What is the appropriate starting dose of Megace (megestrol acetate) for an elderly patient with appetite issues?

From the Guidelines

The starting dose of Megace (megestrol acetate) for an elderly patient with appetite issues should not be initiated due to lack of conclusive evidence supporting its effectiveness in this population. When considering the use of Megace for appetite stimulation in elderly patients, it is essential to weigh the potential benefits against the risks, as evidenced by studies such as 1. The ESPEN guideline on nutrition and hydration in dementia updates in 2024 suggests that drugs that stimulate appetite, including megestrol acetate, should not be offered to promote food intake in persons with dementia, based on a consensus with 87% agreement 1. Some key points to consider include:

• The effects of megestrol acetate were tested in two studies in nursing home residents with weight loss or at risk of weight loss, but only 41% of the samples in both studies had dementia, and the results were inconclusive 1.
• In hospitalized older subjects, no effect on body weight was observed in an open-label study with different daily doses of megestrol acetate 1.
• In older hospitalized patients with recent functional decline, 800 mg of megestrol acetate per day attenuated the beneficial effects of twelve-week resistance training, reflected in smaller gains or even deterioration in muscle strength and functional performance compared to placebo 1. Given the lack of conclusive evidence supporting the use of Megace for appetite stimulation in elderly patients, alternative approaches to managing appetite issues should be considered, such as addressing underlying medical conditions, optimizing nutrition, and providing supportive care.

From the FDA Drug Label

The recommended adult initial dosage of megestrol acetate oral suspension, USP is 800 mg/day (20 mL/day). The starting dose of Megace for an elderly patient with appetite issues is 800 mg/day.

• This dose is based on the recommended adult initial dosage.
• No specific dose adjustment is mentioned in the label for elderly patients, so the standard adult dose is applied. 2

From the Research

Starting Dose of Megace for Elderly Patients with Appetite Issues

• The appropriate starting dose of Megace (megestrol acetate) for an elderly patient with appetite issues is not explicitly stated in the provided studies as a single, universally accepted dose.
• However, according to the study by 3, megestrol acetate suspension was administered at doses of 200 mg, 400 mg, or 800 mg daily for 9 weeks to elderly patients with reduced appetite after hospitalization.
• The study found that participants in the 400-mg and 800-mg groups demonstrated significant improvement from baseline on some appetite questions, and prealbumin levels increased in a dose-response relationship across the four groups.
• Another study by 4 suggests that megestrol acetate should be tried at a dose of 800 mg per day for no longer than 3 months in persons with a large excess cytokine production.
• It is essential to note that the use of megestrol acetate in elderly patients should be carefully considered, as it may be associated with adverse effects such as deep vein thrombosis, cortisol suppression, and diarrhea, as reported in the studies by 3 and 4.
• The studies by 5, 6, and 7 provide additional information on the use of appetite stimulants, including megestrol acetate, in various patient populations, but do not specifically address the starting dose for elderly patients with appetite issues.