiding this behavior from others (Mrs. L hid her orlistat use from her husband). We do not know whether, without intervention, Mrs. L’s purging would have escalated in frequency and duration sufficiently as to warrant a diagnosis change to BN. Nonetheless, similarities in the drive for compensatory behaviors between Mrs. L, a BED patient, and BN patients are clinically striking.

When used properly, clinical intervention research has documented orlistat’s effectiveness in reducing binge episodes and facilitating weight loss among BED patients.^2–4 and as a weight-loss aid among obese persons.^5–7 However, unmonitored Alli^TM use by an individual with disordered eating may result in misuse and purging, as demonstrated here.

In such cases, clinicians are encouraged to consider: 1) orlistat’s proper and recommended use among its target population; 2) unregulated and easy access to orlistat over the counter; 3) unknown short- and long-term physical consequences of orlistat abuse; 4) orlistat’s usefulness in weight-loss and binge-episode reduction when taken as directed and monitored by a healthcare professional; and 5) orlistat’s benefits when clinically and/or medically indicated. Although orlistat misuse rates among the eating-disordered population are currently unknown, clinician familiarity with these issues will facilitate readiness to identify such purging behavior and intervene accordingly.

REFERENCES

1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC, American Psychiatric Association, l994
2. Golay A, Laurent-Jaccard A, Habicht F, et al: Effect of orlistat in obese patients with binge-eating disorder. Obesity Res 2005; 13:1701–1708[CrossRef][Medline]
3. Grilo CM, Masheb RM, Salant S: Cognitive-behavioral therapy, guided self-help, and orlistat for the treatment of binge-eating disorder. Biol Psychiatry 2005; 57:1193–1201[CrossRef][Medline]
4. Grilo CM, Masheb RM: Rapid response predicts binge eating and weight loss in binge-eating disorder: findings from a controlled trial of orlistat with guided self-help cognitive-behavioral therapy. Behav Res Ther 2007; 45:2537–2550[CrossRef][Medline]
5. Davidson MH, Hauptman J, DiGirolamo M, et al: Weight control and risk-factor reduction in obese subjects treated for 2 years with orlistat. JAMA 1999; 281:235–242[Abstract/Free Full Text]
6. Halperm A, Mancini MC, Suplicy H, et al: Latin-American trial of orlistat for weight loss and improvement in glycaemic profile in obese diabetic patients. Diabetes Obesity Metab 2003; 5:180–188[CrossRef]
7. Avenell A, Brown TJ, McGee MA, et al: What interventions should we add to weight-reducing diets in adults with obesity? a systematic review of randomized, controlled trials of adding drug therapy, exercise, behaviour therapy, or combinations of these interventions. J Human Nutrition Dietetics 2004; 17:293–316[CrossRef]

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