What conservative medication therapy can increase appetite in an elderly male patient with Chronic Obstructive Pulmonary Disease (COPD), fatty liver, and hypertension?

From the Guidelines

For an elderly male patient with COPD, fatty liver, and hypertension who needs appetite stimulation, I recommend starting with megestrol acetate 400-800mg daily, as it has been shown to increase appetite and body weight in underweight individuals with COPD 1. This medication should be used with caution, monitoring for adrenal suppression and thromboembolic risk. Other options such as mirtazapine and dronabinol may also be considered, but megestrol acetate is the most directly relevant to increasing appetite in the context of COPD, as supported by the American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation 1. It's also important to combine pharmacological approaches with practical dietary strategies, such as:

• Offering smaller, more frequent meals
• Ensuring food is seasoned adequately, as COPD can diminish taste sensation
• Scheduling meals when energy levels are highest
• Using nutritional supplements between meals rather than with meals to add calories without affecting main meal consumption Additionally, addressing any medication side effects that might be suppressing appetite, treating constipation, optimizing COPD management to reduce dyspnea during meals, and ensuring adequate vitamin D levels can all contribute to improved appetite. Regular monitoring of liver function is essential given the patient's fatty liver disease, and blood pressure should be closely watched as some appetite stimulants may affect cardiovascular parameters. The most recent guidelines on managing polypharmacy in older adults with cardiovascular disease emphasize the importance of individualized care, considering the patient's overall health context, functional status, life expectancy, and personal preferences 1. However, in the context of appetite stimulation for an elderly male patient with COPD, fatty liver, and hypertension, megestrol acetate stands out as a directly relevant option, despite the need for careful monitoring and consideration of the patient's broader health needs.

From the FDA Drug Label

In U. S. controlled clinical studies, appetite increase was reported in 17% of patients treated with mirtazapine tablets, compared to 2% for placebo. In these same trials, weight gain of ≥7% of body weight was reported in 7.5% of patients treated with mirtazapine, compared to 0% for placebo. A greater percentage of MA-treated patients (67%) than placebo-treated patients (38%) showed an improvement in appetite at last evaluation during the 12 study weeks; this difference was statistically significant.

Conservative medication therapy to increase appetite in an elderly male patient with COPD, fatty liver, and hypertension could be mirtazapine or megesterol acetate.

• Mirtazapine may increase appetite in 17% of patients.
• Megesterol acetate has been shown to improve appetite in 67% of patients in a clinical trial. However, it is crucial to consider the patient's specific medical conditions and potential interactions with other medications before making a decision. It is also important to weigh the potential benefits against the potential risks, such as weight gain and increased cholesterol and triglycerides associated with mirtazapine and megesterol acetate 2 3.

From the Research

Conservative Medication Therapy for Increasing Appetite

To increase appetite in an elderly male patient with COPD, fatty liver, and hypertension, several medication options can be considered:

• Megestrol acetate, a progestational appetite stimulant, has been shown to safely increase appetite and body weight in underweight COPD patients 4, 5.
• The use of megestrol acetate has been associated with improved nutritional parameters, sense of wellbeing, and blood gases, but it does not improve respiratory muscular function or exercise tolerance 4, 5.
• Combination therapy with megestrol acetate and testosterone may also be beneficial for patients with COPD cachexia, as it has been shown to increase lean mass and fat mass 6.

Considerations for Elderly Patients with COPD

When managing COPD in elderly patients, it is essential to consider the complexity of the disease and the presence of comorbidities:

• COPD is often underdiagnosed and undertreated in the elderly population due to atypical clinical presentation and difficulty with current respiratory function diagnostic standards 7.
• The disease has a significant impact on quality of life, morbidity, and mortality, and its management requires a multidisciplinary approach 7, 8.
• Pharmacologic and nonpharmacologic interventions can be effective in ameliorating symptoms, but appropriate drug delivery and reduction of side effects are crucial in the management of patients with COPD 8.