Best Medication Options for Increasing Appetite

First-Line Options

The American College of Physicians recommends progestins, particularly megestrol acetate, as the most effective first-line medications for increasing appetite, with a recommended starting dose of 160-200 mg daily 1, 2
Megestrol acetate is the most extensively studied appetite stimulant with high-level evidence supporting its efficacy, and the recommended starting dose is considered the optimal initial dose 1, 2, 3
The dose of megestrol acetate can be increased up to 480-800 mg daily if needed, though higher doses increase the risk of side effects, including thromboembolic events, which occur in approximately one in six patients 1, 2
Megestrol acetate increases appetite and body weight, primarily through fat gain, not lean muscle mass, and has demonstrated significant advantages over placebo for appetite improvement, increased caloric intake, and weight gain in multiple randomized controlled trials 2, 3

The Clinical Nutrition society notes that cannabinoids, such as dronabinol, have limited and inconsistent evidence for effectiveness in cancer-related anorexia, and are not recommended as first-line therapy due to inconsistent results and significant side effect profile 4, 5
Dronabinol may improve chemosensory perception and pre-meal appetite compared to placebo, but side effects include euphoria, hallucinations, vertigo, psychosis, and cardiovascular disorders 4

The Clinical Nutrition society reports that ghrelin analogs, such as anamorelin, have shown promise in clinical trials, improving appetite, body weight, and lean body mass compared to placebo in patients with advanced non-small cell lung cancer 4

Corticosteroids may be considered for very short-term use (1-3 weeks) in patients with advanced disease, but are not recommended for long-term appetite stimulation due to significant adverse effects, including muscle wasting, insulin resistance, and increased risk of infections 5

One in four patients treated with megestrol acetate will experience increased appetite, and one in twelve will have weight gain, according to the National Comprehensive Cancer Network 6
Thromboembolic phenomena occur in approximately 1 in 6 patients, and mortality risk is 1 in 23 patients, when treated with megestrol acetate 6
Dronabinol may improve pre-meal appetite compared to placebo, but is less effective than megestrol acetate for promoting weight gain (49% vs 75% of patients) and appetite improvement (3% vs 11%) 6

A combination of medroxyprogesterone, megestrol acetate, eicosapentaenoic acid, L-carnitine supplementation, and thalidomide has shown superior outcomes compared to single agents, as recommended by the National Comprehensive Cancer Network 6
Another effective combination includes megestrol acetate plus L-carnitine, celecoxib, and antioxidants, according to the National Comprehensive Cancer Network 6

Nutritional consultation should be considered alongside pharmacological interventions, as calorie-dense, high-protein supplementation has shown some efficacy for weight stabilization, as suggested by the National Comprehensive Cancer Network 6
Cannabinoid administration in elderly patients may induce delirium, and its use is subject to local state rules and regulations, according to the National Comprehensive Cancer Network 6

In older hospitalized patients with functional decline, megestrol acetate (800 mg daily) may attenuate benefits of resistance training, causing smaller gains or deterioration in muscle strength and functional performance, as reported by the Clinical Nutrition and Gastroenterology journals 7, 8
Mirtazapine may be considered only when depression coexists with weight loss, as it can serve dual purposes in that specific context, although it is not recommended solely for appetite stimulation or weight loss, according to Clinical Nutrition and Gastroenterology 7, 8
Appetite stimulant drugs should NOT be used in persons with dementia, due to limited evidence and potential harmful side effects, as stated in Gastroenterology 8 and supported by Clinical Nutrition 7, 8