Megestrol acetate for the palliation of anorexia in advanced, incurable cancer patients

A novel megestrol acetate electrochemical sensor based on conducting functionalized acetylene black-CeO2NPs nanohybrids decorated glassy carbon microspheres

For the first time, megestrol acetate (MGA), a synthetic progestin with therapeutic use in breast cancer, is electrochemically studied to propose a new electroanalytical alternative for its detection in real samples. In the present work, a novel electrochemical sensor based on functionalized acetylene black-CeO₂NPs nanohybrids modified glassy carbon microspheres paste electrode (FAB-CeO₂NPs/GCMPE) was successfully fabricated and used for sensitive determination of MGA. The modified electrode has been characterized using scanning electron microscope (SEM), cyclic voltammetry (CV) and electrochemical impedance spectroscopy (EIS). The electrocatalytic reduction of MGA using FAB-CeO₂NPs/GCMPE was carried out via CV and square wave voltammetry (SWV). By employing FAB-CeO₂NPs/GCMPE, the SWV signal of MGA reduction was 8 fold higher than the bare GCMPE. A wide concentration range from 4.20 × 10^-8 to 1.13 × 10^-6 M with the low LOD of 1.30 nM for MGA was achieved. The practical analytical utilities of the prospective FAB-CeO₂NPs/GCMPE sensor were demonstrated successfully by the detection of MGA in Megace tablets, human serum and urine samples obtained from healthy and patient volunteers after oral administration of 160 mg Megace tablets. HPLC method was also developed for comparison with the electroanalytical method.

Pharmacological management of cachexia in adult cancer patients: a systematic review of clinical trials

Background

Cachexia is a multisystem syndrome characterized by weight loss, anorexia, loss of muscle mass, systemic inflammation, insulin resistance, and functional decline. Management of cachexia involves addressing multiple underlying biological mechanisms. Previous review on pharmacological management of cancer cachexia identified progestins and corticosteroids as effective agents for treatment of cachexia. However, to date no consensus exists on a single effective or standard treatment for management of cachexia. The aim of this systematic review is to determine the effectiveness of pharmacological treatments used to manage cachexia among adult cancer patients.

Methods

We performed literature searches of PubMed (NLM), Embase (Ovid), and Medline(Ovid) to identify clinical trials focused on pharmacological management of cancer cachexia among adult cancer patients from 2004 to 2018. Three reviewers screened a random selection of abstracts to measure for interrater reliability. After this step, each screener screened two-thirds of all abstracts and 177 studies were identified for full text review. The primary outcome was impact of pharmacological management on change in either weight or lean body mass in cancer patients.

Results

We identified 19 articles (representing 20 RCTs) that focused on pharmacological management of cancer cachexia. Agents showing promising results included Anamorelin and Enobosarm. Anamorelin at 50 or 100 mg per day for 12 weeks showed a consistent benefit across all studies and resulted in significant improvement in weight as compared to baseline among cancer patients. Enobosarm at 1 and 3 mg per day was also effective in improving lean body mass and QOL symptoms among advancer stage cancer patients. Finally, use of combination agents provide evidence for targeting multiple pathways underlying cachexia mechanism to achieve maximum benefit. No agents showed functional improvement in cancer patients.

Conclusion

Anamorelin as a single agent shows promising results in improving cachexia related weight loss among cancer patients. Further research on combination therapies may be helpful to address critical gaps in cachexia management.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-5080-4) contains supplementary material, which is available to authorized users.

Fabrication of Eudragit polymeric nanoparticles using ultrasonic nebulization method for enhanced oral absorption of megestrol acetate

Megestrol acetate (MGA) is used as a progestagen to treat advanced cancers in the breast or uterus and anorexia-cachexia syndrome in cancer patients. Due to its low solubility (BCS class II), MGA bioavailability needs to be enhanced for efficacy and safety. We developed MGA-encapsulated Eudragit^® L100 (EUD) nanoparticles (MGA-EUD (1:1) and MGA-EUD (2:1)) using an ultrasonic nebulization method. MGA-EUD (1:1) and MGA-EUD (2:1) consisted of MGA and EUD at the mass ratios of 1:1 and 2:1. Their physicochemical properties, i.e. particle size, loading efficiency, morphology, and crystallinity were determined. Dissolution tests were performed using USP method II. For pharmacokinetics, they were orally administered at 50 mg/kg to mice. Microcrystalline MGA suspension (MGA-MC, Megace^®, BMS) was used as control. MGA-EUD (1:1) and MGA-EUD (2:1) had a smooth and spherical shape of 0.70 and 1.05 µm in diameter with loading efficiencies of 93 and 95% showing amorphous states of MGA. They significantly enhanced the dissolution potential of MGA. Oral bioavailability of MGA-EUD (1:1) and MGA-EUD (2:1) increased 2.0- and 1.7-fold compared to that of MGA-MC. It suggests that ultrasonic nebulization method for the fabrication of polymeric nanoparticles is a promising approach to improve the bioavailability of poorly soluble drugs.

