Desport, J.C., Gory-Delabaere, G., Blanc-Vincent, M.P., Bachmann, P., Beal, J., Benamouzig, R., . . . Senesse, P. (2003). Standards, options and recommendations for the use of appetite stimulants in oncology (2000). British Journal of Cancer, 89(Suppl. 1), S98–S100.

To review the literature on the use of appetite stimulants in oncology by a multidisciplinary group established by the French National Federation of Cancer Centers

The group conducted a literature search of four databases (MEDLINE, CancerLit, Embase, and the Cochrane Library) using search phrases: appetite stimulants, anorexia/drug therapy, cachexia/drug, or appetite associated with neoplasms. The search yielded 55 reports of randomized controlled trials (RCTs) published between 1990–1999 that evaluated the appetite-stimulating effect of corticosteroids, synthetic progestogens, or other drugs. 

The group defined standards, options, and recommendations for the use of appetite stimulants.

• Standards: Clinical situations for which there exist strong indications or contraindications for a particular intervention.
• Options: Situations for which there are several alternatives without clear superiority of one choice over another.
• Recommendations: Additional information to enable the available options to be ranked using explicit criteria with an indication of the level of evidence.

They also defined the level of evidence. 

• A: High-standard, meta-analysis, or several high-standard RCTs with consistent results.
• B: Good-quality evidence from randomized trials or prospective or retrospective studies with consistent results.
• C: Weak methodology of studies or inconsistent results.
• D: Lack of scientific data or case study reports only.
• Expert Agreement: Data do not exist for the method concerned, but the experts are unanimous in their judgment.

The primary outcome used in analysis of study results was anorexia. Secondary outcomes were improved quality of life, increase in body weight, increased food consumption, decrease in nausea and/or vomiting, and improvement in anthropometric and biologic parameters.

Corticosteroids

Corticosteroids were found to be effective appetite stimulants. Their level of evidence was B1 (good-quality evidence from randomized trials), but optimal dose and scheduling information was lacking.

Synthetic Progestogens

Megesterol acetate: Effective appetite stimulant (level B1) and beneficial effect on body weight (level B1). Minimum effective dose is 160 mg/day (level B1). Optimal dose is 480 mg/day (level C). No greater efficacy was seen with doses higher than 480 mg/day (level B1).*

Medroxyprogesterone acetate: Effective appetite stimulant (level B1). Effect on weight was not confirmed (level C). The group recommended more clinical trials to establish optimal dose and duration of therapy.

Cyproheptadine: May be an appetite stimulant, but adverse effects were reported (level C).

Dronabinol, metoclopramide, nandrolone, pentoxifylline: No appetite-stimulating effects were shown (level C). These should be used only in the setting of RCTs.

Hydrazine sulfate: Not an appetite stimulant (level A).

Corticosteroids and progestogens can be used in the treatment of anorexia in patients with cancer, especially in patients with advanced disease and with any type of cancer. Hydrazine sulfate should not be used.

* Data from trials completed after 1999 establish the safety and efficacy of higher doses of megesterol acetate.