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Fuseini H, Gyan BA, Kyei GB, Heimburger DC, Koethe JR. Undernutrition and HIV Infection in Sub-Saharan Africa: Health Outcomes and Therapeutic Interventions. Curr HIV/AIDS Rep 2021; 18:87-97. [PMID: 33606196 PMCID: PMC8404370 DOI: 10.1007/s11904-021-00541-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Sub-Saharan Africa (SSA) is disproportionately burdened by the twin epidemics of food insecurity and HIV infection, and protein-calorie undernutrition is common among persons with HIV (PWH) initiating antiretroviral therapy (ART) in the region. In this review, we discuss the intersection of HIV infection and undernutrition, health outcomes among undernourished PWH starting ART, and the demonstrated and potential benefits of therapeutic interventions such as micro/macronutrient supplementation and pharmacological agents. RECENT FINDINGS A low body mass index (BMI), used as a general indicator of poor nutrition in most studies, is associated with impaired immune recovery and increased mortality in the early ART period. The increased risk of mortality is multifactorial, and contributors include undernutrition-related immune system dysfunction, increased susceptibility to opportunistic infections, and metabolic and cardiovascular dysregulation. Clinical trials of micro/macronutrient supplementary feeding, appetite stimulants (hormones and anabolic agents), and recombinant adipokines have shown a benefit for weight gain and metabolic health, but there are few data on mortality or immune recovery. A substantial proportion of PWH in SSA are undernourished, and undernutrition contributes to an increased risk of mortality and other adverse health outcomes. To date, there have been few prospective trials of nutritional supplementation and/or pharmacologic therapy among undernourished PWH in SSA, though findings from other settings suggest a potential benefit in this population.
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Affiliation(s)
- Hubaida Fuseini
- Department of Immunology, Noguchi Memorial Institute for Medical Research, Legon, Ghana.
- Department of Virology, Noguchi Memorial Institute for Medical Research, Legon, Ghana.
- Divison of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, 37232-2582, USA.
| | - Ben A Gyan
- Department of Immunology, Noguchi Memorial Institute for Medical Research, Legon, Ghana
- Department of Virology, Noguchi Memorial Institute for Medical Research, Legon, Ghana
| | - George B Kyei
- Department of Immunology, Noguchi Memorial Institute for Medical Research, Legon, Ghana
- Department of Virology, Noguchi Memorial Institute for Medical Research, Legon, Ghana
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | | | - John R Koethe
- Divison of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, 37232-2582, USA
- Vanderbilt Institute for Global Health, Nashville, TN, USA
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Siddiqui JA, Pothuraju R, Jain M, Batra SK, Nasser MW. Advances in cancer cachexia: Intersection between affected organs, mediators, and pharmacological interventions. Biochim Biophys Acta Rev Cancer 2020; 1873:188359. [PMID: 32222610 DOI: 10.1016/j.bbcan.2020.188359] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 03/10/2020] [Accepted: 03/23/2020] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Jawed A Siddiqui
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ramesh Pothuraju
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Maneesh Jain
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA; Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, USA
| | - Surinder K Batra
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA; Eppley Institute for Research in Cancer and Allied Diseases, University of Nebraska Medical Center, Omaha, NE, USA; Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Mohd W Nasser
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA; Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, USA.
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Ruiz‐García V, López‐Briz E, Carbonell‐Sanchis R, Bort‐Martí S, Gonzálvez‐Perales JL. Megestrol acetate for cachexia-anorexia syndrome. A systematic review. J Cachexia Sarcopenia Muscle 2018; 9:444-452. [PMID: 29542279 PMCID: PMC5989756 DOI: 10.1002/jcsm.12292] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 01/09/2018] [Indexed: 11/08/2022] Open
Abstract
In 1993, megestrol acetate (MA) was approved by the US Food and Drug Administration for the treatment of anorexia, cachexia, or unexplained weight loss in patients with acquired immunodeficiency syndrome. The mechanism by which MA increases appetite is unknown, and its effectiveness for anorexia and cachexia in neoplastic, elderly, and acquired immunodeficiency syndrome patients is under investigation. This is an updated version of a Cochrane systematic review first published in 2005 and later updated in 2013 entitled 'Megestrol acetate for the treatment of anorexia-cachexia syndrome'. MA vs. placebo: in studies where MA was compared with placebo, the overall results showed that MA patients gained weight (mean difference, MD 2.25 kg, 95% CI [1.19, 3.3]) but did not gain quality of life (QOL) (standarized mean difference, SMD 0.5, 95% CI [-0.13, 1.13]), with more adverse events (relative risk, RR 1.46, 95% CI [1.05, 2.04]), but no difference in deaths (RR 1.26, 95% CI [0.70, 2.27]). MA vs. no treatment: MA patients gained weight (MD 1.45 kg, 95% CI [0.15, 2.75]) but did not gain QOL (standardized mean difference 3.89 95% CI [-14, 6.28]). There was no increase in adverse events (RR 0.90, 95% CI [0.39, 2.08]) or deaths (RR 1.01, 95% CI [0.42, 2.45]). MA vs. active drugs: MA patients gained weight (MD 2.5 kg, 95% CI [0.37, 4.64]) but did not gain QOL (MD 0.20 95% CI [-0.02, 0.43]) and did not report an increase in adverse events (RR 1.05 95% CI [0.95, 1.16]) or in deaths (RR 1.53, 95% CI [1.02, 2.29]) Different doses of MA: in studies where lower doses of MA were compared with higher doses of MA, we did not find differences either in weight gain (MD -0.94 kg, 95% CI [-3.33, 1.45]), QOL (MD 0.31 95% CI [-0.19, 0.81]), or adverse events (RR 1.34, 95% CI [0.65, 2.76]). Thus, we cannot reach a conclusion for an optimal dose of MA.
