From the Guidelines
Besides Remeron (mirtazapine), no other medication is recommended to increase appetite in the elderly due to limited evidence and potential harmful side effects, as stated in the most recent guideline update 1. When considering alternatives to increase appetite in elderly individuals, it's essential to prioritize interventions that are evidence-based and minimize potential harm.
- Practical approaches, such as offering smaller, more frequent nutrient-dense meals, ensuring food is visually appealing and properly seasoned, creating a pleasant dining environment, and encouraging social eating, can be beneficial.
- Addressing underlying depression or medical conditions, providing nutritional supplements between meals, and promoting exercise, particularly before meals, can also help stimulate appetite.
- Medications like dronabinol, megestrol acetate, and cyproheptadine have been studied, but their use is not recommended due to limited evidence and potential side effects, as highlighted in the 2024 ESPEN guideline update 1.
- Low-dose corticosteroids like prednisone may be considered for short periods, but their use is associated with significant side effect concerns. The choice of approach should be individualized based on the elderly person's specific health conditions, medication interactions, and preferences, with a focus on minimizing harm and promoting overall well-being, as emphasized in the guideline update 1.
From the Research
Appetite-Stimulating Agents
Besides Remeron (Mirtazapine), several other agents can increase appetite in the elderly, including:
- Megestrol acetate: a synthetic progestinic drug that has been shown to stimulate appetite and improve weight gain in elderly patients with anorexia 2, 3, 4
- Dronabinol: a cannabinoid agonist that can stimulate appetite and improve weight gain in patients with anorexia 2, 5, 6
- Testosterone replacement therapy: may be beneficial for older men with low testosterone levels and weight loss 2
- Oxandrolone: an anabolic agent that may be reserved for patients with profound cachexia 2
- Taste enhancers: may be considered for patients who complain that food does not taste good 2
Dosage and Administration
The optimal dosage and administration of these agents vary:
- Megestrol acetate: typically administered at a dose of 800 mg per day for no longer than 3 months, with a lower dose of 400 mg per day also showing efficacy 2, 3
- Dronabinol: typically initiated at a low dose of 2.5 mg in the evening, with the dose increased to 5 mg per day if no improvement in appetite is seen after 2 to 4 weeks 2
- Testosterone replacement therapy: dosing varies depending on the individual patient's needs and testosterone levels 2
Safety and Efficacy
The safety and efficacy of these agents in the elderly population are not fully established:
- Megestrol acetate: may cause adverse effects such as deep vein thrombosis and cortisol suppression 2, 3
- Dronabinol: may cause adverse effects such as diarrhea and thromboembolism 3, 5
- Mirtazapine: may be effective for appetite stimulation and weight gain, but its use should be thoroughly evaluated on an individual basis 4