J Korean Med Assoc.  2015 Nov;58(11):1027-1033. 10.5124/jkma.2015.58.11.1027.

Appetite stimulants for older persons

• Yoon JL

• KMID: 2195132
• DOI: http://doi.org/10.5124/jkma.2015.58.11.1027

Abstract

Anorexia is one of the most common issues in older patients. Although there is a tendency for loss of appetite in older persons due to decreased physical activity and reduced resting metabolic rate, this physiological anorexia of aging can easily develop into progressive anorexia and weight loss. This pathologic anorexia and resultant weight loss is associated with increased morbidity and mortality, especially in the frail elderly. To prevent older persons from entering a vicious cycle of frailty, that is, anorexia-malnutrition-sarcopenia-functional impairment, routine screening for anorexia and malnutrition should be implemented in geriatric clinical practice. All anorexic elderly patients should be strongly encouraged to maintain their nutrition, and appetite stimulants can be considered if non-pharmacological interventions are not effective. Although there are no US or Korea Food and Drug Administration approved medications for geriatric-specific anorexia and weight loss, several appetite stimulants can be prescribed and are used widely. Megestrol acetate is the most widely studied and commonly used of these drugs. Cyproheptadine, dronabinol, mirtazapine, corticosteroids, anabolic steroids (e.g., testosterone or oxandrolone), and growth hormone are also effective in increasing appetite or weight. However, the use of these orexigenic agents should occur only after their benefit-to-risk ratio has been carefully considered.

Keyword

Anorexia; Weight loss; Older persons; Appetite stimulant

MeSH Terms

Adrenal Cortex Hormones
Aged
Aging
Anorexia
Appetite Stimulants*
Appetite*
Cyproheptadine
Diethylpropion
Dronabinol
Frail Elderly
Growth Hormone
Humans
Korea
Malnutrition
Mass Screening
Megestrol Acetate
Mortality
Motor Activity
Steroids
Testosterone
United States Food and Drug Administration
Weight Loss
Adrenal Cortex Hormones
Appetite Stimulants
Cyproheptadine
Diethylpropion
Dronabinol
Growth Hormone
Megestrol Acetate
Steroids
Testosterone

Figure

• 

  Figure 1 Vicious cycle of frailty. (Modified from Ahmed N, et al. Am J Med 2007;120:748-753) [10].

Reference

1. Flacker JM. What is a geriatric syndrome anyway? J Am Geriatr Soc. 2003; 51:574–576.

2. Olde Rikkert MG, Rigaud AS, van Hoeyweghen RJ, de Graaf J. Geriatric syndromes: medical misnomer or progress in geriatrics? Neth J Med. 2003; 61:83–87.

3. Inouye SK, Studenski S, Tinetti ME, Kuchel GA. Geriatric syndromes: clinical, research, and policy implications of a core geriatric concept. J Am Geriatr Soc. 2007; 55:780–791.

4. Lambert PD, Wilding JP, al-Dokhayel AA, Bohuon C, Comoy E, Gilbey SG, Bloom SR. A role for neuropeptide-Y, dynorphin, and noradrenaline in the central control of food intake after food deprivation. Endocrinology. 1993; 133:29–32.

5. Morley JE. Anorexia of aging: physiologic and pathologic. Am J Clin Nutr. 1997; 66:760–773.

6. Ministry of Health and Welfare, Korea Centers for Disease Con-trol and Prevention. Korea health statistics 2013: Korea National Health and Nutrition Examination Survey (KNHANES VI-1) [Internet]. Cheongju: Korea Centers for Disease Control and Prevention;2015. cited 2015 Nov 4. Available from: http://stat.mw.go.kr/front/statData/publicationView.jsp?menuId=47&topSelect=B00005&bbsSeq=13&nttSeq=21549&searchKey=&searchWord=&nPage=1.

7. Yoon JL. Overview of geriatric syndromes. International Association of Gerontology and Geriatrics. In : 5th IAGG Master Class on Ageing in Asia; 2014 Jun 23-25; Seoul, Korea. Seoul: International Association of Gerontology and Geriatrics;2014. p. 4–10.

8. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, Seeman T, Tracy R, Kop WJ, Burke G, McBurnie MA. Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001; 56:M146–M156.