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Affiliation(s)
- Vicente Ruiz‐García
- Hospital at Home Unit, Tower C, Floor 1 Office 5La Fe University HospitalValenciaSpain & CASPeSpain
| | - Eduardo López‐Briz
- Department of PharmacyLa Fe University HospitalValenciaSpain, & CASPeSpain
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Casaburi R, Nakata J, Bistrong L, Torres E, Rambod M, Porszasz J. Effect of Megestrol Acetate and Testosterone on Body Composition and Hormonal Responses in COPD Cachexia. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2015; 3:389-397. [PMID: 28848861 DOI: 10.15326/jcopdf.3.1.2015.0128] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background: Underweight chronic obstructive pulmonary disease (COPD) patients with involuntary weight loss have a poor prognosis; no effective therapy is currently available. We conducted the first clinical trial seeking to determine whether combination therapy with an appetite stimulant and an anabolic steroid would have beneficial effects on body composition for patients with COPD cachexia. Methods: We conducted a 12-week pilot study in which 4 men and 5 women (age 64±10 y, forced expiratory volume in 1 second [FEV1] 31±9 %pred., body mass index [BMI] 18±3 kg/m2) with low-normal testosterone levels (average 532±45ng/dl in men and 12.4±5.3ng/dl in women) and weight loss ≥10 lbs over the previous year were treated with oral megestrol acetate 800mg/day plus weekly testosterone enanthate injections, initially 125 mg in men and 40 mg in women, with doses subsequently adjusted targeting circulating nadir testosterone levels of 850 and 300 ng/dl, respectively. Results: On treatment, nadir testosterone level increases averaged 160±250 ng/dl (NS) in men and 322±49 (p<0.001) ng/dl in women. Body weight increased in all individuals, with average end-intervention weight gain of 3.1±2.2 kg (p<0.005). Two women and 2 men had COPD exacerbations and did not complete the 12-week study. In the 5 individuals who completed, dual energy x ray absorptiometry (DEXA) scans revealed an average 2.0±1.5 kg lean mass and 2.3±1.7 kg fat mass increase (each p<0.05). No adverse effects of treatment were detected. Conclusions: Combination therapy reversed the trajectory of involuntary weight loss and increased lean mass in cachectic COPD patients. Though the interventions were apparently well tolerated, participant drop-out rate was high. Larger randomized placebo-controlled long-term studies with functional outcomes are needed.
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Affiliation(s)
- Richard Casaburi
- Rehabilitation Clinical Trials Center, Los Angeles Biomedical Research Institute at Harbor-University of California, Los Angeles Medical Center, Torrance
| | - Junko Nakata
- Rehabilitation Clinical Trials Center, Los Angeles Biomedical Research Institute at Harbor-University of California, Los Angeles Medical Center, Torrance
| | - Lawrence Bistrong
- Rehabilitation Clinical Trials Center, Los Angeles Biomedical Research Institute at Harbor-University of California, Los Angeles Medical Center, Torrance
| | - Edwardo Torres
- Rehabilitation Clinical Trials Center, Los Angeles Biomedical Research Institute at Harbor-University of California, Los Angeles Medical Center, Torrance
| | - Mehdi Rambod
- Rehabilitation Clinical Trials Center, Los Angeles Biomedical Research Institute at Harbor-University of California, Los Angeles Medical Center, Torrance.,Division of Cardiology, University of Vermont College of Medicine, Burlington
| | - Janos Porszasz
- Rehabilitation Clinical Trials Center, Los Angeles Biomedical Research Institute at Harbor-University of California, Los Angeles Medical Center, Torrance
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A new look at an old drug for the treatment of cancer cachexia: Megestrol acetate. Clin Nutr 2013; 32:319-24. [DOI: 10.1016/j.clnu.2013.01.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Revised: 01/08/2013] [Accepted: 01/08/2013] [Indexed: 12/27/2022]
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Ruiz Garcia V, López-Briz E, Carbonell Sanchis R, Gonzalvez Perales JL, Bort-Marti S. Megestrol acetate for treatment of anorexia-cachexia syndrome. Cochrane Database Syst Rev 2013; 2013:CD004310. [PMID: 23543530 PMCID: PMC6418472 DOI: 10.1002/14651858.cd004310.pub3] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND This is an updated version of a previously published review in The Cochrane Library (2005, Issue 2) on 'Megestrol acetate for the treatment of anorexia-cachexia syndrome'. Megestrol acetate (MA) is currently used to improve appetite and to increase weight in cancer-associated anorexia. In 1993, MA was approved by the US Food and Drug Administration for the treatment of anorexia, cachexia or unexplained weight loss in patients with AIDS. The mechanism by which MA increases appetite is unknown and its effectiveness for anorexia and cachexia in neoplastic and AIDS (acquired immunodeficiency syndrome) patients is under investigation. OBJECTIVES To evaluate the efficacy, effectiveness and safety of MA in palliating anorexia-cachexia syndrome in patients with cancer, AIDS and other underlying pathologies. SEARCH METHODS We sought studies through an extensive search of electronic databases, journals, reference