What is the best medication for stimulating appetite in patients with decreased appetite?

From the Guidelines

Megestrol acetate (400-800mg daily) is the most effective medication for stimulating appetite, particularly in patients with cancer cachexia, as it has been shown to improve appetite, weight, and quality of life in these patients 1. When considering appetite stimulation, it's essential to evaluate the underlying cause of appetite loss and address it accordingly. In patients with cancer, AIDS, or other underlying pathologies, megestrol acetate has been found to be more effective than other medications, including dronabinol, in improving appetite and weight gain 1.

• The mechanism of action of megestrol acetate is not fully understood, but it is thought to act as a synthetic progesterone, which can help stimulate appetite and improve weight gain.
• Other medications, such as mirtazapine and cyproheptadine, may also be effective in stimulating appetite, but the evidence is less robust, and they may be more suitable for specific patient populations, such as those with depression or children 1.
• Dronabinol, a cannabinoid, may be considered for patients with cancer or HIV-related appetite loss, but the evidence is limited, and it may not be as effective as megestrol acetate in improving appetite and weight gain 1.
• It's crucial to use these medications under medical supervision, as part of a comprehensive approach that includes dietary modifications and nutritional supplements, to ensure optimal outcomes and minimize potential side effects.

From the FDA Drug Label

The appetite stimulant effect of dronabinol capsules in the treatment of AIDS-related anorexia associated with weight loss was studied in a randomized, double-blind, placebo-controlled study involving 139 patients. A statistically significant difference between dronabinol capsules and placebo was seen in appetite as measured by the visual analog scale at weeks 4 and 6

Dronabinol is a medication that has been shown to be effective in stimulating appetite, particularly in patients with AIDS-related anorexia associated with weight loss 2.

• The initial dosage of dronabinol was 5 mg/day, administered in doses of 2.5 mg one hour before lunch and one hour before dinner.
• Dronabinol has been found to have a statistically significant effect on appetite, with trends toward improved body weight and mood, and decreases in nausea.
• The medication has been associated with side effects such as feeling high, dizziness, confusion, and somnolence, which occurred in 18% of patients at the initial dosage level.

From the Research

Medications for Stimulating Appetite

• The majority of evidence on the efficacy of appetite-stimulating medications, such as dronabinol, megestrol acetate, and mirtazapine, is limited to specific populations and the outpatient treatment setting 3.
• Megestrol acetate has been shown to increase total body weight and body mass index in HIV-infected patients with wasting, while dronabinol has conflicting data on weight increases but may have minimal benefit on body composition compared to other appetite stimulants 4.
• A study comparing dronabinol and megestrol acetate for cancer-associated anorexia found that megestrol acetate provided superior anorexia palliation, with a greater percentage of patients reporting appetite improvement and weight gain 5.
• Combination therapy with megestrol acetate and dronabinol did not appear to confer additional benefit compared to megestrol acetate alone 5.
• The safety and pharmacokinetics of single-agent and combination therapy with megestrol acetate and dronabinol for the treatment of HIV wasting syndrome have been assessed, with megestrol acetate showing a positive correlation between pharmacokinetic parameters and weight change, hunger scores, and quality of life 6.

Comparison of Medications

• Dronabinol and megestrol acetate are two commonly used orexigenic agents, with megestrol acetate recommended for persons with a large excess cytokine production and dronabinol recommended for most anorectic patients 7.
• Mirtazapine may be a promising pharmacologic option in the management of HIV wasting and depression, but further research is needed 4.
• Testosterone has been shown to be effective in HIV wasting for those who suffer from hypogonadism, and recombinant human growth hormone has been evaluated for HIV wasting with promising results for weight and lean body mass increases 4.

Treatment Considerations

• The appropriate use of anabolic agents in older persons with weight loss is controversial, but bioavailable testosterone measurement and replacement therapy may be beneficial for older men with low testosterone levels 7.
• The use of taste enhancers can be considered in persons who complain that food does not taste good, and an approach to the management of anorexia and weight loss in older persons has been proposed 7.