LC-MS/MS method for determination of megestrol in human plasma and its application in bioequivalence study

A rapid and highly selective liquid chromatography-tandem mass spectrometric (LC-MS/MS) method for the determination of megestrol in human plasma was described using medrysone as internal standard (IS). Blood samples were collected from 20 healthy volunteers after oral administration of 160 mg megestrol acetate dispersible tablets. The analytes were extracted by liquid-liquid extraction procedure and separated on a hanbon lichrospher column with the mobile phase of methanol and water containing 0.1% formic acid and 20 mmol/L ammonium acetate (5:1, v/v). Positive ion electrospray ionization with multiple reaction-monitoring mode (MRM) was employed by monitoring the transitions m/z 385.5-325.4 and m/z 387.5-327.4 for megestrol and medrysone, respectively. Under the isocratic separation conditions, the chromatographic run time was approximately 2.54 min for megestrol and 2.59 min for medrysone. The calibration curve range was from 0.5 to 200.0 ng/mL. The inter-batch and intra-batch precision and accuracy were less than 5.2% relative standard deviation (RSD) and 6.4% relative error (RE). The proposed method was successfully applied in the bioequivalence study of megestrol acetate dispersible tablets.

Safety of megestrol acetate in palliating anorexia-cachexia syndrome in patients with castration-resistant prostate cancer

There are concerns whether megestrol acetate (MA) stimulates the growth of prostate cancer in castration-resistant prostate cancer (CRPC). We evaluated the effect of cumulative doses of MA on the disease-specific survival (DSS) in patients with CRPC who were receiving Docetaxel-based chemotherapy. From July 2003 through June 2009, we identified 109 consecutive patients with CRPC and who had received docetaxel-based chemotherapy. Of these patients, 68 (62.4%) have not received MA, whereas 21 patients (19.3%) and 20 patients (18.3%) had received low dose MA (total ≤ 18,400 mg) and high dose MA (total > 18,400 mg), respectively. We assessed the effect of several variables on DSS. None of the clinicopathological variables differed among the three groups. When comparing DSS using Kaplan-Meier analysis, there was no statistically significant survival differences among the three groups (P = 0.546). Using multivariate Cox proportional analyses with backward elimination, the number of docetaxel cycles was only significant factor predicting DSS (HR: 0.578, 95% CI: 0.318-0.923, P = 0.016). Cumulative doses of MA as adjuvant treatment for patients with CRPC and who are receiving docetaxel-based chemotherapy, did not affect their DSS. Therefore, MA can be safely administered in cachexic patients with CRPC.

Megestrol acetate for treatment of anorexia-cachexia syndrome

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.

Enhanced dissolution of megestrol acetate microcrystals prepared by antisolvent precipitation process using hydrophilic additives

Microcrystals of megestrol acetate (MA), a poorly water-soluble drug, were successfully prepared using an antisolvent precipitation technique for improving the dissolution rate. The effective hydrophilic polymers and surfactants used were screened for their abilities to produce smaller particle sizes. Raw micronized MA and processed MA microcrystals were ranked by the Student-Newman-Keuls test in order of increasing particle size and SPAN values as follows: processed MA microcrystals in the presence of polymer and surfactant (mean diameter 1048nm)<processed MA microcrystals in the presence of polymer (1654nm)<processed MA microcrystals in the absence of polymer and surfactant (3491nm)<raw micronized MA (4352nm). The order of BET surface area was reversely ranked. Processed MA microcrystals in the presence of polymer and surfactant slightly decreased crystallinity and altered crystal habit and preferred orientation without change in polymorph. In addition, the dissolution properties of the processed MA microcrystals in the presence of polymer and surfactant were significantly enhanced as compared to that of the raw micronized MA. This effect is mainly due to a reduction in particle size resulting in an increased surface area. Therefore, it was concluded that the antisolvent precipitation technique in mild conditions could be a simple and useful technique to prepare poorly water-soluble drug particles with reduction in particle size, a narrow particle size distribution and enhanced dissolution properties.