lists, contact with investigators and other search strategies outlined in the methods. The most recent search for this update was carried out in May 2012. SELECTION CRITERIA Studies were included in the review if they assessed MA compared to placebo or other drug treatments in randomised controlled trials of patients with a clinical diagnosis of anorexia-cachexia syndrome related to cancer, AIDS or any other underlying pathology. DATA COLLECTION AND ANALYSIS Two independent review authors conducted data extraction and evaluated methodological quality. We performed quantitative analyses using appetite and quality of life as a dichotomous variable, and analysed weight gain as continuous and dichotomous variables. MAIN RESULTS We included 35 trials in this update, the same number but not the same trials as in the previous version of the review. The trials comprised 3963 patients for effectiveness and 3180 for safety. Sixteen trials compared MA at different doses with placebo, seven trials compared different doses of MA with other drug treatments and 10 trials compared different doses of MA. Meta-analysis showed a benefit of MA compared with placebo, particularly with regard to appetite improvement and weight gain in cancer, AIDS and other underlying conditions, and lack of benefit in the same patients when MA was compared to other drugs. There was insufficient information to define the optimal dose of MA, but higher doses were more related to weight improvement than lower doses. Quality of life improvement in patients was seen only when comparing MA versus placebo but not other drugs in both subcategories: cancer and AIDS. Oedema, thromboembolic phenomena and deaths were more frequent in the patients treated with MA. More than 40 side effects were studied. AUTHORS' CONCLUSIONS This review shows that MA improves appetite and is associated with slight weight gain in cancer, AIDS and in patients with other underlying pathology. Despite the fact that these patients are receiving palliative care they should be informed of the risks involved in taking MA.
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Affiliation(s)
- Vicente Ruiz Garcia
- Unidad de Hospitalización a Domicilio & CASP Spain, Hospital Universitari i Politècnic La Fe, Valencia, Spain.
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Anorexia nervosa and estrogen: Current status of the hypothesis. Neurosci Biobehav Rev 2010; 34:1195-200. [DOI: 10.1016/j.neubiorev.2010.01.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2009] [Revised: 01/28/2010] [Accepted: 01/29/2010] [Indexed: 01/25/2023]
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Yeh SS, Marandi M, Thode HC, Levine DM, Parker T, Dixon T, Schuster MW. Report of a Pilot, Double-Blind, Placebo-Controlled Study of Megestrol Acetate in Elderly Dialysis Patients With Cachexia. J Ren Nutr 2010; 20:52-62. [DOI: 10.1053/j.jrn.2009.08.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2008] [Indexed: 11/11/2022] Open
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Yeh SS, Lovitt S, Schuster MW. Usage of megestrol acetate in the treatment of anorexia-cachexia syndrome in the elderly. J Nutr Health Aging 2009; 13:448-54. [PMID: 19390752 DOI: 10.1007/s12603-009-0082-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
UNLABELLED The aim of this review is to assess the efficacy and safety of megestrol acetate (MA) in geriatric cachexia. The paper presented here reviews a previously published study of MA use in 69 patients in a randomized double blind placebo-controlled trial. This paper will also address the underlying pathogenesis of cachexia (specifically, the role of cytokines) along with the use of MA, its mechanism of action and its side effects. OBJECTIVE To compare the effects of MA oral suspension (O.S.), 800 mg/day, versus placebo on weight in geriatric nursing home patients with weight loss or low body weight. DESIGN Twelve weeks, randomized, double-blind, placebo-controlled trial with a 13-week follow-up period. PATIENTS Northport VAMC Nursing home patients with weight loss of * 5% of usual body weight over the past 3 months, or body weight 20% below their ideal body weight. INTERVENTIONS Patients were randomly assigned to receive placebo or MA 800 mg/d for 12 weeks and were then followed for 13 weeks off treatment and mortality 4 years post treatment. MEASUREMENTS Primary outcome- weight and appetite change. Secondary outcome-sense of well being, enjoyment of life, change in depression scale, laboratory nutrition parameters, energy intake counts, body composition, and adverse events. RESULTS At 12 weeks there were no significant differences in weight gain between treatment groups, while MA-treated patients reported significantly greater improvement in appetite, enjoyment of life, and well being. At week 25 (3 months after treatment), 61.9% of MA-treated patients had gained * 1.82 kg (4 lbs) compared to 21.7% of placebo patients. There was no difference in survival between MA and placebo groups. Considering possible confounders, higher initial IL-6, initial TNFR-p75 levels, and final neutrophil percentage were associated with elevated mortality, whereas higher initial pre-albumin, initial albumin, final pre-albumin, final albumin and final weight gain were associated with decreased death.
