What are the recommended appetite stimulants for patients with decreased appetite?

Recommended Appetite Stimulants for Patients with Decreased Appetite

Megestrol acetate is the most effective medication for appetite stimulation in patients with decreased appetite, with high-quality evidence showing significant appetite stimulation and weight gain, though it carries risks that must be monitored. 1

First-Line Pharmacological Options

Megestrol Acetate

• Dosing: Start with 80 mg twice daily after meals 2
• Evidence: Shows a positive dose-response effect for appetite stimulation 3
• Optimal dose: 800 mg/day; no further benefit was derived from using higher doses 3
• Considerations:
  • Most effective for increasing appetite with significant evidence for weight gain
  • Monitor for side effects including thromboembolic events (relative risk 1.84), edema (relative risk 1.36), and increased mortality risk (relative risk 1.42) 1

Dexamethasone

• Dosing: Short-term use only (1-3 weeks)
• Benefits: Provides rapid appetite stimulation
• Limitations: Side effects include muscle wasting, insulin resistance, and increased infection risk 1
• Best for: Patients needing immediate but short-term appetite improvement

Mirtazapine

• Dosing: 15-30 mg daily
• Benefits: Treats both underlying anxiety and appetite symptoms simultaneously
• Target population: Particularly useful in patients with comorbid depression or anxiety 1

Cyproheptadine

• Dosing: 2-4 mg three times daily
• Benefits: Well-established safety profile
• Target population: Especially effective in pediatric patients 1

Dronabinol (Synthetic THC)

• Dosing: Initial dose 2.5 mg 1-2 times daily, administered one hour before lunch and dinner 4
• Evidence: FDA-approved for AIDS-related anorexia with weight loss 4
• Administration: Early morning administration associated with increased adverse effects; better tolerated when dosed later in day 4
• Side effects: Feeling high, dizziness, confusion, somnolence (occurred in 18% of patients at 5 mg/day dosing) 4
• Limitations: Inconsistent evidence for cancer-related anorexia 5

Olanzapine

• Dosing: 5 mg/day
• Benefits: Alternative with fewer thromboembolic risks than megestrol acetate
• Monitoring: Requires careful observation for metabolic side effects 1

Non-Pharmacological Approaches

Dietary Modifications

• Provide energy-dense and protein-rich foods to decrease food volume while increasing nutritional content
• Offer oral nutritional supplements providing at least 400 kcal/day including 30g or more of protein/day 1
• Implement small, frequent meals with high-calorie, nutrient-dense foods

Environmental Factors

• Create a pleasant eating environment
• Promote shared meals and social eating opportunities
• Provide adequate mealtime assistance for those with functional limitations
• Implement protected mealtimes in institutional settings 1

Physical Activity

• Encourage moderate physical activity alongside nutritional interventions
• Evaluate health status and physical performance level before starting exercise interventions
• Supervised or home-based moderate-intensity training can naturally stimulate appetite 1

Step-Wise Approach to Treatment

1. Start with comprehensive non-pharmacological approaches for 2-4 weeks
2. If insufficient response, initiate cyproheptadine (particularly if mild anxiety is present)
3. If no response to cyproheptadine after 4 weeks, consider alternatives:
   • Megestrol acetate (most effective but with more side effects)
   • Mirtazapine (if depression/anxiety is present)
   • Dronabinol (particularly in AIDS-related anorexia)
   • Dexamethasone (for short-term use only) 1

Monitoring and Evaluation

• Assess weight changes, appetite improvement, and side effects
• Reassess appetite and weight after 2-4 weeks of therapy
• Monitor for medication-specific side effects:
  • Megestrol acetate: fluid retention, thromboembolic events
  • Dronabinol: cognitive impairment, dizziness, confusion
  • Mirtazapine: sedation, dry mouth
  • Dexamethasone: hyperglycemia, muscle wasting 1

Special Considerations

• Elderly patients: Start with lower doses; higher risk for cognitive side effects with dronabinol 4
• Cancer patients: Megestrol acetate has better evidence than dronabinol for cancer-related anorexia 5
• AIDS patients: Dronabinol is FDA-approved specifically for AIDS-related anorexia with weight loss 4
• Patients with anxiety/depression: Consider mirtazapine as first choice 1

Cautions and Contraindications

• Dronabinol: Avoid in patients with history of substance abuse, psychiatric disorders, or heart conditions 4
• Megestrol acetate: Use with caution in patients with history of thromboembolic events
• Corticosteroids: Avoid long-term use due to significant side effect profile
• All appetite stimulants: Limited evidence for efficacy in hospitalized patients 6