Top Banner
Appetite Appetite Stimulants: Stimulants: Effects in Elderly Effects in Elderly By: Nicole Parello and Jeanette Kimszal
25

Appetite Stimulants:

Jan 02, 2016

Download

Documents

Appetite Stimulants:. Effects in Elderly. By: Nicole Parello and Jeanette Kimszal. Appetite Stimulants: Overview. May help promote appetite and weight gain in elderly with unintentional weight loss or poor P.O. intake Drugs should not be considered as first-line treatment - PowerPoint PPT Presentation
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Page 1: Appetite Stimulants:

Appetite Appetite Stimulants:Stimulants:Effects in ElderlyEffects in Elderly

By: Nicole Parello and Jeanette Kimszal

Page 2: Appetite Stimulants:

Appetite Stimulants: Appetite Stimulants: OverviewOverview

May help promote appetite and weight gain in elderly with unintentional May help promote appetite and weight gain in elderly with unintentional weight loss or poor P.O. intakeweight loss or poor P.O. intake

Drugs should not be considered as first-line treatmentDrugs should not be considered as first-line treatment

Even if successful in inducing weight gain, long-term effects on quality of Even if successful in inducing weight gain, long-term effects on quality of life are unknownlife are unknown

The following appetite stimulants have been researched in literature The following appetite stimulants have been researched in literature Dronabionol (Marinol)Dronabionol (Marinol) Mirtazapine (Remeron)Mirtazapine (Remeron) Megestrol Acetate (Megace)Megestrol Acetate (Megace) Metoclopraminde (Reglan)Metoclopraminde (Reglan) Cyproheptadine (Periactin)Cyproheptadine (Periactin) Anabolic Steroids (Oxandrolone; Oxandrin)Anabolic Steroids (Oxandrolone; Oxandrin) GhrelinGhrelin Recombinant Human Growth Hormone (Serostim)Recombinant Human Growth Hormone (Serostim) TestosteroneTestosterone

Page 3: Appetite Stimulants:

DronabinolDronabinol Drug name:Drug name: Marinol Marinol

What it is:What it is: A tetrahydrocannabinol A tetrahydrocannabinol

Use:Use: • Weight gain in cancer-related anorexia patientsWeight gain in cancer-related anorexia patients

Side EffectsSide Effects: : • LightheadednessLightheadedness• SleepinessSleepiness• Blurred visionBlurred vision• Can’t think clearlyCan’t think clearly• DizzinessDizziness• SedationSedation• FatigueFatigue• HallucinationsHallucinations

Page 4: Appetite Stimulants:

Dronabinol ResearchDronabinol Research Useful in anorexia, weight gain, & behavior problems in patients with advanced Useful in anorexia, weight gain, & behavior problems in patients with advanced

Alzheimer's disease according to limited non-randomized trial well-tolerated & Alzheimer's disease according to limited non-randomized trial well-tolerated & showed trend toward weight gain in small 12 week retrospective observational showed trend toward weight gain in small 12 week retrospective observational study (Agarwal, 2012) study (Agarwal, 2012)

Trend toward weight gain among 28 long-term care patients in retrospective Trend toward weight gain among 28 long-term care patients in retrospective uncontrolled 12 week observational study (Stajkovic et al., 2011)uncontrolled 12 week observational study (Stajkovic et al., 2011)• 2.5 mg 1x/week, then 2.5 mg 2x daily 30 min before lunch and dinner 2.5 mg 1x/week, then 2.5 mg 2x daily 30 min before lunch and dinner

Few major outcomes of anorexia & weight loss patients treated 12+ weeks in Few major outcomes of anorexia & weight loss patients treated 12+ weeks in retrospective observational pilot study (Rudolph, 2010)retrospective observational pilot study (Rudolph, 2010)• 53.5% had minimal weight gain53.5% had minimal weight gain• 11 subjects lost weight on Dronabinol and were younger in age then those 11 subjects lost weight on Dronabinol and were younger in age then those

who gained weight (70.9 versus 90.8 years) and the outcomes were not very who gained weight (70.9 versus 90.8 years) and the outcomes were not very significantsignificant

No controlled trials done on Dronabinol (Stajkovic et al., 2011)No controlled trials done on Dronabinol (Stajkovic et al., 2011)