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Affiliation(s)
- S-S Yeh
- Northport VAMC, Geriatric Division, Northport, NY 11768, USA
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Halford JCG, Harrold JA. Neuropharmacology of human appetite expression. ACTA ACUST UNITED AC 2008; 14:158-64. [PMID: 18646016 DOI: 10.1002/ddrr.20] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The regulation of appetite relies on the integration of numerous episodic (meal) and tonic (energy storage) generated signals in energy regulatory centres within the central nervous system (CNS). These centers provide the pharmacological potential to modify human appetite (hunger and satiety) to increase or decrease caloric intake, or to normalize aberrant eating behavior. With regard to obesity, the satiety enhancing anti-obesity drug sibutramine has proved effective at reducing body weight. Additionally, the endocannabinoid CB(1) antagonist rimonabant has recently been approved for use in Europe (but not in the US). A 5-HT(2C) agonist lorcaserin is also currently undergoing large-scale clinical trials, but the effect of the drug on human appetite is unknown as yet. Appetite enhancing drugs such as magestrol acetate and dronabiol are currently used to promote weight gain. Finally, sibutramine, selective serotonergic reuptake inhibitors such as fluoxetine and some anti-epileptic drugs have all been used to normalise aberrant eating behaviour. All these drugs act by modifying the expression of human appetite. An assessment of a drug's effects on caloric intake and feelings of hunger and satiety is necessary before they can be considered for clinical use.
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Affiliation(s)
- Jason C G Halford
- Kissileff Laboratory for the Study of Human Ingestive Behaviour, School of Psychology, University of Liverpool, Liverpool, United Kingdom.
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Abstract
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.
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Affiliation(s)
- Shing-Shing Yeh
- Northport VAMC, Geriatric division, Northport, NY 11768, USA.
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12
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Sullivan DH, Roberson PK, Smith ES, Price JA, Bopp MM. Effects of muscle strength training and megestrol acetate on strength, muscle mass, and function in frail older people. J Am Geriatr Soc 2007; 55:20-8. [PMID: 17233681 DOI: 10.1111/j.1532-5415.2006.01010.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To determine the independent and combined effects of progressive resistance muscle strength training (PRMST) and megestrol acetate (MA) on strength, muscle mass, and function in older recuperative care patients. DESIGN Double-blind, randomized, controlled intervention using a two-by-two factorial design and conducted between 1999 and 2001. SETTING University-affiliated Department of Veterans Affairs hospital. PARTICIPANTS Twenty-nine patients (mean age 79.4 +/- 7.4, 90% white) aged 65 and older and had recent functional decline. INTERVENTIONS After randomization to one of four treatment groups (low-resistance exercises plus 800 mg per day of MA or a placebo or high-intensity PRMST plus 800 mg/d of MA or placebo), subjects received training and the drug or placebo for 12 weeks. MEASUREMENTS Change in muscle strength, mid-thigh muscle area, and aggregate functional performance score as assessed using analysis of covariance. RESULTS Five subjects withdrew from the study before its completion. Based on intent-to-treat analyses, subjects who received high-intensity PRMST and placebo experienced the greatest strength gains. The addition of MA was associated with worse outcomes than with high-intensity exercise training alone, especially with regard to the leg exercises. Post hoc analysis demonstrated that subjects who received high-intensity PRMST and placebo experienced significantly greater percentage increases in leg strength than subjects in either of the MA treatment groups (P<.05 for each comparison). There was also a significant negative effect of MA on physical function. In general, subjects who received MA experienced a deterioration in aggregate physical function scores, whereas the remaining subjects improved (-0.80+/-0.40 vs 0.48+/-0.41, P=.04). There was not a significant interaction between exercise and MA for any outcome. CONCLUSION High-intensity PRMST is a safe and well-tolerated exercise regimen for frail elderly patients. The addition of MA appears to blunt the beneficial effects of PRMST, resulting in less muscle strength and functional performance gains.
