Only 1 appetite stimulate, megestrol acetate oral suspension (Megace) at 400 mg or 800 mg daily, has been studied in this population. The data show only limited benefit, mixed outcomes, and potential harm (strength of recommendation: B, based on small, randomized, controlled trials)

Nichols, William

Persons, Robert K.

University of Missouri: MOspace

	 vol	56,	No	9	/	September	2007	 761www.jfponline.comCliniCal INquIrIeS From the Family Physicians Inquiries Network  Should we use appetite  stimulants for malnourished elderly patients?Robert K. Persons, DO, FaaFP  and William nichols, MlSHQ Air Armament Center (Eglin) Family Medicine Residency, Eglin Air Force Base, Flaprobably	not.	only	1	appetite	stimulate,	megestrol	acetate	oral	suspension	(megace)	at	400	mg	or	800	mg	daily,	has	been	studied	in	this	population.	the	data	show	only	limited	benefit,	mixed	outcomes,	and	potential	harm	(strength	of	recommendation:	B,	based	on	small,	randomized,	controlled	trials).	Good advice for a common problem this	question	hits	home	for	me.	I	recently	sat	down	with	the	husband,	and	main	caregiver,	of	a	woman	with	advanced	dementia.	the	woman	eats	very	little	and	is	losing	weight	despite	her	husband’s	great	efforts	at	encouraging	her	to	eat.	under	the	care	of	another	physician,	she	had	been	given	megestrol	acetate	and	there	had	been	some	improvement.	Her	visit	to	my	office	was	an	opportunity	to	continue	an	ongoing	conversation	with	her	husband	about	his	wife’s	overall	decline,	her	advancing	dementia,	and	the	sorrow	he	was	feeling	over	her	failing	health.		 Should	we	use	appetite	stimulants	in	malnourished	elderly	patients?	“probably	not.”	that	is	a	good	place	to	start	to	avoid	harm	to	our	most	frail,	declining,	elderly	patients	for	whom	we	care.	that	leaves	open	flexibility	to	patient,	family,	and	caregiver	preferences,	but	reminds	us	that	the	most	important	part	of	caring	for	these	patients	and	their	families	is	clear,	compassionate	communication	regarding	goals	and	expectations.	 Kayleen P. Papin, MDmedical	College	of	Wisconsin,	milwaukeez 	Evidence summaryAlthough a number of studies have evaluated various appetite stimu-lants—megestrol, dronabinol (Marinol), cyproheptadine (Periactin), thalidomide (Thalomid), pentoxifylline (Pentoxil/Trental), nandrolone decanoate (Deca-Durabolin), oxandrolone (Oxandrin), and corticosteroids—in patients with AIDS, anorexia cachexia syndrome, and advanced cancer, only megestrol has been studied in malnourished elderly patients. Two studies, mixed resultsOne placebo-controlled randomized clinical trial studied 45 malnourished patients who were recently discharged from an acute care hospital to a nursing home. The patients (predominately fe-male, with a mean age of 83) were ran-domized into 4 treatment arms (placebo or megestrol 200 mg, 400 mg, or 800 mg daily) and followed for 63 days. Only those receiving megestrol (400 mg or 800 mg daily) demonstrated a sta-Clinical commentaryEvidence-based answerfast trackOnly megestrol  has been studied for appetite  stimulation in the elderly; results have been mixedCopyright® Dowden Health Media  For personal use onlyFor mass reproduction, content licensing and permissions contact Dowden Health Media.fast trackCliniCal INquIrIeS762 vol	56,	No	9	/	September	2007		ThE Journal of family PraCTiCEtistically significant increase in patient appetite and a dose-responsive increase in prealbumin level at the 20 day interim analysis (7.5 and 9.0 mg/dL, respectful-ly). But at the final assessment (63 days), only the 400-mg dose maintained a sta-tistically significant increase in prealbu-min over placebo. However, there was no significant improvement in serum albumin or clinical