Increase desire to eat, improves taste, reduces anxiety, improves sleep, good for Increase desire to eat, improves taste, reduces anxiety, improves sleep, good for hospice care (Morley, 2012)hospice care (Morley, 2012)

Triggers brain to tell stomach to eat more, eases stomach and throwing up (Up-Triggers brain to tell stomach to eat more, eases stomach and throwing up (Up-to-Date, 2013)to-Date, 2013)

Limit use in older adult populations due to side effects (Agarwal, 2012)Limit use in older adult populations due to side effects (Agarwal, 2012)

Avoid use with not well defined cognitive deficits (Hoffman, 2002)Avoid use with not well defined cognitive deficits (Hoffman, 2002)

Improve appetite in AIDS patients; little research on older adults (Agarwal, 2012)Improve appetite in AIDS patients; little research on older adults (Agarwal, 2012)

Page 5: Appetite Stimulants:

Drug Name: Drug Name: RemeronRemeron

What it is:What it is: A serotonergic norepinephrine uptake inhibitor A serotonergic norepinephrine uptake inhibitor used to treat depression in older adultsused to treat depression in older adults

Use:Use: • Appetite stimulant for cachexia and treats underlying Appetite stimulant for cachexia and treats underlying

depression in older adultsdepression in older adults

Side Effects:Side Effects: • SedationSedation• Dry mouthDry mouth• ConstipationConstipation• FatigueFatigue• Weight gainWeight gain• DizzinessDizziness• Other studies show causes hepatotoxicity, bone marrow Other studies show causes hepatotoxicity, bone marrow

suppression, restless legs syndrome, arthralgia, and suppression, restless legs syndrome, arthralgia, and coagulopathycoagulopathy

MirtazapineMirtazapine

Page 6: Appetite Stimulants:

Weight gain in 12% of patients, inhibits receptors of serotonin and stimulates Weight gain in 12% of patients, inhibits receptors of serotonin and stimulates appetite (Fox et al., 2009)appetite (Fox et al., 2009)

Treatment of choice for people with depression & weight loss in older adults; Treatment of choice for people with depression & weight loss in older adults; no studies on use as an appetite stimulant in a long term care setting; Use no studies on use as an appetite stimulant in a long term care setting; Use for unintended weight loss not recommended in the absence of depression for unintended weight loss not recommended in the absence of depression (Rudolph, 2010) (Rudolph, 2010)

The treatment of depression likely had a greater effect on weight gain than The treatment of depression likely had a greater effect on weight gain than the specific agent used when compared with other nontricyclic the specific agent used when compared with other nontricyclic antidepressants in two groups of depressed older adults with similar weight antidepressants in two groups of depressed older adults with similar weight gain (Agarwal, 2012)gain (Agarwal, 2012)(Agarwal, 2012)(Agarwal, 2012)

1.1 pounds weight increase in 4 weeks & 1.32 pounds in 12 weeks; outcome 1.1 pounds weight increase in 4 weeks & 1.32 pounds in 12 weeks; outcome was not found to be statistically significant (Rudolph 2010)was not found to be statistically significant (Rudolph 2010)

Mean dosage 15 mg/day; recommended initial dose in elderly is 7.5 mg/day Mean dosage 15 mg/day; recommended initial dose in elderly is 7.5 mg/day with a slow titration (every 2-4 wks) to effect; due to sedative properties, this with a slow titration (every 2-4 wks) to effect; due to sedative properties, this drug should be titrated with caution especially in patients with a high risk for drug should be titrated with caution especially in patients with a high risk for falls (Fox et al., 2009)falls (Fox et al., 2009)

Not initially recommended for patients with swallowing difficulties (Fox et al., Not initially recommended for patients with swallowing difficulties (Fox et al., 2009)2009)

Inexpensive substitution for Megace (Fox et all, 2009)Inexpensive substitution for Megace (Fox et all, 2009)

Not recommended to have patients take this drug to promote weight gain Not recommended to have patients take this drug to promote weight gain while continuing on another depression medication (Fox et al., 2009) while continuing on another depression medication (Fox et al., 2009)

Mirtazapine ResearchMirtazapine Research

Page 7: Appetite Stimulants:

