What are the treatment options for loss of appetite?

Treatment of Loss of Appetite

For cancer-related loss of appetite, megestrol acetate (400-800 mg daily) is the first-line pharmacologic option, improving appetite in approximately 1 in 4 patients, while dexamethasone serves as an alternative for patients with shorter life expectancy. 1

Cancer-Related Anorexia/Cachexia

Pharmacologic Interventions

Primary Options:

• Megestrol acetate is recommended by the National Comprehensive Cancer Network for cancer-related anorexia when appetite improvement is important for quality of life 1

  • Improves appetite in ~25% of patients and produces modest weight gain in ~8% of patients 1
  • Critical warning: May cause adrenal insufficiency, new-onset diabetes, and thromboembolic events; monitor closely and consider stress-dose glucocorticoids during illness or withdrawal 2
  • Typical dosing: 400-800 mg daily 3

• Dexamethasone is suggested as an appropriate alternative, particularly for patients with weeks-to-months life expectancy 1

  • Offers similar appetite improvement to megestrol acetate with faster onset 1
  • Additional benefit of reducing fatigue 1
  • Preferred in palliative settings due to shorter treatment duration needs 3

Second-Line Options:

• Olanzapine may be considered, especially when concurrent nausea/vomiting is present 1

  • Causes weight gain as a side effect 1
  • Limited evidence specifically for anorexia/cachexia but recognized clinically 3

• Cannabinoids (dronabinol) have limited evidence but may increase body weight and meal consumption in select populations 1

Non-Pharmacologic Interventions

Nutritional Support:

• Provide dietary counseling focused on patient preferences and aversions ("preference-guided nutrition") 4
• Serve energy-dense meals with adequate feeding assistance 1
• Provide emotional support during meals 1
• Caution: Overly aggressive enteral or parenteral nutrition in dying patients (weeks-to-days life expectancy) can increase suffering 3

Symptom Management:

• Treat underlying symptoms interfering with intake: pain, nausea, vomiting, depression, dysgeusia 3
• Address early satiety through prokinetic agents if appropriate 4
• Manage dry mouth and thirst in advanced disease 3

Treatment Approach by Life Expectancy

Years-to-Months Prognosis:

• Consider appetite stimulants (megestrol acetate or dexamethasone) 3, 1
• Treat reversible causes and comorbid conditions 3
• Evaluate endocrine abnormalities 3
• Consider nutrition support consultation 3

Weeks-to-Days Prognosis:

• Focus shifts from prolonging life to maintaining quality of life 3
• Avoid aggressive nutritional interventions 3
• Provide family education about alternate ways to provide comfort 3
• Treat dry mouth and thirst rather than forcing nutrition 3

Diabetes-Related Appetite Disturbances

Assessment and Management

Initial Evaluation:

• Screen for disordered or disrupted eating using validated measures when hyperglycemia and weight loss are unexplained 3
• Review the medical treatment plan to identify treatment-related effects on hunger/caloric intake 3
• Critical distinction: Caution against labeling as psychiatric eating disorder when disrupted eating patterns are driven by physiologic disruption in hunger/satiety cues, metabolic perturbations, or medication effects 3, 5

Pharmacologic Considerations:

• GLP-1 receptor agonists may help manage hunger-related issues by modulating food intake and reducing uncontrollable hunger and overeating 3, 5

  • Work in appetite and reward circuitries 3
  • Early evidence suggests effectiveness in reducing binge-eating behaviors 3

• Monitor patients on second-generation antipsychotics for changes in weight, glycemia, and lipids every 12-16 weeks 3

Eating Disorders

Anorexia Nervosa

• Adults: Treat with eating disorder-focused psychotherapy including normalization of eating behaviors and weight restoration 3
• Adolescents/emerging adults: Treat with eating disorder-focused family-based treatment when caregiver is involved 3
• Set individualized goals for weekly weight gain and target weight 3

Bulimia Nervosa

• Adults: Treat with eating disorder-focused cognitive-behavioral therapy 3
  • Add fluoxetine 60 mg daily initially or if minimal/no response to psychotherapy by 6 weeks 3
• Adolescents/emerging adults: Consider family-based treatment when caregiver is involved 3

Binge-Eating Disorder

• Treat with eating disorder-focused cognitive-behavioral therapy or interpersonal therapy (individual or group formats) 3
• If medication preferred or psychotherapy ineffective, consider antidepressant or lisdexamfetamine 3

Elderly and General Medical Populations

Common Causes to Address

• Gastrointestinal and metabolic disorders 6
• Cardiopulmonary disease 6
• Medication side effects 6
• Poor oral and dental health 6
• Social factors: loneliness, depression, isolation 6
• Inability to obtain and prepare foods 6

Important Caveats

• Do not use appetite stimulants systematically in dementia patients due to limited evidence and potential risks 1
• Treatment goals should focus on quality of life rather than simply weight gain 1
• Regular reassessment is essential to evaluate benefit versus harm, particularly in frail patients 1
• Lower starting doses and closer monitoring for side effects (especially sedation and thromboembolic events) are recommended in elderly patients 1
• Loss of appetite in acute illness may represent an adaptive, protective response that improves autophagy and detoxification; indiscriminate nutritional support can be harmful 7