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Affiliation(s)
- Dennis H Sullivan
- Geriatric Research, Education and Clinical Center, Central Arkansas Veterans Healthcare System, Little Rock, AR 72205, USA.
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Jacobson DL, Bica I, Knox TA, Wanke C, Tchetgen E, Spiegelman D, Silva M, Gorbach S, Wilson IB. Difficulty Swallowing and Lack of Receipt of Highly Active Antiretroviral Therapy Predict Acute Weight Loss in Human Immunodeficiency Virus Disease. Clin Infect Dis 2003; 37:1349-56. [PMID: 14583869 DOI: 10.1086/379072] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2003] [Accepted: 07/08/2003] [Indexed: 11/04/2022] Open
Abstract
In human immunodeficiency virus (HIV) disease, symptoms of underlying illness may promote weight loss through decreased caloric intake, increased metabolic needs, or nutrient malabsorption. We evaluated disease symptoms as predictors of acute weight loss (i.e., loss of > or =5% of weight). HIV-infected men and women (n=415) were telephoned every 5 weeks to obtain information about weight and recent symptoms. Weight change between each pair of consecutive calls (telephone intervals, 2814) was calculated. Acute weight loss occurred across 4.5% of intervals and among 24% of individuals. Patients reported > or =1 symptom before 58% of telephone intervals. The most common symptoms or symptom complexes before intervals were diarrhea (21% of patients), anorexia (17%), upper respiratory symptoms (16%), skin symptoms (12%), and abdominal pain (12%). Trouble swallowing (6%) and oral symptoms (7%) were less common. Risk of acute weight loss was significantly increased when oral symptoms or trouble swallowing were present, and it was decreased when highly active antiretroviral therapy (HAART) was used or when diarrhea was not present. Even when HAART is being administered, clinicians should remain vigilant regarding weight loss, oral symptoms, and trouble swallowing.
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Affiliation(s)
- Denise L Jacobson
- Department of Family Medicine and Community Health, Tufts University School of Medicine, Boston, Massachusetts 02111, USA.
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Abstract
Anorexia and weight loss represent a major cause of morbidity and mortality. At present in the United States two effective anorectic agents are commonly used, namely, megestrol acetate and dronabinol. These two agents are compared in Table 1. In persons with a large excess cytokine production. megestrol acetate should be tried at a does of 800 mg per day for no longer than 3 months. Megestrol acetate should be administered with testosterone in men. It should be avoided in persons who are bed-bound because of the risk of deep vein thrombosis. Dronabinol should be used for most anorectic patients. Dronabinol should initially be given in a low dose (2.5 mg) in the evening. The dose should be increased to 5 mg per day if no improvement in appetite is seen after 2 to 4 weeks. Dronabinol can be continued indefinitely. It seems to have a particularly good profile for persons with anorexia who are at the end of life. In persons with depression and anorexia. mirtazapine seems to be the antidepressant of choice. In addition, the use of taste enhancers can be considered in persons who complain that the food does not taste good. The appropriate use of anabolic agents in older persons with weight loss is controversial. Certainly all older men who are losing weight should have bioavailable testosterone measured and, if the testosterone level is low, should receive testosterone replacement therapy. Women who are losing weight may benefit from the use of low-dose testosterone (eg, Estratest). Anabolic agents, such as oxandrolone, should be reserved for those who have profound cachexia. An approach to the management of anorexia and weight loss in older persons is given in Fig. 1. Thomas et al have provided a more complex algorithm the management of weight loss in nursing home residents.
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Affiliation(s)
- John E Morley
- Division of Geriatric Medicine, Saint Louis University School of Medicine, 1402 South Grand Boulevard M238, Saint Louis, MO 63104, USA.
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Weisberg J, Wanger J, Olson J, Streit B, Fogarty C, Martin T, Casaburi R. Megestrol acetate stimulates weight gain and ventilation in underweight COPD patients. Chest 2002; 121:1070-8. [PMID: 11948034 DOI: 10.1378/chest.121.4.1070] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES To assess the effect of megestrol acetate (MA), a progestational appetite stimulant commonly used in patients with AIDS and cancer, on body weight and composition, respiratory muscle strength, arterial blood gas levels, and subjective perceptions in COPD patients. DESIGN AND SETTING Prospective, double-blind, randomized, placebo-controlled trial conducted on an outpatient basis at 18 sites. PATIENTS Underweight (< 95% ideal body weight) COPD patients > or = 40 years old. INTERVENTIONS Either MA, 800 mg/d oral suspension, or placebo at a 1:1 ratio for 8 weeks. RESULTS Of 145 randomized patients (63% men), 128 patients completed the trial. Body weight increased by 3.2 kg in the MA group and 0.7 kg in the placebo group (p < 0.001). Anthropometric and dual-energy radiograph absorptiometry assessments confirmed that weight gain was mainly fat. Spirometry and maximal voluntary ventilation showed no significant changes from baseline in either group, and the difference in the change in maximum inspiratory pressure between groups was not significant. The 6-min walk distances did not differ statistically between groups at week 2 and week 4, but were greater in the placebo group at week 8 (p = 0.012). Consistent with the known ability of MA to stimulate ventilation, PaCO(2) decreased (4.6 mm Hg, p < 0.001) and PaO(2) increased (2.8 mm Hg, p < 0.04) in the MA group. Questionnaires revealed that body image and appetite improved in the MA group but not the placebo group. Adverse event frequency and type were similar in both groups, but cortisol and testosterone (in men) levels decreased substantially in the MA group. CONCLUSIONS We conclude that MA safely increased appetite and body weight, stimulated ventilation, and improved body image in underweight COPD patients, but did not improve respiratory muscle function or exercise tolerance.