Megestrol AcetateMegestrol Acetate Drug NameDrug Name: Megace: Megace

What it is:What it is: A progestational agent A progestational agent

Use:Use: • Weight gain in Anorexia, AIDS, Cachexia, and Cancer Weight gain in Anorexia, AIDS, Cachexia, and Cancer

patientspatients

Side Effects:Side Effects: • EdemaEdema• Constipation & deliriumConstipation & delirium• DiarrheaDiarrhea• FlatulenceFlatulence• RashRash• HypertensionHypertension• Fluid retentionFluid retention• Glucose intoleranceGlucose intolerance• NauseaNausea• InsomniaInsomnia

• Gastrointestinal upsetGastrointestinal upset• ImpotenceImpotence• Adrenal insufficiencyAdrenal insufficiency• Thromboembolic events Thromboembolic events

(thrombosis) & possibly (thrombosis) & possibly death in elderly (UptoDate, death in elderly (UptoDate, Beers)Beers)

• Confusion occurred as major Confusion occurred as major side effect (Rudolph, 2010)side effect (Rudolph, 2010)

Page 8: Appetite Stimulants:

Megestrol Acetate Megestrol Acetate ResearchResearch

Doses <320 mg may be effective for stimulating weight gain in frail Doses <320 mg may be effective for stimulating weight gain in frail elderly patients, needs to be tested in randomized controlled trials elderly patients, needs to be tested in randomized controlled trials (Hoffman, 2002)(Hoffman, 2002)

Weight gain not significant (<4 lbs) until after 3 months (800 mg/d) Weight gain not significant (<4 lbs) until after 3 months (800 mg/d) (Agarwal, 2012)(Agarwal, 2012)

Long term care populations used as an appetite stimulant; 9 Long term care populations used as an appetite stimulant; 9 studies with mixed outcomes(Rudolph, 2010)studies with mixed outcomes(Rudolph, 2010)

Fat gain main component to increased body weight; this drug does Fat gain main component to increased body weight; this drug does not restore lean muscle mass in older adults (Rudolph, 2012)not restore lean muscle mass in older adults (Rudolph, 2012)

Safe & efficient to improve nursing home malnutrition but Safe & efficient to improve nursing home malnutrition but confounding factors of other interventions and supplements need to confounding factors of other interventions and supplements need to be studied (Rudolph, 2010)be studied (Rudolph, 2010)

Use with caution in older patients with unintentional weight loss Use with caution in older patients with unintentional weight loss due to evidence of benefit and significant side effects (Agarwal, due to evidence of benefit and significant side effects (Agarwal, 2012)2012)

Causes weight gain in patients with anorexia and cachexia (Agarwal, Causes weight gain in patients with anorexia and cachexia (Agarwal, 2012)2012)

Page 9: Appetite Stimulants:

MetoclopramideMetoclopramide

Drug Name:Drug Name: Reglan Reglan

What it is:What it is: Prokinetic agent Prokinetic agent

Use:Use: • Relieves nausea-induced anorexia (Hoffman, 2002)Relieves nausea-induced anorexia (Hoffman, 2002)

Side Effects:Side Effects: • Dystonia & Parkinsonian symptoms in elderlyDystonia & Parkinsonian symptoms in elderly• Many drug interactions such as B12, D3, Lipitor, Fish oils, Many drug interactions such as B12, D3, Lipitor, Fish oils,

Aspirin, CrestorAspirin, Crestor• Can cause GI obstruction, perforation or hemorrhage Can cause GI obstruction, perforation or hemorrhage • Causes GI obstruction, perforation or hemorrhage; Causes GI obstruction, perforation or hemorrhage;

pheochromocytoma; history of seizures or concomitant use of pheochromocytoma; history of seizures or concomitant use of other agents likely to increase movement disorder reactionsother agents likely to increase movement disorder reactions

• May increase risk of seizures and movement disorders May increase risk of seizures and movement disorders (extrapyramidal reactions)(extrapyramidal reactions)

Page 10: Appetite Stimulants:

Metoclopramide ResearchMetoclopramide Research

Treatment > 12 weeks is not recommended (Uptodate, 2013)Treatment > 12 weeks is not recommended (Uptodate, 2013)

The initial dosage of metocloproadmide in a 19 yr old girl with The initial dosage of metocloproadmide in a 19 yr old girl with anorexia nervosa and delayed gastric emptying, showed no anorexia nervosa and delayed gastric emptying, showed no significant change in body weight until an increase in dose significant change in body weight until an increase in dose resulted in a 20% increase in the patient’s body weight over a 2-resulted in a 20% increase in the patient’s body weight over a 2-month period (Sansone et. al, 2003)month period (Sansone et. al, 2003)

