Thrombotic events associated with megestrol acetate in patients with AIDS cachexia

Clinical implication of megestrol acetate in metastatic gastric cancer: a big data analysis from Health Insurance Review and Assessment (HIRA) database

OBJECTIVE

Megestrol acetate (MA) is used to manage anorexia and cachexia in patients with advanced cancer. This study investigated the prescription patterns of MA in patients with metastatic gastric cancer, as well as evaluated its impact on survival outcomes and the incidence of venous thromboembolism (VTE).

METHODS

A Health Insurance Review and Assessment (HIRA) service database was used to investigate differences in baseline characteristics, survival, and the incidence of VTE according to MA prescription patterns (i.e., prescription vs. no prescription) in patients diagnosed with metastatic gastric cancer from July 2014 to December 2015.

RESULTS

A total of 1938 patients were included in this study. In total, 65% of the patients were prescribed MA. Older age, treatment in tertiary hospitals, and palliative chemotherapy were statistically significant predictive factors for MA prescription. Continuous prescription of MA was observed in 37% of patients. There was no statistically significant difference in survival between the MA and non-MA prescription groups on multivariate analysis. Among the 1427 patients included in the analysis for VTE incidence, 4.3% and 2.9% were diagnosed with VTE during the follow-up period in the MA and non-MA prescription groups, respectively. However, there was no statistically significant difference in VTE diagnosis between the groups on multivariate analysis.

CONCLUSION

MA is commonly prescribed for metastatic gastric cancer, especially in elderly patients and those undergoing palliative chemotherapy, without significantly affecting survival or VTE risk.

Advances in cancer cachexia: Intersection between affected organs, mediators, and pharmacological interventions

Advanced cancer patients exhibit cachexia, a condition characterized by a significant reduction in the body weight predominantly from loss of skeletal muscle and adipose tissue. Cachexia is one of the major causes of morbidity and mortality in cancer patients. Decreased food intake and multi-organ energy imbalance in cancer patients worsen the cachexia syndrome. Cachectic cancer patients have a low tolerance for chemo- and radiation therapies and also have a reduced quality of life. The presence of tumors and the current treatment options for cancer further exacerbate the cachexia condition, which remains an unmet medical need. The onset of cachexia involves crosstalk between different organs leading to muscle wasting. Recent advancements in understanding the molecular mechanisms of skeletal muscle atrophy/hypertrophy and adipose tissue wasting/browning provide a platform for the development of new targeted therapies. Therefore, a better understanding of this multifactorial disorder will help to improve the quality of life of cachectic patients. In this review, we summarize the metabolic mediators of cachexia, their molecular functions, affected organs especially with respect to muscle atrophy and adipose browning and then discuss advanced therapeutic approaches to cancer cachexia.

Guidelines for the Use of Orexigenic Drugs in Long-Term Care

Undernutrition is defined as a state induced by nutrient deficiency that may be improved solely by administration of nutrients. By this definition, provision of adequate protein and energy sources should reverse the clinical presentation and correct the problem. However, a large number of patients who seem to be undernourished fail to respond to refeeding. A developing understanding of the acute-phase inflammatory response to illness and the role of cytokines in the pathophysiology of chronic illness has challenged the current diagnostic paradigm of undernutrition. In the presence of adequate food, weight loss is most often due to cytokine-associated cachexia and anorexia. Failure of appetite, or anorexia, may play a role in involuntary weight loss. Intervention for involuntary weight loss should aim first at the provision of adequate calories and protein, often in the form of high-density nutrition supplements. However, cytokine-mediated cachexia is remarkably resistant to hypercaloric feeding. With continued weight loss, the use of an orexigenic drug should be considered. Orexigenic drugs have been demonstrated to improve appetite and produce weight gain. The mechanism is unknown but may relate to suppression of proinflammatory cytokines. General guidelines for the use of orexigenic agents are presented. Although much work remains to be done, anticytokine drugs seem to be a promising avenue for the treatment of involuntary weight loss.