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Affiliation(s)
- Jeffrey Weisberg
- Nova Southeastern University College of Osteopathic Medicine, Fort Lauderdale, FL, USA.
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Yeh SS, Wu SY, Levine DM, Parker TS, Olson JS, Stevens MR, Schuster MW. The correlation of cytokine levels with body weight after megestrol acetate treatment in geriatric patients. J Gerontol A Biol Sci Med Sci 2001; 56:M48-54. [PMID: 11193233 DOI: 10.1093/gerona/56.1.m48] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Cachexia is associated with elevated levels of cytokines in cancer and human immunodeficiency virus patients. Studies in cancer and acquired immunodeficiency syndrome patients showed that treatment with megestrol acetate (MA) is associated with improvement in appetite and weight gain. Reduction in the levels of cytokines is associated with weight gain in laboratory animals with cancer. This study evaluates the correlation between changes in cytokine (or their receptor) levels and weight following MA treatment in geriatric weight-loss patients. METHODS Veterans Administration Medical Center nursing home patients (N = 69) with a weight loss of > or =5% of usual body weight over the past 3 months or body weight 20% below their ideal body weight participated in a 12-week, randomized, double-blind, placebo-controlled trial, with an additional 13-week follow-up period. Patients were randomly assigned to receive a placebo or MA oral suspension of 800 mg/d for 12 weeks. Levels of the following cytokines (or their receptors) were measured at baseline and after 12 weeks of treatment: tumor necrosis factor soluble receptor (TNFR) subunits. TNFR-p55 and TNFR-p75: interleukin 6 (IL-6); and the soluble interleukin-2 receptor (sIL-2R). The subjects' weight and body composition were measured at the start of the study. Weight and mortality were followed up for another 13 weeks after discontinuing the MA study drug. RESULTS Elevated levels of IL-6 in almost all geriatric cachexic patients, compared with normal volunteers (mean, <4.6 pg/ml). were noted at baseline. At 12 weeks after the study drug treatment, there was a decrease in cytokine levels (or their receptors) in the MA group (mean change in IL-6, 3.63+/-6.62 pg/ml; TNFR-p55, -0.06+/-0.11 ng/ml; TNFR-p75. -0.01+/-0.29 ng/ml; and sIL-2R, 0.08+/-0.07 ng/ml) and the placebo group (mean change in IL-6, -2.08+/-3.92 pg/ml; TNFR-p55, -0.02+/-0.08 ng/ml; TNFR-p75, -0.20+/-0.18 ng/ml; and sIL-2R, 0.02+/-0.03 ng/ml). Although the change in cytokine levels was not statistically significant between the two groups, significant negative correlation (p < .05) was found. For example, increased weight correlated with decreased sIL-2R levels (r = .36) and TNFR-p75 (r = -.31; fat-free mass (FFM) gain and reduction of sIL-2R (r = -.39), TNFR-p75 (r = -.30). There was a significant correlation between weight gain and reduction of TNFR-p75 (r = .54), TNFR-p55 (r- = .47), and sIL-2R (r = -.53); FFM gain and reduction of sIL-2R (r = -.59), TNFR-p75 (r = -.41), TNFR-p55 (r = -.42); and fat gain and reduction of TNFR-p75 (r = -.41) in the MA group (p < .05), but not in the placebo group. CONCLUSIONS Although there was no significant change in cytokine levels between the two groups, the reduction in cytokine levels after MA treatment correlated with improvement in weight, fat mass, and FFM at 12 weeks.
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Affiliation(s)
- S S Yeh
- Department of Medicine, VA Medical Center at Northport, New York 11768, USA.