Geriatrics should start at low end of dosage 10 mg/dose up to Geriatrics should start at low end of dosage 10 mg/dose up to 4x/day (Uptodate, 2013)4x/day (Uptodate, 2013)

Page 11: Appetite Stimulants:

CyproheptadineCyproheptadine

Drug name:Drug name: Periactin Periactin

What it is:What it is: Antihistaminic and serotonin-blocking drug Antihistaminic and serotonin-blocking drug

Use: Use: • Weight gain in children with anorexia nervosa & Weight gain in children with anorexia nervosa &

cancercancer• Elderly in nursing homesElderly in nursing homes

Side Effects:Side Effects: • Blurred visionBlurred vision• Dry mouthDry mouth• Urinary retentionUrinary retention• ConstipationConstipation• Tachycardia and delirium in older patientsTachycardia and delirium in older patients

Page 12: Appetite Stimulants:

Cyproheptadine ResearchCyproheptadine Research Decrease weight loss rate in 65 yrs, no weight gain (Hoffman, Decrease weight loss rate in 65 yrs, no weight gain (Hoffman,

2002)2002)

Drowsiness and dizziness in the elderly population which is Drowsiness and dizziness in the elderly population which is problematic elderly (Hoffman, 2002)problematic elderly (Hoffman, 2002)

Some benefits of 4 mg qd or bid without reversing Some benefits of 4 mg qd or bid without reversing antidepressant efficacy (Ernst, 2012)antidepressant efficacy (Ernst, 2012)

Increase appetite in adults without reducing weight loss (AND, Increase appetite in adults without reducing weight loss (AND, Kardinal, 1990) Kardinal, 1990)

Weight gain in pediatric cancer patients (AND, Couluris, 2008) Weight gain in pediatric cancer patients (AND, Couluris, 2008)

Avoid use of this potent anticholinergic agent due to increased Avoid use of this potent anticholinergic agent due to increased risk of confusion, clearance decreases in patients of advanced risk of confusion, clearance decreases in patients of advanced age (Rudolph, 2010)age (Rudolph, 2010)

Weight gain in pediatric anorexia nervosa & Cancer patients Weight gain in pediatric anorexia nervosa & Cancer patients (Rudolph, 2012)(Rudolph, 2012)

Limit use in long-term care of older patients since no appetite Limit use in long-term care of older patients since no appetite stimulant studies have been developed (Rudolph, 2010)stimulant studies have been developed (Rudolph, 2010)

Page 13: Appetite Stimulants:

Anabolic SteroidsAnabolic Steroids

Drug Name: Drug Name: Oxandrolone (Oxandrin), OrnithineOxandrolone (Oxandrin), Ornithine

What it is: What it is: Synthetic anabolic steroidsSynthetic anabolic steroids

Use:Use: • Treats wasting in AIDS & Cachexia in CancerTreats wasting in AIDS & Cachexia in Cancer

Side EffectsSide Effects• Carpal tunnel syndrome Carpal tunnel syndrome • HeadacheHeadache• ArthralgiasArthralgias• Myalgias, & gynecomastiaMyalgias, & gynecomastia• Risk of prostate hyperplasia, fluid retention, and Risk of prostate hyperplasia, fluid retention, and

transaminase elevationstransaminase elevations

Page 14: Appetite Stimulants:

Anabolic Steroids Anabolic Steroids ResearchResearch

Wound healing improvement: weight loss & non-healing Wound healing improvement: weight loss & non-healing chronic wounds (Rudolph, 2010) chronic wounds (Rudolph, 2010)

Weight loss associated COPD patients improved appetite & Weight loss associated COPD patients improved appetite & increased weight gain (Rudolph, 2010)increased weight gain (Rudolph, 2010)

Studied to improve sarcopenia & frailty in older patients Studied to improve sarcopenia & frailty in older patients (Agarwal, 2012)(Agarwal, 2012)

Systematic review found that the risk of exogenous growth Systematic review found that the risk of exogenous growth hormone outweigh potential benefits (Agarwal, 2012)hormone outweigh potential benefits (Agarwal, 2012)

