What are the treatment options for decreased appetite?

Treatment Options for Decreased Appetite

The treatment of decreased appetite should focus on identifying and addressing underlying causes while implementing appropriate nutritional interventions, with pharmacological therapy reserved for specific clinical scenarios. 1

Underlying Cause Assessment

First, identify potential causes of decreased appetite:

• Medical conditions: Cancer, heart failure, diabetes, infections, gastrointestinal disorders 1, 2
• Medication side effects: Opioids, sedatives, digoxin, metformin, antibiotics, NSAIDs, cholinesterase inhibitors 1
• Psychological factors: Depression, anxiety, eating disorders 1
• Social factors: Social isolation, lack of support with meal preparation 1
• Treatment-related effects: Chemotherapy, radiation therapy 1

Non-Pharmacological Interventions

Nutritional Support

• Dietary counseling: Provide personalized nutrition education 1
• Meal modifications:
  • Offer smaller, more frequent meals
  • Enhance flavor with seasonings
  • Serve food at preferred temperature
  • Prioritize calorie-dense foods 1
• Supplemental nutrition: Consider parenteral nutrition if oral/enteral intake is inadequate (<60% of estimated energy expenditure) for more than 10 days 1

Environmental/Social Interventions

• Verbal prompting: Remind patients to eat and drink
• Mealtime support: Provide assistance with shopping and meal preparation
• Social eating: Arrange shared meals or meals on wheels services 1
• Address conflicts: Resolve family or caregiver conflicts that may affect eating 1

Pharmacological Interventions

First-Line Options

1. Megestrol acetate: Most effective appetite stimulant with demonstrated improvements in appetite and weight gain in cancer patients 1

   • One in four patients will experience increased appetite
   • One in twelve will have weight gain
   • Monitor for thromboembolic risk

2. Corticosteroids (e.g., dexamethasone): Significant short-term impact on appetite, especially in cancer patients 1

   • Effects may last only a few weeks
   • Consider for patients with shorter life expectancy

Second-Line Options

1. Dronabinol: FDA-approved for appetite stimulation in AIDS-related anorexia 3

   • Less effective than megestrol acetate but may improve appetite in some patients
   • Initial dosage: 2.5 mg before lunch and dinner; may reduce to 2.5 mg at supper/bedtime if side effects occur
   • Monitor for neuropsychiatric effects, especially in elderly patients

2. Olanzapine: Consider for cancer-related anorexia with weeks-to-months life expectancy 1

3. Mirtazapine: May show numerical improvements in meal intake in hospitalized patients 4

   • Particularly useful when depression is contributing to decreased appetite

Combination Therapy

• For cancer cachexia, combination regimens (megestrol acetate, L-carnitine, anti-inflammatory agents) may be more effective than single agents 1

Special Populations

Diabetes Patients

• Screen for disordered eating using validated measures when unexplained weight loss occurs 1
• Consider incretin therapies (GLP-1 receptor agonists) which may help modulate food intake and reduce uncontrollable hunger 1

Cancer Patients

• Address reversible causes first (oral candidiasis, pain, constipation, nausea)
• Use metoclopramide for early satiety 1
• Consider appetite stimulants when increased appetite would improve quality of life in patients with limited life expectancy 1

Elderly Patients

• Review medication regimen to identify and modify drugs that may affect appetite
• Provide increased support with meal preparation and eating
• Monitor for dehydration due to decreased thirst sensation 1

Monitoring and Follow-up

• Regularly assess meal intake, weight, and nutritional parameters
• Document improvement in diet after starting interventions
• Adjust treatment plan if no improvement is seen after 2-4 weeks
• Monitor for adverse effects of pharmacological interventions 4

Pitfalls and Caveats

• Avoid labeling all eating disturbances as psychiatric disorders; physiological disruptions in hunger/satiety cues may be responsible 1
• Be cautious with appetite stimulants in patients with thromboembolic risk (megestrol) or cognitive impairment (dronabinol) 1, 3
• Parenteral nutrition is ineffective and potentially harmful in patients who can eat but choose not to 1
• Recognize that decreased appetite may be an adaptive response in acute illness; forced feeding may not always be beneficial 5