Appetite Stimulation in Hospice Patients
Posted by Dr. Jim Joyner
Is Megace a good drug for appetite stimulation in a hospice patient?
Megace (megestrol acetate) is a progestin-type hormonal drug that has been used for appetite stimulation. It has an FDA approved indication for the treatment of anorexia, cachexia, and unexplained weight loss in patients with AIDS. Despite the very narrow indication, it has been widely used for the treatment of weight loss in cancer patients, frail nursing home residents, dementia patients, and frail elderly patients in the community with non-cancerous chronic health conditions, which includes many in hospice care.
Studies in patients with cancer and AIDS have shown Megace to be an effective appetite stimulant that is associated with weight gain. Alternatively, studies in geriatric patients including mostly nursing home residents have failed to demonstrate similar consistent benefits. Reports on the clinical significance of Megace induced weight gain vary considerably. Some clinicians believe that the weight gains that have been achieved with Megace are not related to reversing the catabolic state of advanced disease, but reflect only increased body fat or water retention.
The high cost of this drug coupled with the high volume of use in non-approved applications stimulated numerous clinical reviews and research reports regarding its effectiveness for treatment of weight loss and its adverse effects potential during the past few years. The majority of these studies have been conducted in geriatric patients. To date, the reports in the medical literature indicate only modest benefits at best and a potential for serious adverse events.1
A retrospective study by Bodenner, et al. in The American Journal of Geriatric Pharmacology (June 2007), concluded that megestrol acetate was associated with an increase in death among elderly nursing home residents being treated for weight loss. A statistical analysis by the authors demonstrated that the survival time of those patients receiving Megace was on average 7.3 months less than case matched cohorts who did not receive Megace and this was determined to be highly significant. Furthermore their results found no significant increase in weight for their study population of 709 nursing home residents.
Deep venous thrombosis (DVT) is another potentially devastating adverse effect that has been associated with the use of Megace for treatment of weight loss in elderly patients. A 2003 article by Kropsky, et al, reported a 5% incidence of DVT in elderly nursing home residents receiving Megace for treatment of weight loss.2 DVT has been identified as a significant risk of Megace therapy in geriatric patients by other researchers as early as 2000 in the Journal of the American Medical Directors Association and again in a 2003 review of cases by Marshall, et al. 3,4
There is sufficient evidence to formulate some guidelines about which patients are at high-risk for potentially serious adverse effects. Megace probably should not be used in the following types of hospice patients due to serious risks outweighing potential benefits:
- History of thromboembolic disease
- Bed-bound, or otherwise immobile
- Heart failure
- Elderly patients
Megace has been shown to increase the appetite and induce weight gain in non-geriatric adult patients with cancer or AIDS, however, the weight gain may be due to increased fat production or water retention, not lean muscle mass. Given the current information, Megace would appear to have a very limited role as an appetite stimulant in hospice patients. Alternative drugs for appetite stimulation and treatment of weight loss have included various agents from different pharmacologic classes: the steroid dexamethasone (Decadron); the antidepressant mirtazapine (Remeron); and the antihistamine cyproheptadine (Periactin). All of these drugs have potential side effects of varying significance, however, none have been associated with an increased risk of death in the elderly or increased risk of DVT. In addition, these alternatives for hospice patients are all available as low-cost generics.
1. Bodenner, et al. The American Journal of Geriatric Pharmacology 2007;5(2):137-146 2. Kropsky, eta al. Journal of the American Medical Directors Association 2003;4:255-256 3. Bolen, et al Jouranal of the American Medical Directors Association 2000;48:248-52 4. Marshall, LL The Consultant Pharmacist 2003;18:764-63
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Estimated Cost of Megace for 15 days |
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Megace ES 625mg/5ml; 5ml once daily
$300.00 |
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