Venous Thrombosis Among Patients with AIDS

Thrombosis has been considered an uncommon complication in patients with AIDS. In a 42-month period, 28 adult male homosexuals with AIDS experienced 34 thrombotic events. All but three received HAART regimen, two a successful round of double nucleoside analog therapy, and one patient received no treatment. Median age of group was 38.5 years (range, 24 to 56 years). Median time from HIV infection to thrombosis was 40.5 months (range, 3 to 108 months). No patient had previous thrombosis, family history of thrombosis, or prothrombotic conditions. There were 31 deep vein thromboses, two pulmonary thromboembolisms, and one renal vein thrombosis. Six patients had two thrombotic events. The rate of thrombosis during the 42-month study period was 1.52% (cumulative incidence = 0.30%/year), while the rate of thrombosis in 600 patients before the era of protease inhibitor therapy was 0.33% (cumulative incidence approximately 0.055%/year) (p < 0.001). Due to high incidence of thrombotic recurrences and hemorrhagic complications while using oral anticoagulants, acetylsalicylic acid was initiated; no thrombotic episodes were recorded while using this drug. Protein C and protein S deficiency were found in nine and two patients, respectively. Two patients had lupus anticoagulant and two activated protein C resistance (APCR) without FV Leiden mutation (APCR test was negative after initial screening). Fifteen patients had no thrombophilic abnormalities. These data suggest that protease inhibitors could be a risk factor for venous thrombosis not due to thrombophilic abnormalities but likely related to abnormalities in platelets or endothelium.

Breakthrough in cachexia treatment through a novel selective androgen receptor modulator?!

Cachexia, and particularly the loss of metabolically active lean tissue, leads to increased morbidity and mortality in affected patients. An impairment of strength and functional status is usually associated with cachexia. A variety of anabolic and appetite-stimulating agents have been studied in patients with cachexia caused by various underlying diseases. Overall, these studies have demonstrated that treatment can increase body weight and/or lean body mass. However, these therapies may have severe side effects, particularly when utilizing testosterone and related anabolic steroids targeting the androgen receptor. These side effects include cardiovascular problems, prostate hyperplasia and cancer in men, as well as virilization in women.

Nutritional interventions for cancer-induced cachexia

Cancer-induced cachexia remains a significant cause of morbidity and mortality in cancer treatment. Cancer research and development continues at an aggressive pace and yet a degree of cancer-induced cachexia is experienced by up to 80% of advanced stage cancer patients. Unfortunately, there are no established treatment regimens for this condition. Weight loss and fatigue consistently appear in patient oncologic histories and progress notes. However, few oncologists fully understand the pathologic mechanisms causing cachexia resulting in well-meaning advice to increase caloric intake with minimal results. Our goal is to describe the pathologic basis of cancer-induced cachexia and to detail accompanying metabolic derangements. Understanding the causes of cachexia sheds light on the subsequent need for multi-modality therapy including clinical intervention with specialized nutrition support, drug therapy, lifestyle and diet changes. In addition to nutrition support modalities, practicing oncologists may prescribe medical therapies designed to increase body weight and lean body mass, including megestrol acetate, tetrahydrocannibinol, oxandrolone, and non-steroidal anti-inflammatory drugs. A variety of experimental therapies are also being investigated for cancer-induced cachexia including tumor necrosis factor-alpha inhibitors and ghrelin infusions. We review the available data to support nutrition-oriented interventions in cancer-induced cachexia, including omega-3 fatty acids, amino-acid loading/protein supplementation, parenteral and enteral nutrition support, and food-derived compounds such as curcumin, reservatrol, and pomegranate.

Update on clinical trials of growth factors and anabolic steroids in cachexia and wasting

This article and others that focused on the clinical features, mechanisms, and epidemiology of skeletal muscle loss and wasting in chronic diseases, which include chronic kidney disease, cancer, and AIDS, were presented at a symposium entitled "Cachexia and Wasting: Recent Breakthroughs in Understanding and Opportunities for Intervention," held at Experimental Biology 2009. The clinical and anabolic efficacy of specific growth factors and anabolic steroids (eg, growth hormone, testosterone, megestrol acetate) in malnutrition and other catabolic states has been the subject of considerable research during the past several decades. Research on the effects of these agents in cachexia or wasting conditions, characterized by progressive loss of skeletal muscle and adipose tissue, focused on patients with AIDS in the early 1990s, when the devastating effects of the loss of body weight, lean body mass, and adipose tissue were recognized as contributors to these patients' mortality. These same agents have also been studied as methods to attenuate the catabolic responses observed in cancer-induced cachexia and in wasting induced by chronic obstructive pulmonary disease, congestive heart failure, renal failure, and other conditions. This article provides an updated review of recent clinical trials that specifically examined the potential therapeutic roles of growth hormone, testosterone, oxandrolone, and megestrol acetate and emerging data on the orexigenic peptide ghrelin, in human cachexia and wasting.