A placebo-controlled, double-blind trial of infliximab for cancer-associated weight loss in elderly and/or poor performance non-small cell lung cancer patients (N01C9)

PURPOSE

This study tested whether infliximab, a chimeric IgG1kappa monoclonal antibody that blocks tumor necrosis factor (TNF) alpha, improves/stabilizes weight loss in elderly and/or poor performance status patients with metastatic non-small cell lung cancer (NSCLC).

METHODS

This double-blind trial randomly assigned patients to infliximab/docetaxel (n=32) versus placebo/docetaxel (n=29). The primary endpoint was > or = 10% weight gain.

RESULTS

Groups were balanced with respect to age, number of prior chemotherapy regimens, baseline weight loss, and performance status. No patient gained > or = 10% baseline weight, and early evidence of the lack of efficacy prompted early trial closure. Appetite improvement was negligible in both arms. However, infliximab-/docetaxel-treated patients developed greater fatigue and worse global quality of life scores. Other outcomes, such as tumor response rate (<10% in both groups) and overall survival, were not statistically different between groups. There were no statistically significant differences in adverse events, although one death was attributed to infliximab. Genotyping for the TNF alpha -238 and -308 polymorphisms revealed no clinical significance of these genotypes, as relevant to the loss of weight or appetite.

CONCLUSIONS

This trial closed early because infliximab did not prevent or palliate cancer-associated weight loss. Infliximab was associated with increased fatigue and inferior global quality of life.

[Evaluating the nutritional status of a lung cancer patient is an important element in patient management]

Nutritional status assessment during the comprehensive management of patients treated for cancer is becoming increasingly necessary. Various data are currently available which show a relationship between the nutritional status and certain morbidity-mortality parameters. In contrast, there is a paucity of data concerning lung cancer. A relationship between survival and the nutritional status has been found in the literature, exclusively in advanced stages of lung cancer. Unlike that observed in oncological digestive tract surgery, where artificial nutrition is recommended preoperatively in severely malnourished patients, no link has been evidenced between postoperative morbidity and mortality and the preoperative nutritional status in lung surgery. The scientific nutritional societies simply recommend preoperative nutritional assessment. Reflection on management of malnourished patients receiving chemotherapy is still "archaic" and recent studies and recommendations are lacking. Although largely prescribed, oral nutritional supplements have not proven efficient and patient compliance will probably have to be improved. According to "good nutrition practice" rules, the digestive tube should be used when it is functional and in theory, enteral nutrition is indicated in this situation. In addition to the lack of clinical studies, one of the obstacles to its use is cultural with the need to obtain not only patient approval but also that of the prescriber. Parenteral nutrition was discredited in earlier studies. It should probably be reevaluated in the context of new chemotherapeutic molecules and a different way of handling nutrition care. The physiological concept of omega-3 fatty acid modulation of inflammation is of interest in animal studies but the clinical modalities of use remain to be defined and determined. The role of nutrition in the management of lung cancer is still very limited but there are major expectations and many solutions are awaited in the coming years.

Supportive care for women with gynecologic cancers

Supportive care is a multidimensional field, that involves caring for a patient's symptoms either during and/or after treatment. Ideally, once these supportive care needs are met, patients can enjoy an improved quality of life. Supportive care needs include all body systems, and are, therefore, difficult to manage, secondary to the fact that they require collaboration among multiple medical specialties. In this review, several components of supportive care are separated into two categories: tumor-related morbidities and treatment-related morbidities. Some of the themes discussed include nausea and vomiting, cancer pain, psychological distress, fatigue and anemia, small bowel obstruction and peripheral neuropathy. While all of these components are challenging to manage, it is perhaps the psychosocial realm that remains the most unmet need. Regardless, the oncologist must act as a facilitator who addresses these needs and, if unable to address the issue alone, knows how to steer the patient toward the appropriate provider. As these needs are met, the goal is for quality of life to improve; and with the improvement in quality of life we may expect to see improved survival outcomes.