Medications for Appetite Loss Treatment
Megestrol acetate and corticosteroids are the most effective first-line pharmacological appetite stimulants for treating appetite loss, with megestrol acetate showing significant improvement in appetite in approximately 25% of patients and modest weight gain in about 8% of patients. 1, 2
First-Line Pharmacological Options
Progestogens
- Megestrol acetate is an effective appetite stimulant with proven benefits for appetite and weight gain in patients with cancer-related anorexia 1
- The minimum effective dose is 160 mg/day, which appears to be optimal, with no evidence that doses greater than 480 mg/day have higher efficacy 1
- Megestrol acetate improves appetite in 1 in 4 patients and increases weight in 1 in 12 patients 1, 2
- Side effects include increased risk of thromboembolic events (1 in 6 patients), edema, and potential mortality risks 1, 3
Corticosteroids
- Dexamethasone (2-8 mg/day) is an alternative with faster onset of action, making it suitable for patients with shorter life expectancy 1, 2
- Corticosteroids are effective appetite stimulants but have significant side effects with prolonged use including hyperglycemia, muscle wasting, and immunosuppression 1, 2
- There is insufficient information to define the optimal dose and scheduling for corticosteroids in this indication 1
Second-Line Options
For Patients with Concurrent Depression
- Mirtazapine (7.5-30 mg at bedtime) is effective for patients with concurrent depression and appetite loss 2, 4
- In a small retrospective study, mirtazapine at 30 mg daily resulted in a mean weight gain of 1.9 kg after three months and 2.1 kg after six months, with about 80% of patients experiencing weight gain 4
Other Options
- Olanzapine (5 mg/day) may be considered for patients with concurrent nausea/vomiting 2, 5
- Medroxyprogesterone acetate (MPA) is an appetite stimulant with significant increase in appetite, though its effect on weight gain has not been confirmed 1
- The minimum dose of MPA shown to have a positive effect on appetite is 200 mg/day 1
Limited Evidence Options
- Cannabinoids (e.g., dronabinol) have limited evidence for treating anorexia/cachexia in cancer patients 1, 6
- Dronabinol is FDA-approved for treating loss of appetite (anorexia) in people with AIDS who have lost weight 6
- Cyproheptadine may be an appetite stimulant, but adverse effects have been reported 1
- Metoclopramide, nandrolone, and pentoxifylline have not been shown to have appetite-stimulating effects 1
Special Considerations
For Elderly Patients
- Use lower starting doses with close monitoring for side effects, particularly sedation and thromboembolic events 2, 5
- Drugs to stimulate appetite should NOT be used in persons with dementia due to limited evidence and potential risks 1, 2
For Cancer Patients
- For patients with months-to-weeks or weeks-to-days life expectancy, consider appetite stimulants if increased appetite is an important aspect of quality of life 1
- Reversible causes of anorexia, such as oropharyngeal candidiasis and depression, should be addressed first 1
Non-Pharmacological Approaches
- Provide emotional support during meals and ensure adequate feeding assistance 2, 4
- Serve energy-dense meals to help meet nutritional requirements without increasing meal volume 2, 4
- Offer oral nutritional supplements when food intake is between 50-75% of usual intake 2, 4
- Protein-enriched foods and drinks can improve protein intake in patients with poor appetite 2, 4
Important Caveats
- Regular reassessment is essential to evaluate benefit versus harm of pharmacological interventions 2, 5
- Megestrol acetate can cause fluid retention and increased risk of thromboembolic events 1, 3, 7
- Dexamethasone has significant side effects with prolonged use 2
- Weight gain with megestrol acetate may be primarily due to increases in body water and fat mass rather than lean body mass 8
- Megestrol acetate can lead to cortisol and testosterone depletion, requiring monitoring of these hormones 8