No studies done in nursing home populations (Rudolph, 2010) No studies done in nursing home populations (Rudolph, 2010) and not test on elderly (Argarwal, 2012)and not test on elderly (Argarwal, 2012)

Only drug approved by the FDA for the treatment of cachexia Only drug approved by the FDA for the treatment of cachexia (Rudolph, 2010)(Rudolph, 2010)

Costly intervention (Hoffman, 2002)Costly intervention (Hoffman, 2002)

Risks with growth hormones (Agarwal, 2012)Risks with growth hormones (Agarwal, 2012)

Page 15: Appetite Stimulants:

GhrelinGhrelin

• Drug Name: Drug Name: None None

• What it is: What it is: Growth hormone produced from the fundus of the Growth hormone produced from the fundus of the stomach increases food intake by stimulating nitric oxide in stomach increases food intake by stimulating nitric oxide in the hypothalamusthe hypothalamus

Use: Use: Appetite stimulant in oncology patients and older adultsAppetite stimulant in oncology patients and older adults

Side Effects: Side Effects: None notedNone noted

Page 16: Appetite Stimulants:

Ghrelin ResearchGhrelin Research Stimulates appetite and induces a positive energy balance that can Stimulates appetite and induces a positive energy balance that can

lead to weight gain (uptodate)lead to weight gain (uptodate)

Implicated in regulating mealtime hunger and meal initiation Implicated in regulating mealtime hunger and meal initiation (uptodate)(uptodate)

Plays role in neurohormonal regulation of food intake and energy Plays role in neurohormonal regulation of food intake and energy homeostasis (uptodate)homeostasis (uptodate)

An endogenous ligand for growth hormone secretagogue receptor, An endogenous ligand for growth hormone secretagogue receptor, holds promise for the future, with preliminary studies holds promise for the future, with preliminary studies demonstrating benefit in oncology patients and older adults; demonstrating benefit in oncology patients and older adults; however long-term functional studies need to be completed before however long-term functional studies need to be completed before recommendations can be made (Agarwal, 2012)recommendations can be made (Agarwal, 2012)

Limited research and few studies done on stimulant (Medication Limited research and few studies done on stimulant (Medication Guide, 2013) Guide, 2013)

Page 17: Appetite Stimulants:

Recombinant Human Growth Recombinant Human Growth HormoneHormone

Drug Name: Serostim

What it is: Anabolic Growth Hormone

Use: • Increase lean body mass in HIV patients with wasting or

cachexia

Side Effects: • Carpal Tunnel Syndrome• Headache• Arthralgia• Myalgias• Gynecomastia• Edema• Arthralgia• Impaired fasting glucose

Page 18: Appetite Stimulants:

Recombinant Human Growth Recombinant Human Growth Hormone ResearchHormone Research

Studied as a way to improve sarcopenia and frailty in older patients (Agarwal, 2012)

Increase in weight & lean muscle mass w/ decrease in body fat after 12 weeks among randomized double-blind placebo controlled study of 178 HIV-infected patients treated with 0.1 mg/kg of growth hormones (avg 6mg/d) (Schambelan et. al, 1996)

Dosing caution with some patients ≥65 years sensitive treatment & prone to adverse effects (uptodate)

Risks may out weight potential benefits (Agarwal, 2012)

Expensive intervention Costly (Hoffman, 2002)

Drug may be inappropriate for geriatric patents (BEERS); also avoid use in elderly as hormone replacement after pituitary gland removal (BEERS)

Page 19: Appetite Stimulants:

TestosteroneTestosterone Drug name:Drug name: None None

What it is:What it is: A steroid hormone from the androgen group A steroid hormone from the androgen group and is found in mammals, reptiles, birds, and other and is found in mammals, reptiles, birds, and other vertebrates vertebrates

Use:Use: Treat cachexia and weight loss in HIV Patients Treat cachexia and weight loss in HIV Patients

Side EffectsSide Effects: : • Higher hematocritHigher hematocrit• Leg edemaLeg edema• Prostate events (exacerbation of prostate cancer)Prostate events (exacerbation of prostate cancer)• Lower HDL levelsLower HDL levels• Possible metabolic syndrome in menPossible metabolic syndrome in men

Page 20: Appetite Stimulants:

