Can dronabinol be given to patients with appetite loss due to critical illness?

Dronabinol for Appetite Loss in Critical Illness

Dronabinol is not recommended as a first-line treatment for appetite loss in critically ill patients due to limited evidence of efficacy and potential risks in this population. 1

Evidence Assessment

• Guidelines do not support the systematic use of appetite stimulants, including dronabinol, for critically ill patients due to very limited evidence and potential adverse effects 1
• While dronabinol has FDA approval for appetite stimulation in AIDS-related anorexia, there is insufficient evidence supporting its use specifically in critical illness 2
• The National Comprehensive Cancer Network acknowledges that cannabinoids have limited data to support their use for anorexia/cachexia in cancer patients, with megestrol acetate showing superior efficacy 1

Preferred Alternatives for Critical Illness

First-Line Options:

• Megestrol acetate (400-800 mg/day) is recommended as the primary pharmacological intervention for appetite stimulation in patients with serious illness when increased appetite is important for quality of life 3, 4
• Approximately 1 in 4 patients treated with megestrol acetate will experience increased appetite and 1 in 12 will have measurable weight gain 3
• Dexamethasone (2-8 mg/day) may be considered for short-term appetite stimulation in patients with limited life expectancy due to its rapid onset of action 4, 5

Second-Line Option:

• Mirtazapine can be useful for appetite stimulation, particularly in patients with concurrent sleep difficulties or mood disorders 1, 4
• Olanzapine (5 mg/day) may be considered, especially for patients with concurrent nausea or anxiety 5

Dronabinol Considerations in Critical Illness

Limited Evidence:

• A small retrospective study of hospitalized patients showed numerical improvements in meal intake with dronabinol, but no significant difference compared to other appetite stimulants 6
• Most evidence for dronabinol comes from studies in AIDS and cancer patients, not specifically critical illness 7, 8

Safety Concerns:

• Neuropsychiatric adverse reactions are common with dronabinol, including cognitive impairment, altered mental state, dizziness, and confusion 2
• Hemodynamic instability, including hypotension, hypertension, syncope, or tachycardia may occur with dronabinol use - particularly concerning in critically ill patients 2
• Cannabinoid administration in elderly patients may induce delirium 1

Dosing if Used:

• If dronabinol is considered despite limited evidence, start with 2.5 mg once daily in the evening to minimize adverse effects 2
• Maximum recommended dose is 10 mg twice daily, but lower doses are preferred in critically ill or elderly patients 2

Non-Pharmacological Approaches

• Address reversible causes of anorexia first (pain, constipation, nausea/vomiting, depression, oropharyngeal candidiasis) 1
• Provide emotional support and specific behavioral strategies during meals, which can positively affect eating behavior and increase food intake 1
• Consider nutrition consultation for calorie-dense, high-protein supplementation 1

Monitoring and Reassessment

• Monitor for neuropsychiatric effects, including cognitive impairment and altered mental state 2
• Assess for hemodynamic changes, particularly in patients with cardiac disorders 2
• Regularly evaluate benefit versus risk, particularly in critically ill patients 4, 9

Conclusion

Based on current evidence, dronabinol should not be considered a first-line agent for appetite stimulation in critically ill patients. Megestrol acetate, dexamethasone, or mirtazapine have better evidence profiles for this indication. If dronabinol is used, careful monitoring for adverse effects is essential, particularly neuropsychiatric and hemodynamic changes that could be especially problematic in critical illness.