Review: thromboses among HIV-infected patients during the highly active antiretroviral therapy era

Venous thrombotic events (VTEs) may occur at higher rates among patients with HIV; some studies suggest that highly active antiretroviral therapy (HAART) may increase the risk for these potentially life-threatening events. We performed a retrospective study among patients with HIV to evaluate the incidence and risk factors for VTEs during the HAART era. A literature review was performed examining VTEs in the pre- and post-HAART eras. Seventeen (3.7%) of 465 patients with HIV experienced a VTE. The overall incidence rate of deep VTEs among HIV-positive persons was 377 cases per 100,000 person-years, a fourfold higher rate compared to age-matched males in the general population. The median age at VTE was 36 years (range, 27-68). Patients with a thrombosis compared to those without had significantly lower current CD4 (153 versus 520 cells/mm(3), p < 0.001) and nadir (76 versus 276 cells/mm(3), p < 0.001) CD4 counts, higher viral loads (3.6 versus 1.7 log(10) copies per milliliter, p = 0.003), and more likely to have a diagnosis of AIDS (76% versus 32%, p < 0.001); there were no differences in demographics, hyperlipidemia, current use of HAART, the duration of HAART or protease inhibitor (PI) exposure. A review of the literature noted 129 VTE cases; mean age was 40 years, mean CD4 count was 181 cells/mm(3), the majority of patients were not receiving HAART, and the most common risk factor was an ongoing infection. Thrombotic events are occurring among patients with HIV despite their relatively young ages. Advanced HIV disease is a risk factor for development of thromboses, possibly due to an increased inflammatory state or the presence of concurrent comorbidities such as infections. HAART or PI therapy does not appear to play a significant role in the occurrence of VTEs.

Nutritional and anti-inflammatory interventions in chronic heart failure

Currently, there are 5 million individuals with chronic heart failure (CHF) in the United States who have poor clinical outcomes, including high death rates. Observational studies have indicated a reverse epidemiology of traditional cardiovascular risk factors in CHF; in contrast to trends seen in the general population, obesity and hypercholesterolemia are associated with improved survival. The temporal discordance between the overnutrition (long-term killer) and undernutrition (short-term killer) not only can explain some of the observed paradoxes but also may indicate that malnutrition, inflammation, and oxidative stress may play a role that results in protein-energy wasting contributing to poor survival in CHF. Diminished appetite or anorexia and nutritional deficiencies may be both a cause and a consequence of this so-called malnutrition-inflammation-cachexia (MIC) or wasting syndrome in CHF. Neurohumoral activation, insulin resistance, cytokine activation, and survival selection-resultant genetic polymorphisms also may contribute to the prominent inflammatory and oxidative characteristics of this population. In patients with CHF and wasting, nutritional strategies including amino acid supplementation may represent a promising therapeutic approach, especially if the provision of additional amino acids, protein, and energy includes nutrients with anti-inflammatory and antioxidant properties. Regardless of the etiology of anorexia, appetite-stimulating agents, especially those with anti-inflammatory properties such as megesterol acetate or pentoxyphylline, may be appropriate adjuncts to dietary supplementation. Understanding the factors that modulate MIC and body wasting and their associations with clinical outcomes in CHF may lead to the development of nutritional strategies that alter the pathophysiology of CHF and improve outcomes.

Megestrol acetate in cachexia and anorexia

The aim is to review major clinical trials that have used megestrol acetate (MA) in the treatment of cachexia across several disease states. A review of general usage and potential side-effects are discussed. A theory that the newly approved nanocrystal formation of MA can better deliver this potent medication for treatment will also be reviewed.