Testosterone ResearchTestosterone Research Supplementation increases skeletal muscle mass and strength; Supplementation increases skeletal muscle mass and strength;

especially in older men (Agarwal, 2012) Weight and lean muscle especially in older men (Agarwal, 2012) Weight and lean muscle mass increase but with unknown clinically meaningful changes in mass increase but with unknown clinically meaningful changes in muscle function and disease outcome in HIV infected men (Yeh, muscle function and disease outcome in HIV infected men (Yeh, 2007)2007)

Studies in healthy older men have not demonstrated improvement in Studies in healthy older men have not demonstrated improvement in functional statue, physical function, or cognitive function (Agarwal, functional statue, physical function, or cognitive function (Agarwal, 2012)2012)

Small study in undernourished community-dwelling older men and Small study in undernourished community-dwelling older men and women did not find that combined treatment with oral testosterone women did not find that combined treatment with oral testosterone undecanoate and oral nutritional supplement decreased hospital undecanoate and oral nutritional supplement decreased hospital admission rates over one years, larger trials needed to confirm admission rates over one years, larger trials needed to confirm findings (Agarwal, 2012) findings (Agarwal, 2012)

Selective androgen-receptor modulators that are preferentially Selective androgen-receptor modulators that are preferentially anabolic and that spare the prostate hold promise as anabolic anabolic and that spare the prostate hold promise as anabolic therapies (Yeh, 2007)therapies (Yeh, 2007)

Due to insufficient psychological safety and efficacy evidence, use in Due to insufficient psychological safety and efficacy evidence, use in elderly hypogonadal men (and to maintain the physiological elderly hypogonadal men (and to maintain the physiological circadian rhythm of serum testosterone levels) is not warranted circadian rhythm of serum testosterone levels) is not warranted (Yeh, 2007)(Yeh, 2007)

Page 21: Appetite Stimulants:

Stimulants Currently on Stimulants Currently on Formulary:Formulary:

Appetite Stimulants:Appetite Stimulants:• Cypropheptadine (Periactin)Cypropheptadine (Periactin)• Megace (Megestrol Acetate)Megace (Megestrol Acetate)

Anabolic SteroidsAnabolic Steroids Mirtazpine (Remeron)Mirtazpine (Remeron) Metoclopramide (Metoclopramide (Reglan)Reglan)

Page 22: Appetite Stimulants:

RecommendationRecommendation Limited Appetite stimulant research in long term care (Agarwal, 2012)Limited Appetite stimulant research in long term care (Agarwal, 2012)

No evidence to support the use of Cyproheptadine (Periactin), Anabolic No evidence to support the use of Cyproheptadine (Periactin), Anabolic Steroids (Oxandolone), Metoclopramide (Reglan), or Mirtzapine Steroids (Oxandolone), Metoclopramide (Reglan), or Mirtzapine (Remeron) as an appetite stimulant for treating unintentional weight (Remeron) as an appetite stimulant for treating unintentional weight in long term care (Rudolph, 2010)in long term care (Rudolph, 2010)

Limited evidence suggests Dronabinol (Marinol) may be of benefit but Limited evidence suggests Dronabinol (Marinol) may be of benefit but not for more than 12 weeks (Rudolph, 2010); no control studies were not for more than 12 weeks (Rudolph, 2010); no control studies were done on Dronabinol (Marinol) so should not be recommended done on Dronabinol (Marinol) so should not be recommended (Uptodat, 2013)(Uptodat, 2013)

Some evidence shows Megestrol (Megace) may be of benefit; however Some evidence shows Megestrol (Megace) may be of benefit; however its use is not without risks and has not been studied for long term its use is not without risks and has not been studied for long term periods of time (greater than 6 months) (Agarwal, 2013); Fat gain is periods of time (greater than 6 months) (Agarwal, 2013); Fat gain is main component in increase of body weight; may be inappropriate for main component in increase of body weight; may be inappropriate for geriatric patients (Rudolph, 2010)geriatric patients (Rudolph, 2010)

Page 23: Appetite Stimulants:

Mirtazapine (Remeron) can be recommended for use with patients who Mirtazapine (Remeron) can be recommended for use with patients who have depression but not already taking other medications for depression have depression but not already taking other medications for depression Rudolph, 2010)Rudolph, 2010)