9. Morley JE. Anorexia, sarcopenia, and aging. Nutrition. 2001; 17:660–663.

10. Ahmed N, Mandel R, Fain MJ. Frailty: an emerging geriatric syndrome. Am J Med. 2007; 120:748–753.

11. Spalding MC, Sebesta SC. Geriatric screening and preventive care. Am Fam Physician. 2008; 78:206–215.

12. Wilson MM, Vaswani S, Liu D, Morley JE, Miller DK. Prevalence and causes of undernutrition in medical outpatients. Am J Med. 1998; 104:56–63.

13. Lauque S, Arnaud-Battandier F, Mansourian R, Guigoz Y, Paintin M, Nourhashemi F, Vellas B. Protein-energy oral supplementation in malnourished nursing-home residents: a controlled trial. Age Ageing. 2000; 29:51–56.

14. Thomas DR. Use of orexigenic medications in geriatric patients. Am J Geriatr Pharmacother. 2011; 9:97–108.

15. Kardinal CG, Loprinzi CL, Schaid DJ, Hass AC, Dose AM, Athmann LM, Mailliard JA, McCormack GW, Gerstner JB, Schray MF. A controlled trial of cyproheptadine in cancer patients with anorexia and/or cachexia. Cancer. 1990; 65:2657–2662.

16. Mainguet P. Effect of cyproheptadine on anorexia and loss of weight in adults. Practitioner. 1972; 208:797–800.

17. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012; 60:616–631.

18. Korea Food and Drug Administration. Guide to appropriate medication use in older adults [Internet]. Seoul: Korea Pharmaceutical Information Center;2009. cited 2015 Nov 4. Available from: http://www.health.kr/bbs/common/kpic_l.asp?show_idx=967&table=bbs_data&category=4&page=1&search=&keyword=.

19. Pascual Lopez A, Roque i Figuls M, Urrutia Cuchi G, Berenstein EG, Almenar Pasies B, Balcells Alegre M, Herdman M. Systematic review of megestrol acetate in the treatment of anorexia-cachexia syndrome. J Pain Symptom Manage. 2004; 27:360–369.

20. Berenstein EG, Ortiz Z. Megestrol acetate for the treatment of anorexia-cachexia syndrome. Cochrane Database Syst Rev. 2005; (2):CD004310.

21. Yeh SS, Wu SY, Lee TP, Olson JS, Stevens MR, Dixon T, Porcelli RJ, Schuster MW. Improvement in quality-of-life measures and stimulation of weight gain after treatment with megestrol acetate oral suspension in geriatric cachexia: results of a double-blind, placebo-controlled study. J Am Geriatr Soc. 2000; 48:485–492.

22. Karcic E, Philpot C, Morley JE. Treating malnutrition with megestrol acetate: literature review and review of our experience. J Nutr Health Aging. 2002; 6:191–200.

23. Yeh SS, Wu SY, Levine DM, Parker TS, Olson JS, Stevens MR, Schuster MW. The correlation of cytokine levels with body weight after megestrol acetate treatment in geriatric patients. J Gerontol A Biol Sci Med Sci. 2001; 56:M48–M54.

24. Rammohan M, Kalantar-Zadeh K, Liang A, Ghossein C. Megestrol acetate in a moderate dose for the treatment of malnutrition-inflammation complex in maintenance dialysis patients. J Ren Nutr. 2005; 15:345–355.

25. American Geriatrics Society. Ten things physicians and patients should question [Internet]. Philadelphia (PA): Choosing Wisely;2015. cited 2015 Nov 4. Available from: http://www.choosingwisely.org/societies/american-geriatrics-society.

26. Beal JE, Olson R, Laubenstein L, Morales JO, Bellman P, Yangco B, Lefkowitz L, Plasse TF, Shepard KV. Dronabinol as a treatment for anorexia associated with weight loss in patients with AIDS. J Pain Symptom Manage. 1995; 10:89–97.

27. Gonzalez-Rosales F, Walsh D. Intractable nausea and vomiting due to gastrointestinal mucosal metastases relieved by tetrahydrocannabinol (dronabinol). J Pain Symptom Manage. 1997; 14:311–314.