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Marchand V, Baker SS, Stark TJ, Baker RD. Randomized, double-blind, placebo-controlled pilot trial of megestrol acetate in malnourished children with cystic fibrosis. J Pediatr Gastroenterol Nutr 2000; 31:264-9. [PMID: 10997370 DOI: 10.1097/00005176-200009000-00012] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Undernutrition is common in patients with cystic fibrosis (CF). Nutritional rehabilitation has been shown to improve linear growth, pulmonary function, well-being, and resistance to infection in this population. The purpose of this study was to determine whether the administration of megestrol acetate (MA) induces weight gain in malnourished patients with CF, and to assess the composition of weight gain. METHODS In a randomized, placebo-controlled, double-blind, crossover study, 12 children with CF received MA (10 mg/kg/d) or placebo for 12 weeks, followed by a 12-week washout period, then the alternative treatment. Anthropometrics, caloric intake, and clinical assessment were obtained every 6 weeks; pulmonary function tests, biochemistry, hematology, cortisol, growth hormone, insulin, C-peptide, insulin-like growth factor-1, insulin-like growth factor binding protein-3, and dual-energy x-ray absorptiometry scans were obtained every 12 weeks. RESULTS Six children did not complete the study, three for reasons unrelated to the study, two because they developed diabetes while receiving MA, and one who had glucose intolerance while receiving the placebo. Average weight gain was 3.05 kg in the MA group and 0.3 kg in the placebo group. The change in weight z score was +0.76 in the MA group and -0.05 in the placebo group. The change in height z score was -0.06 in the MA group and +0.06 in the placebo group. Lean body mass and body fat increased by 1507 g and 1192 g respectively in the MA group. Pulmonary function tests improved in the MA group; serum cortisol levels decreased. Side effects included glucosuria, insomnia, hyperactivity, and irritability. CONCLUSIONS Weight, body fat, and lean body mass increased and pulmonary function improved in the children with CF given MA. Adrenal suppression, glucose intolerance, and diabetes are side effects.
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Affiliation(s)
- V Marchand
- Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina, Charleston 29403, USA
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Yeh SS, Wu SY, Lee TP, Olson JS, Stevens MR, Dixon T, Porcelli RJ, Schuster MW. Improvement in quality-of-life measures and stimulation of weight gain after treatment with megestrol acetate oral suspension in geriatric cachexia: results of a double-blind, placebo-controlled study. J Am Geriatr Soc 2000; 48:485-92. [PMID: 10811540 DOI: 10.1111/j.1532-5415.2000.tb04993.x] [Citation(s) in RCA: 109] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Weight loss among older patients is a severe problem, associated with an increased incidence of infections, decubiti, and death. Megestrol acetate (MA) causes weight gain in cachectic cancer and AIDS patients, but its effects in older cachectic patients are unknown. OBJECTIVE To compare the effects of MA oral suspension (O.S.), 800 mg/day, versus placebo on weight in geriatric nursing home patients with weight loss or low body weight. DESIGN Twelve-week, randomized, double-blind, placebo-controlled trial with a 13-week follow-up period. SETTING Veterans Administration Medical Center (VMAC) nursing home. PATIENTS Nursing home patients with weight loss of > or =5% of usual body weight over the past 3 months, or body weight 20% below their ideal body weight. INTERVENTIONS Patients were randomly assigned to receive placebo or MA 800 mg/day for 12 weeks and were then followed for 13 weeks off treatment. MEASUREMENTS Primary outcome was measured by weight and appetite change. Secondary outcome measures included sense of well-being, enjoyment of life, change in depression scale, laboratory nutrition parameters, energy intake counts, body composition, and adverse events. RESULTS At 12 weeks there were no significant differences in weight gain between treatment groups, whereas MA-treated patients reported significantly greater improvement in appetite, enjoyment of life, and well-being. Body composition was not statistically different between the two groups. At Week 25 (3 months after treatment), 61.9% of MA-treated patients had gained > or =1.82 kg (4 lbs) compared to 21.7% of placebo patients. CONCLUSIONS In geriatric patients with weight loss or low body weight MA improves appetite and well-being after 12 weeks of treatment. During the 3 months of MA treatment, there was no statistically significant weight gain (> or =4 lbs). Three months after treatment, weight gain (> or =4 lbs) was significantly increased in MA-treated patients.