Metoclopramide (Reglan) should not be used until further scientific Metoclopramide (Reglan) should not be used until further scientific testing shows the benefits of this drug; do not take for longer then 12 testing shows the benefits of this drug; do not take for longer then 12 weeks (Uptodate, 2013)weeks (Uptodate, 2013)

• Cyproheptadine (Periactin) has mostly been studied in pediatrics; elderly Cyproheptadine (Periactin) has mostly been studied in pediatrics; elderly should avoid use of this drug due to increased risk of confusion (Rudolph, should avoid use of this drug due to increased risk of confusion (Rudolph, 2012)2012)

Risks of Recombinant Human Growth Hormones (Serostim) outweigh the Risks of Recombinant Human Growth Hormones (Serostim) outweigh the benefits, this drug should not be used until further research on the benefits, this drug should not be used until further research on the elderly has been done (Agarwal, 2012)elderly has been done (Agarwal, 2012)

Ghrelin may work as a future appetite stimulant; however, more Ghrelin may work as a future appetite stimulant; however, more investigation needs to go into this drug (Agarwal, 2012)investigation needs to go into this drug (Agarwal, 2012)

Testosterone should not be used in elderly patients due to the negative Testosterone should not be used in elderly patients due to the negative side affects (Agarwal, 2012)side affects (Agarwal, 2012)

Recommendation ContinuedRecommendation Continued

Page 24: Appetite Stimulants:

Sources:Sources: Agarwal, Kathryn MD. Agarwal, Kathryn MD. Failure to Thrive in elderly adults: Management. Failure to Thrive in elderly adults: Management.

November 28, 2012. Uptodate.com. November 28, 2012. Uptodate.com. Baracos, Bowling, Bruera, Denmark-Wahnefried, Fabbro, & Hopkinson, Baracos, Bowling, Bruera, Denmark-Wahnefried, Fabbro, & Hopkinson,

2010, “Nausea and Vomiting in Advanced Cancer,” 2010, “Nausea and Vomiting in Advanced Cancer,” Nutrition and the Cancer Nutrition and the Cancer PatientPatient, Oxford University Press: New York, Oxford University Press: New York

Couluris, Marisa; Jennifer L.R.Mayer, David R. Freyer, Eric Sandler, Ping Xu, Couluris, Marisa; Jennifer L.R.Mayer, David R. Freyer, Eric Sandler, Ping Xu, Jeffrey P. Krischer. “The effect of cyproheptadine hydrochloride (Periactin) Jeffrey P. Krischer. “The effect of cyproheptadine hydrochloride (Periactin) and megestrol acetate 9Megace) on weight in children with and megestrol acetate 9Megace) on weight in children with cancer/treatment-related cachexia.” Journal Pediatric Hematol Oncolo. cancer/treatment-related cachexia.” Journal Pediatric Hematol Oncolo. 2008. November; 30 (11): 791-797. 2008. November; 30 (11): 791-797.

Ernst, Carrie L. Ernst, Carrie L. Managing Side Effects of Psychotropic MedicationsManaging Side Effects of Psychotropic Medications. . American Psychiatric Association. 2012. American Psychiatric Association. 2012.

Fox, Carol B. Pharm.D.; Angela K. Treadway, Pharm.D., Amie T. Blaszczyk, Fox, Carol B. Pharm.D.; Angela K. Treadway, Pharm.D., Amie T. Blaszczyk, Pharm.D., and Rebecca B. Sleeper, Pharm.D. Pharm.D., and Rebecca B. Sleeper, Pharm.D. Megestrol Acetate and Megestrol Acetate and Mirtazapine for the Treatment of Unplanned Weight Loss in the Elderly. Mirtazapine for the Treatment of Unplanned Weight Loss in the Elderly. Reviews of Therapeutics. Volume 29, Number 4, 2009. Reviews of Therapeutics. Volume 29, Number 4, 2009.

Healthinaging.org. Healthinaging.org. AGS Beers Criteria for Potentially Inappropriate AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. THE AGS FOUNDATION FOR HEALTH IN Medication Use in Older Adults. THE AGS FOUNDATION FOR HEALTH IN AGINGAGING. 2012.. 2012.