endpoints (weight, functional status, or health-related qual-ity of life).1 In contrast, an earlier Veterans Ad-ministration (and predominantly male) study showed 13/21 of those treated with megestrol (800 mg daily for 12 weeks) noted weight gain (≥4 lb sustained at 3 months post-treatment), compared with 5/23 of those receiving placebo (number needed to treat [NNT]=2.5).2 Of note, only 9/26 patients had sus-tained weight gain in the megestrol group at the 12-month endpoint post-treatment, comparable with 7/25 in the placebo group. Some small, but statistically signifi-cant, score improvements were noted during the treatment period in appe-tite and enjoyment of life; however, no differences were noted in scores on the more widely accepted Geriatric Depres-sion Scale. Adverse effectsAs in all therapeutic interventions, ben-efit must be balanced against risk. The Megace ES package insert notes the following potential adverse effects: di-arrhea, cardiomyopathy, palpitation, hepatomegaly, leukopenia, edema, pares-thesia, confusion, convulsion, depression, neuropathy, hypesthesia and abnormal thinking, thrombophlebitis, pulmonary embolism, and glucose intolerance.3 To date, the prevalence rates of these potential adverse effects have only been studied in patients with AIDS. No data reflecting potential rates in elderly patients have been published. Recommendations from othersThe American Geriatric Society4 made 3 comments on appetite stimulation: 1.  There are no FDA-approved drugs available for the promotion of weight gain in older adults. 2.  A minority of patients receiving mirtazapine report appetite stim-ulation and weight gain. 3.  All drugs used for appetite have substantial potential adverse events.We found only 1 national guide-line on this topic: Unintentional Weight Loss in the Elderly from the University of Texas School of Nursing.5 The guide-line indicates that drugs should not be used as first-line intervention in the el-derly, as there has been inadequate test-ing in this population. Benefits are re-stricted to small weight gains without indication of decreased morbidity or mortality, improved quality of life, or improved functional ability. nacknowledgmentsthe	 opinions	 and	 assertions	 contained	 herein	 are	 the	private	views	of	the	author	and	not	to	be	construed	as	official,	 or	 as	 reflecting	 the	 views	of	 the	uS	Air	 Force	medical	Service	or	the	uS	Air	Force	at	large.references	 1.	 	reuben	Db,	Hirsch	SH,	Zhou	K,	Greendale	GA.	the	effects	of	megestrol	acetate	suspension	for	elderly	patients	with	reduced	appetite	after	hospitalization:	a	 phase	 II	 randomized	 clinical	 trial.	J Am Geriatr Soc	2005;	53:970–975.		 2.	 	Yeh	SS,	Wu	SY,	lee	tp,	et	al.	Improvement	in	qual-ity-of-life	measures	and	stimulation	of	weight	gain	after	treatment	with	megestrol	acetate	or	suspen-sion	in	geriatric	cachexia:	results	of	a	double-blind,	placebo	controlled	study.	J Am Geriatr Soc	2001;	48:485–492.		 3.	 	megace.	 Physicians’ Desk Reference.	 61st	 ed.	montvale,	NJ:	thompson;	2007:2461–2463.	 4.	 	malnutrition.	Geriatrics	at	Your	Fingertips	[website].	Available	 at:	 www.geriatricsatyourfingertips.org/ebook/gayf_20.asp.	Accessed	August	6,	2007.		 5.	 	university	 of	 texas,	 School	 of	 Nursing.	 Uninten-tional Weight Loss in the Elderly.	Austin,	tex:	uni-versity	 of	 texas,	 School	 of	 Nursing;	 2006.	 Avail-able	 at:	 www.guideline.gov/summary/summary.aspx?doc_id=9435.	Accessed	August	6,	2007.The only national guideline on weight loss in the elderly does not recommend  medication as the first-line treatment

Should we use appetite stimulants for malnourished elderly patients?

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