Alternative Appetite Stimulants When Mirtazapine Cannot Be Tolerated

First-Line Alternatives

The National Comprehensive Cancer Network recommends megestrol acetate for patients with cancer-related anorexia/cachexia when increased appetite is important for quality of life 2
Megestrol acetate improves appetite in approximately 1 in 4 patients and results in modest weight gain in approximately 1 in 12 patients 2, 3
The National Comprehensive Cancer Network suggests dexamethasone as an appropriate alternative for patients with shorter life expectancy, offering similar appetite improvement to megestrol acetate 2, 4
Dexamethasone may also help with fatigue and has a faster onset of action compared to other options 5, 4

Cannabinoids, such as dronabinol, have limited evidence in dementia and cancer patients but may increase body weight and improve meal consumption in certain populations 1, 2, 6, 7
Olanzapine may be considered for patients with concurrent nausea/vomiting and has been shown to cause weight gain as a side effect, although evidence for its use in anorexia/cachexia is limited 2, 3

For patients with concurrent depression, other antidepressants with appetite-stimulating properties or a combined approach with antidepressant plus appetite stimulant may be considered 5, 1
For elderly patients, lower starting doses of all medications and closer monitoring for side effects, particularly sedation and thromboembolic events, are recommended 1, 2, 5

The American College of Nutrition and other organizations suggest implementing non-pharmacological approaches, such as providing emotional support during meals, ensuring adequate feeding assistance, and serving energy-dense meals, alongside pharmacological interventions 6, 7, 1

Current guidelines do not recommend systematic use of appetite stimulants in dementia patients due to limited evidence and potential risks, and treatment goals should focus on quality of life rather than simply weight gain 6, 1, 2
Regular reassessment is essential to evaluate benefit versus harm, and benefits must be weighed against risks, particularly in frail patients 1, 2