Homnick, Douglas N; John H. Marks, Karyl L. Hare, Sally K. Bonnema. “Long-Homnick, Douglas N; John H. Marks, Karyl L. Hare, Sally K. Bonnema. “Long-term trial of cyproheptadine as an appetite stimulant in cystic fibrosis.” term trial of cyproheptadine as an appetite stimulant in cystic fibrosis.” Pedicatric Pulmonology. Volume 40, Issue 3, p 251-256. September 2005. Pedicatric Pulmonology. Volume 40, Issue 3, p 251-256. September 2005.

Huffman, Grace Brooke M.D.; Brooke Grove Foundation, Sandy Spring, Huffman, Grace Brooke M.D.; Brooke Grove Foundation, Sandy Spring, Maryland. Maryland. Evaluating and Treating Unintentional Weight Loss in the Elderly. Evaluating and Treating Unintentional Weight Loss in the Elderly. American Family Physician. Volume 65, Number 4. February 15, 2002. American Family Physician. Volume 65, Number 4. February 15, 2002.

Page 25: Appetite Stimulants:

Sources Cont’d:Sources Cont’d: Inui, Akio. Cancer Anorexia-Cachexia Syndrome: Current Issues in Inui, Akio. Cancer Anorexia-Cachexia Syndrome: Current Issues in

Research and Management. A Cancer Journal for Clinicians. CA; Research and Management. A Cancer Journal for Clinicians. CA; March/April 2002; 52: 72-91. (p.82-83). March/April 2002; 52: 72-91. (p.82-83).

Managing weight loss and fatigue in advanced illness. January 18, 2012. Managing weight loss and fatigue in advanced illness. January 18, 2012. U.S. National Library of Medicine, PubMed Health. Cochrane Library. U.S. National Library of Medicine, PubMed Health. Cochrane Library.

Medication Guide. “Cancer Cachexia Appetite Stimulants (Orexigenic Medication Guide. “Cancer Cachexia Appetite Stimulants (Orexigenic Medications).” March 15, 2013. Medications).” March 15, 2013.

Morley, J.E. Anorexia of Aging: A True Geriatric Syndrome. The Journal of Morley, J.E. Anorexia of Aging: A True Geriatric Syndrome. The Journal of Nutrition, Health & Aging. Volume 16, November 5, 2012. Nutrition, Health & Aging. Volume 16, November 5, 2012.

Rudolph, D.M. Appetite Stimulants in Long Term Care; A Literature Rudolph, D.M. Appetite Stimulants in Long Term Care; A Literature Review. The Internet Journal of Advanced Nursing Practice. 2010 Volume Review. The Internet Journal of Advanced Nursing Practice. 2010 Volume 11 Number 1. DOI: 10.5580/186d.11 Number 1. DOI: 10.5580/186d.

Schambelan, Morris; Kathleen Mulligan, Carl Grunfeld, Eric S. Daar, Schambelan, Morris; Kathleen Mulligan, Carl Grunfeld, Eric S. Daar, Anthony Lamarca, Donald P. Kotler, Jack Wang, Samuel A. Bozzette, James Anthony Lamarca, Donald P. Kotler, Jack Wang, Samuel A. Bozzette, James B. Breitmeyer. “Recombinant Human Growth Hormone in Patients with B. Breitmeyer. “Recombinant Human Growth Hormone in Patients with HIV-Associated Wasting: A Randomized, Placebo-Controlled Trial.” Annals HIV-Associated Wasting: A Randomized, Placebo-Controlled Trial.” Annals of Internal Medicine. 1 December 1996, Vol 125, No. 11. of Internal Medicine. 1 December 1996, Vol 125, No. 11.

Stajkovic, Svetlana; Elizabeth M. Aitken, Jayna Holroyd-Leduc. Stajkovic, Svetlana; Elizabeth M. Aitken, Jayna Holroyd-Leduc. Unintentional weight loss in older adults. CMAJ, March 8 2011, 183 (4). Unintentional weight loss in older adults. CMAJ, March 8 2011, 183 (4).

UpToDate.com. 2013.UpToDate.com. 2013. Yeh, Shing-Shing MD, PhD, Sherri Lovitt, MD, and Michael W. Schuster, Yeh, Shing-Shing MD, PhD, Sherri Lovitt, MD, and Michael W. Schuster,

MDCachexia: Evidence and Safety in Perspective, 2007 from MDCachexia: Evidence and Safety in Perspective, 2007 from http://cmda.us/Articles/PDF/Geriatric%20Cachexia.pdf