Tuesday, June 28, 2005

Megestrol use in nursing homes.Are we treated the chart?

Megestrol acetate ( Megace ) at a dose of 800 mg/day was shown in a RCT in patients with AIDS related cachexia to stimulate appetite, increase food intake and bring about weight gain that appeared to be nonfluid weight gain. Since one of the quality indicators monitored by state agencies in nursing homes is weight loss, it is not surprising that there would be interest in megestrol use in that setting. A clinical trial of megestrol in nursing home patients was reported in 2001 by Yeh et al. The results are interesting but hard to explain mechanistically.After 12 weeks of 800mg/day there was no change in weight but reportedly better appetite and sense of well being but 3 months after treatment was stopped, the treatment group had more weight gain.Could there have been some lingering appetite stimulating effect that lead to weight gain? Yeh et al have suggested that megestrol might decrease cytokines which have been implicated as one factor in the weight loss syndrome of the frail and elderly. More recently Simmons et al report a small study (n=17) where there was no increase in food intake under "usual" nursing home care but there was a significant increase in food intake when combined with " optimal mealtime feeding assistance" The abstract made no mention weight measurements. Also from the abstract one cannot tell the real operational difference between the two feeding approaches. So it seems fair to say neither of these trials were associated with significant weight gain, yet from my experience there is a definite tendency for nursing home staff to encourage its use. The data supporting its use are scarce and in journals not widely read, how do nursing home nursing staff know about it? Could drug detailing play a role. You think? Or is is it that docs who see patients in nursing homes have learned that megestrol really works and they have transmitted their experience through staff meetings and informal consultations with primary care doctors?
My 94 year aunt has been a nursing home patient for 3 years. With progressive vascular dementia and probably Alzheimer's disease, her apraxia had progressed to the point at which she could not regularly feed herself. Her weight began to fall and the nursing home nursing supervisor contacted the attending physician and Megace was ordered on the nurses suggestion. Apparently this is standard operating procedure there.Over the next several months her weight increased and bilateral edema to midthigh was finally acted upon when he developed acute pulmonary edema. I believe the fluid retaining properties of megestrol played a role in tipping her over into CHF. So important is the imperative to not have nursing home patients loose weight, several weeks later the nurses wanted to restart megestrol. I was able to intervene and her chf has been well compensated for the last 5 months. Venous thromboembolism may well be a more concerning side effect in general but in this case, I think, megestrol lead to her decompensation.
In conversations I have had with geriatric docs and NPs who attend at nursing homes, megestrol is fairly widely used ( I realize this is not much of a scientific survey) and the 2 academic geriatric physicians I contacted both discourage its use because of lack of proof of efficacy and the concern for thromboembolism and fluid retention. Monitoring nursing home patients for weight loss by state regulatory agencies concerns nursing home personnel and use of Megace is appealing. How effective this off-label use may be is another matter. Data are scarce and the prevalence of its use seems disproportionate to evidence supporting its safety and efficacy.They may be trying to treat the chart but if it doesn't work they are not even doing a good job of that.

1 comment:

Anonymous said...

Consider that your relative has Lyme Disease, not Alzeihmer's. A negative test does not mean the patient is Lyme-free. Columbia University has never autopsied an Alzeihmer's brain without finding the Spiros.