28. Volicer L, Stelly M, Morris J, McLaughlin J, Volicer BJ. Effects of dronabinol on anorexia and disturbed behavior in patients with Alzheimer's disease. Int J Geriatr Psychiatry. 1997; 12:913–919.

29. Yavuzsen T, Davis MP, Walsh D, LeGrand S, Lagman R. Systematic review of the treatment of cancer-associated anorexia and weight loss. J Clin Oncol. 2005; 23:8500–8511.

30. Schell HW. Adrenal corticosteroid therapy in far-advanced cancer. Geriatrics. 1972; 27:131–141.

31. Kenny AM, Prestwood KM, Gruman CA, Marcello KM, Raisz LG. Effects of transdermal testosterone on bone and muscle in older men with low bioavailable testosterone levels. J Gerontol A Biol Sci Med Sci. 2001; 56:M266–M272.

32. Sih R, Morley JE, Kaiser FE, Perry HM 3rd, Patrick P, Ross C. Testosterone replacement in older hypogonadal men: a 12-month randomized controlled trial. J Clin Endocrinol Metab. 1997; 82:1661–1667.

33. Schambelan M, Mulligan K, Grunfeld C, Daar ES, LaMarca A, Kotler DP, Wang J, Bozzette SA, Breitmeyer JB. Recombinant human growth hormone in patients with HIV-associated wasting. A randomized, placebo-controlled trial: Serostim Study Group. Ann Intern Med. 1996; 125:873–882.

34. Kaiser FE, Silver AJ, Morley JE. The effect of recombinant human growth hormone on malnourished older individuals. J Am Geriatr Soc. 1991; 39:235–240.

35. Morley JE. The neuroendocrine control of appetite: the role of the endogenous opiates, cholecystokinin, TRH, gamma-aminobutyric-acid and the diazepam receptor. Life Sci. 1980; 27:355–368.

36. Leinonen E, Skarstein J, Behnke K, Agren H, Helsdingen JT. Efficacy and tolerability of mirtazapine versus citalopram: a double-blind, randomized study in patients with major depressive disorder: Nordic Antidepressant Study Group. Int Clin Psychopharmacol. 1999; 14:329–337.

37. Champion MC, MacCannell KL, Thomson AB, Tanton R, Eberhard S, Sullivan SN, Archambault A. A double-blind ran-domized study of cisapride in the treatment of nonulcer dyspepsia: the Canadian Cisapride Nud Study Group. Can J Gastroenterol. 1997; 11:127–134.

38. Bruera E, Belzile M, Neumann C, Harsanyi Z, Babul N, Darke A. A double-blind, crossover study of controlled-release metoclopramide and placebo for the chronic nausea and dyspepsia of advanced cancer. J Pain Symptom Manage. 2000; 19:427–435.

39. Soykan I, Sarosiek I, Shifflett J, Wooten GF, McCallum RW. Effect of chronic oral domperidone therapy on gastrointestinal symptoms and gastric emptying in patients with Parkinson's disease. Mov Disord. 1997; 12:952–957.

40. Tramontana JM, Utaipat U, Molloy A, Akarasewi P, Burroughs M, Makonkawkeyoon S, Johnson B, Klausner JD, Rom W, Kaplan G. Thalidomide treatment reduces tumor necrosis factor alpha production and enhances weight gain in patients with pulmonary tuberculosis. Mol Med. 1995; 1:384–397.

41. Reyes-Teran G, Sierra-Madero JG, Martinez del Cerro V, Arroyo-Figueroa H, Pasquetti A, Calva JJ, Ruiz-Palacios GM. Effects of thalidomide on HIV-associated wasting syndrome: a randomized, double-blind, placebo-controlled clinical trial. AIDS. 1996; 10:1501–1507.

42. Hellerstein MK, Wu K, McGrath M, Faix D, George D, Shackleton CH, Horn W, Hoh R, Neese RA. Effects of dietary n-3 fatty acid supplementation in men with weight loss associated with the acquired immune deficiency syndrome: Relation to indices of cytokine production. J Acquir Immune Defic Syndr Hum Retrovirol. 1996; 11:258–270.

43. Barber MD, Ross JA, Voss AC, Tisdale MJ, Fearon KC. The effect of an oral nutritional supplement enriched with fish oil on weight-loss in patients with pancreatic cancer. Br J Cancer. 1999; 81:80–86.