Human Immunodeficiency Virus Hematology

The advent of potent antiretroviral therapy has altered the expected natural history of human immunodeficiency virus (HIV) infection and of many previously associated opportunistic complications, including malignancies. At the same time, HIV suppression hasn’t affected all of these complications equally and the longer expected survival of infected patients may allow the development of newer complications. Additionally, the use of potent antiretroviral combination therapy may itself lead to hematological toxicities. Together these changes affect the consultation role of the hematology-oncology specialist in comprehensive HIV care and demand ongoing education.

In Section I, Dr. Paul Volberding reviews the biology of antiretroviral drug development and the progression in discovering new agents as the viral life cycle is further elucidated. He briefly summarizes the process of combining agents to achieve the degree of viral suppression required for long-term clinical benefit.

In Section II, Dr. Kelty Baker reviews the effects of HIV and its therapy on hematologic dyscrasia and clotting disorders. She summarizes how therapy may decrease certain previously common manifestations of HIV disease while adding new problems likely to result in referral to the hematologist. In addition, she addresses the role of secondary infections, such as parvovirus, in this spectrum of disorders.

In Section III, Dr. Alexandra Levine discusses the still challenging aspects of HIV associated non-Hodgkin’s lymphoma and the association between HIV infection and Hodgkin’s disease. She addresses current controversies in the pathogenesis of HIV related lymphomas and summarizes a number of recent trials of combination chemotherapy, with or without monoclonal antibodies, in their management. Additionally, she reviews the complex relationship of HIV disease with multicentric Castleman’s disease and recent attempts to manage this disorder.

[Megestrol acetate: a systematic review usefulness about the weight gain in neoplastic patients with cachexia]

BACKGROUND

The clinical efficacy of megestrol acetate in the treatment of cachexia in cancer patients has not been clearly demonstrated. A systematic review and meta-analysis have been performed to ascertain its effectiveness on weight gain in patients with cancer-associated cachexia.

MATERIAL AND METHOD

A systematic review of randomized clinical trials comparing megestrol acetate with placebo in cancer patients was performed. The outcome measure used was weight gain expressed as the difference in weight at the outset compared with that at the end of treatment. Trials analyzed were those that allowed for this calculation, or those whose authors provided information for the above calculation.

RESULTS

Patients treated with placebo had an average weight loss of 1.090 kg (CI 95%, 1.620 to 0.561), whereas patients treated with megestrol acetate gained an average 0.423 kg (CI 95%, 0.078-0.769). A weight gain of 0.448 kg (CI 95%, 0.021-0.874) was observed with acetate megestrol doses # 240 mg. No statistically significant effect was observed when using higher doses: 0.358 kg (CI 95%, 0.135-0.85).

CONCLUSIONS

Megestrol acetate doses equal to or lower than 240 mg/day lead to slight weight gain in patients with cancer-associated cachexia. The majority of studies have a low methodological quality. Further, well-designed studies comparing megestrol acetate with placebo are warranted.

Aseptic necrosis in HIV seropositive patients: a possible etiologic role for megestrol acetate

The association between pharmacologic doses of corticosteroids and the development of aseptic bone necrosis has been well documented. Recent reports have described the corticosteroid activity of megestrol acetate. A retrospective review of adverse events reported to the U.S. Food and Drug Administration identified three human immunodeficiency virus (HIV) seropositive patients who developed avascular necrosis of the femoral head during treatment with megestrol acetate. All were males, ages 34, 36, and 55 years, and were on therapy for 6, 1.5, and 18 months, respectively, when symptoms of aseptic necrosis occurred in the absence of antecedent trauma. Megestrol acetate doses were 640, 320, and 600-1200 mg/d, respectively. Two patients had no history of corticosteroid use whereas the third had taken an undisclosed dose and duration of corticosteroids concurrent with pentamidine administration. Notably, despite the predominant use of megestrol in women for hormone sensitive malignancies, none of the reports of aseptic necrosis occurred in this population. Megestrol acetate may be associated with the development of avascular necrosis via its glucocorticoid-like effects. Cachectic acquired immunodeficiency syndrome (AIDS) patients may have additional risk factors that predispose them to aseptic necrosis when receiving megestrol acetate.