Question: Dear Dr.

I am writing this inquiry on behalf of my 85 year-old sister who lives in XXXXXXX XXXXXXX Over the past two years, my sister's appetite has waned considerably to the point that she is not interested in food anymore. She desires to eat, and wishes she had a stronger appetite, but usually only eats a few bites at some mealtimes. She is existing mainly on consuming 3 cans of Boost every day.

She has pursued a thorough medical (physiological) evaluation with her GP, her cardiologist, her pulmonologist (she has COPD), and her gastroenterologist. All findings have been normal and they each have suggested no further tests are warranted. Interestingly, none of the doctors are pushing her to gain weight because of the COPD condition. She has been maintaining 100-106 pounds, height about 5'5". Recently she was referred to an internist who deals with eating disorder patients and stated that he concurs with the mentioned doctors' exam results and states, "Many older people have eating disorders and she has to accept that her problem is permanent and she must accept this fact."

It appears to me that there is a good possibility that she may suffer from a hormone deficiency that could be suppressing her appetite. Maybe, though extensive testing by an Endocrinologist may discover her problem area. For example could Leptin and Ghrelin hormones regulation be a restrictor of her appetite?

Would it be possible for you or some recommended specialist in the endocrine field consider seeing my sister?

I would appreciate your assistance and reply when you have time. Thanking you in advance for your consideration in regard to my concerns.

Dr. Bhavsar, thank you for your comments. They do appear relevant to my sister's medical situation. I address my question to the Internet Health Care organization, in which you are a consulting doctor. Is there a possibility that there might be a XXXXXXX XXXXXXX Endocrinologist that you may contact on my behalf, and might subsequently see my sister. Also, understanding what you have related, Dr. Bhavsar, could it possibly be in my sister's interest if she did receive a full battery of tests relating to her total hormone and endocrine system - that might add more specificity to my sister's medical situation and thus provide even more specific steps she could take in helping her gain a better appetite. I would appreciate your Internet organization's help in regard to my specific request. Thank you for your continued assistance. Jim Young

Dr. Bhavsar, thank you for your follow-up answer. I didn't expect you, personally, to help me locate a recommended XXXXXXX XXXXXXX endocrinologist. I hope your HealthcareMagic organization can assist me in this endeavor.

First, I am gratetful for the "syrup containing cyproheptadine" recommendation. However, I would not have a clue as to what specific syrup to recommend to my sister. Would a prescription be required? Finally, this information should be relayed to a doctor, who would be sympathetic to my sister's needs. As you can determine from my original e-mail, her current doctors have pretty much given up on her eating disorder problem. This is why I am pushing toward an endocrinologist or another specialist who has a speciality in eating disorders.

Hopefully, you can ask HealthcareMagic to consider and help me find a specialist. Even a referral to a general medical agency in XXXXXXX who could recommend a specific specialist, would help.

Please don't give up on me and my sister. You have provided some help.

Thank you for any additional assistance you may provide reference this request.
Jim Young

Thank you, Dr. Bhavsar, for your most recent reply. I googled to see if your suggested Syrup Activate, Syrup Aptirich, and Syrup CT plus were known, in some
capacity, in the United States. Goggle could not identify these suggested ingredients. Would it be possible for the Healthcaremagic Team to work with you in identifying what the XXXXXXX version would be? Second, I was glad to hear that the Healthcaremagic Team will help me in identifying a healthcare specialist in XXXXXXX XXXXXXX preferably an endocrinologist with specific eating disorder experience, that might be able to meet and work with my sister. Thank you all for your continued assistance.

Dr. Bhavsar, in reply to your last message, I am sending you information regarding cyproheptadine containing syrup for appetite products in America:

Subject: Cyproheptadine Products

Approved Over the Counter Products     
Show entries
Name     Dosage     Strength     Route     Labeller     Marketing Start     Marketing End     
Cyproheptadine 4mg Tablets     Tablet     4 mg     Oral     Jamp Pharma Corporation     2010-05-03     Not applicable     Canada
Euro-cyproheptadine 2mg/5ml     Syrup     2 mg     Oral     Sandoz Canada Incorporated     2003-05-27     Not applicable     Canada
Euro-cyproheptadine 4mg/tablet     Tablet     4 mg     Oral     Sandoz Canada Incorporated     2006-06-05     Not applicable     Canada
Jamp Cyproheptadine Syrup     Syrup     0.4 mg     Oral     Jamp Pharma Corporation     Not applicable     Not applicable     Canada
Periactin Syr 2mg/5ml     Syrup     2 mg     Oral     Merck Frosst Canada & Cie, Merck Frosst Canada & Co.     1961-12-31     2002-07-29     Canada
Periactin Tab 4mg     Tablet     4 mg     Oral     Merck Frosst Canada & Cie, Merck Frosst Canada & Co.     1961-12-31     2002-07-29     Canada
PMS-cyproheptadine HCl Tab 4mg     Tablet     4 mg     Oral     Pharmascience

I have also researched what XXXXXXX doctors are saying about the use of stimulants for the older people:



FAST TRACK
The only national guideline on weight loss in the elderly does not recommend medication as the first-line treatment
Evidence summary

Although a number of studies have evaluated various appetite stimulants—megestrol, dronabinol (Marinol), cyproheptadine (Periactin), thalidomide (Thalomid), pentoxifylline (Pentoxil/Trental), nandrolone decanoate (DecaDurabolin), oxandrolone (Oxandrin), and corticosteroids—in patients with AIDS, anorexia cachexia syndrome, and advanced cancer, only megestrol has been studied in malnourished elderly patients.
Recommendations from others

The XXXXXXX Geriatric Society4 made 3 comments on appetite stimulation:
There are no FDA-approved drugs available for the promotion of weight gain in older adults.
A minority of patients receiving mirtazapine report appetite stimulation and weight gain.
All drugs used for appetite have substantial potential adverse events.
We found only 1 national guideline on this topic: Unintentional Weight Loss in the Elderly from the University of XXXXXXX School of Nursing.5 The guideline indicates that drugs should not be used as first-line intervention in the elderly, as there has been inadequate testing in this population. Benefits are restricted to small weight gains without indication of decreased morbidity or mortality, improved quality of life, or improved functional ability.
Only 1 appetite stimulate, megestrol acetate oral suspension (Megace) at 400 mg or 800 mg daily, has been studied in this population. The data show only limited benefit, mixed outcomes, and potential harm (strength of recommendation: B, based on small, randomized, controlled trials).

I will appreciate your response to my research. Also, I would appreciate Healthcare Magic sending me a listing of recommended endocrinologists specializing in eating disorders, particular for older people, in the XXXXXXX XXXXXXX area.

Thank you for your continued assistance. Jim Young