What is the best appetite stimulant that does not cause drowsiness?

From the Guidelines

The best appetite stimulant that generally doesn't cause drowsiness is megestrol acetate (Megace), as it has been shown to improve appetite and body weight in patients with cancer cachexia, although it carries risks of blood clots and hormonal effects. According to the 2020 ASCO guideline 1, megestrol acetate improves appetite and body weight in patients with cancer cachexia, with a relative risk of 2.57 for appetite improvement and 1.55 for weight improvement. However, it's essential to note that megestrol acetate can cause adverse events such as thromboembolic events, edema, and adrenal suppression.

Other options like cyproheptadine (Periactin) may also be considered, as it works by blocking serotonin receptors and can increase hunger signals while reducing early satiety feelings 1. However, megestrol acetate is a more established option for appetite stimulation, particularly in patients with cancer cachexia.

Non-medication approaches can also help stimulate appetite, such as:

• Regular meal schedules
• Small frequent meals
• Light exercise before eating
• Using herbs like ginger or mint

It's crucial to consult with a healthcare provider before starting any appetite stimulant, as the underlying cause of poor appetite should be addressed. Additionally, the potential benefits and risks of each option should be carefully considered, particularly in patients with underlying medical conditions or taking other medications. The 2024 American Heart Association scientific statement 1 also highlights the importance of addressing the underlying cause of poor appetite and considering the potential benefits and risks of appetite stimulants.

From the FDA Drug Label

In U. S. controlled clinical studies, appetite increase was reported in 17% of patients treated with mirtazapine tablets, compared to 2% for placebo. In these same trials, weight gain of ≥7% of body weight was reported in 7.5% of patients treated with mirtazapine, compared to 0% for placebo.

The percent of patients gaining five or more pounds at maximum weight gain in 12 study weeks was statistically significantly greater for the 800 mg (64%) and 400 mg (57%) MA-treated groups than for the placebo group (24%). Mean weight increased from baseline to last evaluation in 12 study weeks in the 800 mg MA-treated group by 7.8 pounds, the 400 mg MA group by 4. 2 pounds, the 100 mg MA group by 1.9 pounds, and decreased in the placebo group by 1. 6 pounds. A greater percentage of MA-treated patients (67%) than placebo-treated patients (38%) showed an improvement in appetite at last evaluation during the 12 study weeks; this difference was statistically significant.

The best appetite stimulant that does not cause drowsiness is megestrol acetate.

• Key benefits:
  • Increased appetite
  • Weight gain
  • No reports of somnolence 2 In contrast, mirtazapine is associated with somnolence, which was reported in 54% of patients treated with mirtazapine tablets, compared to 18% for placebo 3.

From the Research

Appetite Stimulants

• Megestrol acetate is a commonly used appetite stimulant that has been shown to improve appetite and weight gain in patients with cancer-associated anorexia-cachexia 4, 5.
• The efficacy of megestrol acetate in stimulating appetite has been demonstrated in various studies, with significant improvements in appetite and weight gain observed in patients with cancer 4, 6.
• Other appetite-stimulating medications, such as dronabinol and mirtazapine, have also been used to promote appetite in hospitalized adults, although their efficacy is limited and more research is needed to fully understand their effects 7, 8.

Side Effects and Considerations

• Megestrol acetate has been associated with adrenal suppression, particularly in children 6.
• The use of appetite-stimulating medications in hospitalized adults has been shown to have numerical improvements in meal intake, although no significant differences were observed between different medications 8.
• The optimal dose of megestrol acetate for appetite stimulation is unclear, and further research is needed to determine the most effective dosage 4.

Specific Patient Populations

• Megestrol acetate has been shown to be effective in children with weight loss due to cancer and/or cancer therapy, resulting in significant increases in mean percent weight change compared to placebo 6.
• The use of appetite-stimulating medications in patients with AIDS or other underlying pathologies is less well-studied, and more research is needed to fully understand their effects in these populations 4.