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Affiliation(s)
- S S Yeh
- VA Medical Center Northport, NY 11768-2290, USA
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Boccanfuso JA, Hutton M, McAllister B. The effects of megestrol acetate on nutritional parameters in a dialysis population. J Ren Nutr 2000; 10:36-43. [PMID: 10671632 DOI: 10.1016/s1051-2276(00)90021-9] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To examine the effect of megestrol acetate on nutritional parameters in a hemodialysis population. DESIGN Prospective case studies of hemodialysis patients. SETTING A freestanding, nonprofit, hemodialysis unit. SUBJECTS Seventeen patients were studied. They were included regardless of gender, age, or cause of renal disease. They had to be on dialysis for at least 2 months, had a serum albumin <3.5 g/dL for these 2 months, and had to be at high nutritional risk. There were 8 women and 9 men. Ages were 44 to 87 years. Eight were diabetics, and 9 were nondiabetics. INTERVENTIONS Megestrol acetate 400 mg orally twice daily was prescribed, and patients were studied for 6 months. OUTCOME MEASURES Pre-evaluation and postevaluation were performed by patient questionnaire, Subjective Global Assessment (SGA), dry weight, and anthropometric measurements. Monthly laboratory monitoring included albumin, prealbumin, blood urea nitrogen (BUN), cholesterol, triglycerides, carbon dioxide, platelets, hematocrit, alanine aminotransferase (ALT), aspartate aminotransferase (AST), gammaglutamyl transpeptidase (GGT), lactate dehydrogenase (LDH), alkaline phosphatase, and glucose. Glycohemoglobin and hemoglobin A1c were monitored in diabetic patients. RESULTS Three patients were able to take megestrol acetate for 5 to 6 months. They reported improved appetite and showed an increase in dry weight. The annualized mortality rate was about 59%. Side effects included diarrhea, confusion, hyperglycemia, headaches, dizziness, and elevated LDH. CONCLUSION Megestrol acetate may help stimulate appetite in the hemodialysis patient, but it is risky and must be monitored closely. Eight hundred milligrams per day is probably too large a dose for the end-stage renal disease (ESRD) patient.
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Koller E, Gibert C, Green L, Mann M, Bernstein B. Thrombotic events associated with megestrol acetate in patients with AIDS cachexia. Nutrition 1999; 15:294-8. [PMID: 10319362 DOI: 10.1016/s0899-9007(99)00007-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- E Koller
- Center for Drug Evaluation, US Food and Drug Administration, Rockville, Maryland 20857, USA
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Newshan G, Sherman DW. PALLIATIVE CARE. Nurs Clin North Am 1999. [DOI: 10.1016/s0029-6465(22)02366-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Grady C, Ropka M, Anderson R, Lane HC. Body composition in clinically stable men with HIV infection. J Assoc Nurses AIDS Care 1996; 7:29-38. [PMID: 9021634 DOI: 10.1016/s1055-3290(96)80022-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Clinically stable HIV-infected men (N = 106) receiving investigational antiretrovirals were recruited. Subjects were divided into three HIV disease severity groups by CD4+ cell count. Standard measures of body composition were assessed, as well as serum measures of visceral protein stores and kilocalorie intake. Group 1 subjects (CD4+ T cells < 200) had significantly lower measures of body fat as compared with Group 2 (CD4 between 200 and 600) and Group 3 (CD4 > 600) despite adequate kilocalorie intake. Group 2 and Group 3 were not significantly different from each other. Our entire cohort had significantly lower muscle mass compared to norms. Our data demonstrate that people with advanced HIV disease have reduced muscle and fat.
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Affiliation(s)
- C Grady
- Clinical Therapeutics Laboratory, National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA
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Abstract
Anorexia is associated with disorders of all systems. Anorexia represents a consistent clinical manifestation during acute and chronic pathophysiological processes (infection, inflammation, injury, toxins, immunological reactions, malignancy and necrosis). Anorexia during disease can be beneficial or deleterious depending on the timing and duration. Temporary anorexia during acute disease may be beneficial to an organism since a restriction in the intake of micro- and macro-nutrients will inhibit bacterial growth. Long-term anorexia during chronic disease, however, is deleterious to an organism and may be associated with cachexia, which can ultimately result in death. Various mechanisms participate in the anorexia observed during disease, including cytokine action. Anorexia induced by cytokines is proposed to involve modulation of hypothalamic-feeding associated sites, prostaglandin-dependent mechanisms, modifications of neurotransmitter systems, gastrointestinal, metabolic, and endocrine factors. In addition, the anorexia-cachexia syndrome is multifactorial and may involve chronic pain, depression or anxiety, hypogeusia and hyposmia, chronic nausea, early satiety, malfunction of the gastrointestinal system, metabolic alterations, cytokine action, production of other anorexigenic substances and/or iatrogenic causes (chemotherapy, radiotherapy). Cachexia may result not only from anorexia and a decreased caloric intake, but also from malabsorption and losses from the body (ulcers, hemorrhage, effusions), or a change in body metabolism. Research has focused on potential interventions to modify anorexia during disease and the anorexia-cachexia syndrome. Nutritional modifications and the use of specific steroids (such as megestrol acetate) are being tested in the clinical setting. Understanding the specific mechanisms responsible for anorexia during disease as well as their interactions is essential to develop interventions for the control of anorexia (during a critical time in a specific disease), and to devise less toxic immunotherapeutic regimens using cytokines.
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Affiliation(s)
- C R Plata-Salamán
- Medical Sciences Faculty, School of Life and Health Sciences, University of Delaware, Newark 19716, USA
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