Effective Appetite Stimulants for Hospitalized Patients

Pharmacological Interventions

• The National Comprehensive Cancer Network recommends megestrol acetate (400-800 mg/day) as the most effective first-line pharmacological appetite stimulant for hospitalized patients with decreased appetite, with an improvement in appetite in approximately 25% of patients and modest weight gain in about 8% of patients 1, 2
• The National Comprehensive Cancer Network suggests dexamethasone (2-8 mg/day) as an alternative with faster onset of action, making it suitable for patients with shorter life expectancy 1
• Mirtazapine (7.5-30 mg at bedtime) can be effective for patients with concurrent depression and appetite loss, according to the National Comprehensive Cancer Network 1
• Olanzapine (5 mg/day) may be considered for patients with concurrent nausea/vomiting, as recommended by the National Comprehensive Cancer Network 1
• Cannabinoids have limited evidence but may increase meal consumption in certain populations, according to the National Comprehensive Cancer Network and Praxis Medical Insights 1, 2

Non-Pharmacological Approaches

Nutritional Support Strategies

• The Clinical Nutrition society recommends providing oral nutritional supplements (ONS) when food intake is between 50-75% of usual intake 3
• Protein-enriched foods and drinks can improve protein intake in hospitalized patients, as suggested by Clinical Nutrition 4
• Energy-dense meals can help patients meet nutritional requirements without increasing meal volume, according to Clinical Nutrition 5

Special Considerations

For Patients with Dementia

• The Clinical Nutrition society advises that drugs to stimulate appetite are NOT recommended for persons with dementia due to limited evidence and potential risks 6
• Focus on non-pharmacological approaches such as feeding assistance and increased time spent by nurses during feeding, emotional support during meals, and specific behavioral and communication strategies, as recommended by Clinical Nutrition 5

Important Caveats

• Regular reassessment is essential to evaluate benefit versus harm of pharmacological interventions, as recommended by Praxis Medical Insights 2
• Lower starting doses should be used for elderly patients with close monitoring for side effects, particularly sedation and thromboembolic events, according to Praxis Medical Insights 2
• Megestrol acetate can cause fluid retention and increased risk of thromboembolic events, as warned by the National Comprehensive Cancer Network 1
• Dexamethasone has significant side effects with prolonged use including hyperglycemia, muscle wasting, and immunosuppression, as cautioned by the National Comprehensive Cancer Network 1

Stimulating Appetite in Patients with Prolonged Poor Eating

Non-Pharmacological Approaches

• Place patients at a dining table rather than isolated in rooms to promote social interaction during meals, as recommended by Clinical Nutrition guidelines 7, 8
• Provide emotional support, supervision, verbal prompting, and encouragement during mealtimes to improve eating experiences 9, 10
• Ensure consistent caregivers during meals when possible, as this improves food consumption 10
• Increase time spent by nursing staff on feeding assistance for patients who need it, which can lead to better nutritional outcomes 10, 7
• Create a relaxed, comfortable, and safe environment during meals to stimulate appetite 8
• Offer foods according to individual preferences and needs, taking into account dietary restrictions and allergies 8
• Provide finger foods for patients who have difficulty using utensils, making mealtime easier and less frustrating 11
• Serve energy-dense meals to help meet nutritional requirements without increasing meal volume, which can be beneficial for patients with high calorie needs 12, 8
• Make snacks available between meals and at other times of day if requested, to prevent excessive hunger and support overall nutrition 8, 11
• Provide oral nutritional supplements (ONS) when dietary intake is between 50-75% of usual intake, to ensure adequate nutrition 11
• Use protein-enriched foods and drinks to improve protein intake, which is essential for maintaining muscle mass and overall health 11
• Offer texture-modified, enriched foods for patients with chewing or swallowing difficulties, to make eating safer and more enjoyable 11

Pharmacological Approaches

• Pharmacological appetite stimulants are not recommended for systematic use in patients with dementia due to limited evidence and potential risks, as stated by Clinical Nutrition guidelines 9, 13, 10

Implementation and Monitoring

• Start with comprehensive environmental and behavioral strategies, including proper positioning, assistance, and supportive environment, to lay the foundation for successful appetite stimulation 10, 7
• Optimize meal presentation and structure by providing preferred foods in appropriate textures, which can enhance eating experiences and improve nutrition 8
• Implement small, frequent meals and snacks, and introduce ONS between meals if necessary, to support overall nutritional well-being 11
• Monitor patients closely for side effects when using pharmacological appetite stimulants, and regularly reassess the benefit versus harm of these interventions 8