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Should We Use Appetite Stimulants for Malnourished Elderly Patients?

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Should We Use Appetite Stimulants for Malnourished Elderly Patients? From the CLINIcAL InQUiRiEs Family Physicians Inquiries Network Robert K. Persons, DO, Should we use appetite FAAFP and William Nichols, MLS stimulants for malnourished HQ Air Armament Center (Eglin) Family Medicine Residency, Eglin elderly patients? Air Force Base, Fla Evidence-based answer Probably not. Only 1 appetite stimulate, data show only limited benefit, mixed megestrol acetate oral suspension outcomes, and potential harm (strength (Megace) at 400 mg or 800 mg daily, of recommendation: B, based on small, has been studied in this population. The randomized, controlled trials). Clinical commentary ® Dowden Health Media Good advice for a common problem he was feeling over her failing health. This question hits homeCopyright for me. I recentlyFor personal Should we use appetite only stimulants in sat down with the husband, and main malnourished elderly patients? “Probably caregiver, of a woman with advanced not.” That is a good place to start to dementia. The woman eats very little and avoid harm to our most frail, declining, is losing weight despite her husband’s elderly patients for whom we care. That FAST TRACK great efforts at encouraging her to eat. leaves open flexibility to patient, family, Only megestrol Under the care of another physician, she and caregiver preferences, but reminds us had been given megestrol acetate and that the most important part of caring for has been studied there had been some improvement. Her these patients and their families is clear, for appetite visit to my office was an opportunity to compassionate communication regarding stimulation in continue an ongoing conversation with her goals and expectations. the elderly; results husband about his wife’s overall decline, Kayleen P. Papin, MD her advancing dementia, and the sorrow Medical College of Wisconsin, Milwaukee have been mixed z Evidence summary Two studies, mixed results Although a number of studies have One placebo-controlled randomized evaluated various appetite stimu- clinical trial studied 45 malnourished lants—megestrol, dronabinol (Marinol), patients who were recently discharged cyproheptadine (Periactin), thalidomide from an acute care hospital to a nursing (Thalomid), pentoxifylline (Pentoxil/ home. The patients (predominately fe- Trental), nandrolone decanoate (Deca- male, with a mean age of 83) were ran- Durabolin), oxandrolone (Oxandrin), domized into 4 treatment arms (placebo and corticosteroids—in patients with or megestrol 200 mg, 400 mg, or 800 AIDS, anorexia cachexia syndrome, and mg daily) and followed for 63 days. advanced cancer, only megestrol has been Only those receiving megestrol (400 studied in malnourished elderly patients. mg or 800 mg daily) demonstrated a sta- www.jfponline.com VOL 56, NO 9 / SEPTEMBER 2007 761 For mass reproduction, content licensing and permissions contact Dowden Health Media. s E i R i QU n I tistically significant increase in patient Recommendations from others appetite and a dose-responsive increase The American Geriatric Society4 made AL c in prealbumin level at the 20 day interim 3 comments on appetite stimulation: analysis (7.5 and 9.0 mg/dL, respectful- 1. There are no FDA-approved ly). But at the final assessment (63 days), drugs available for the promotion CLINI only the 400-mg dose maintained a sta- of weight gain in older adults. tistically significant increase in prealbu- 2. A minority of patients receiving min over placebo. However, there was mirtazapine report appetite stim- no significant improvement in serum ulation and weight gain. albumin or clinical endpoints (weight, 3. All drugs used for appetite have functional status, or health-related qual- substantial potential adverse ity of life).1 events. In contrast, an earlier Veterans Ad- We found only 1 national guide- ministration (and predominantly male) line on this topic: Unintentional Weight study showed 13/21 of those treated with Loss in the Elderly from the University megestrol (800 mg daily for 12 weeks) of Texas School of Nursing.5 The guide- noted weight gain (≥4 lb sustained at line indicates that drugs should not be 3 months post-treatment), compared used as first-line intervention in the el- with 5/23 of those receiving placebo derly, as there has been inadequate test- (number needed to treat [NNT]=2.5).2 ing in this population. Benefits are re- Of note, only 9/26 patients had sus- stricted to small weight gains without tained weight gain in the megestrol indication of decreased morbidity or group at the 12-month endpoint post- mortality, improved quality of life, or treatment, comparable with 7/25 in the improved functional ability. n placebo group. Some small, but statistically signifi- Acknowledgments cant, score improvements were noted The opinions and assertions contained herein are the during the treatment period in appe- private views of the author and not to be construed as FAST TRACK tite and enjoyment of life; however, no official, or as reflecting the views of the US Air Force Medical Service or the US Air Force at large. The only national differences were noted in scores on the more widely accepted Geriatric Depres- guideline on sion Scale. References weight loss in the 1. Reuben DB, Hirsch SH, Zhou K, Greendale GA. The effects of megestrol acetate suspension for elderly elderly does not Adverse effects patients with reduced appetite after hospitalization: recommend As in all therapeutic interventions, ben- a phase II randomized clinical trial. J Am Geriatr efit must be balanced against risk. The Soc 2005; 53:970–975. medication as the Megace ES package insert notes the 2. Yeh SS, Wu SY, Lee TP, et al. Improvement in qual- ity-of-life measures and stimulation of weight gain first-line treatment following potential adverse effects: di- after treatment with megestrol acetate or suspen- arrhea, cardiomyopathy, palpitation, sion in geriatric cachexia: results of a double-blind, hepatomegaly, leukopenia, edema, pares- placebo controlled study. J Am Geriatr Soc 2001; 48:485–492. thesia, confusion, convulsion, depression, 3. Megace. Physicians’ Desk Reference. 61st ed. neuropathy, hypesthesia and abnormal Montvale, NJ: Thompson; 2007:2461–2463. thinking, thrombophlebitis, pulmonary 4. Malnutrition. Geriatrics at Your Fingertips [website]. 3 embolism, and glucose intolerance. Available at: www.geriatricsatyourfingertips.org/ To date, the prevalence rates of ebook/gayf_20.asp. Accessed August 6, 2007. these potential adverse effects have only 5. University of Texas, School of Nursing. Uninten- been studied in patients with AIDS. No tional Weight Loss in the Elderly. Austin, Tex: Uni- versity of Texas, School of Nursing; 2006. Avail- data reflecting potential rates in elderly able at: www.guideline.gov/summary/summary. patients have been published. aspx?doc_id=9435. Accessed August 6, 2007. 762 VOL 56, NO 9 / SEPTEMBER 2007 THe JOURNAL OF FAMILY PRActIce.
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