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Should I prescribe megestrol in COPD?

Q - A consultant has started prescribing megestrol (Megace) for people with COPD to make them put on weight. Why is this drug used, and how long for? As it isn't licenced for this, should I take over the prescribing?

A - Malnutrition occurs in half of patients with COPD in several series and carries a poor prognosis. Nutritionists and dietitians can improve nutrition by supervising small liquid feed supplements at intervals in the day and night-time feeds through microbore tubes into the stomach.

In 1995 a trial of four injections of nandrolone over an eight-week period as well as nutritional supplementation showed a mean additional 2.5kg weight gain in patients with COPD.

Megestrol acetate (Megace) is a progestogen with a product licence for treatment of endometrial cancer and was used in the treatment of breast cancer and renal cell cancer.

It can be given by mouth. Side-effects include menstrual disturbances, premenstrual-like effects, weight gain and nausea. Drowsiness and depression can occur and skin reactions have also been reported. Progestogens must be used with caution in patients with pre-existing conditions that may worsen with fluid retention and in those susceptible to thromboembolic disease.

Neither nandrolone nor megestrol has a product licence for the treatment of malnutrition in patients with COPD and both can cause serious side-effects.

The GP should politely point out to the consultant that they (the GP) have no experience of the use of the drug in this condition and such prescription is outside the product licence.

The patient should be told such treatment is outside the licensed indication, informed of common or severe side-effects and their agreement to take it recorded.

Dr Richard Pearson, consultant physician in clinical pharmacology, Haroldwood and Oldchurch Hospitals, Haroldwood, Essex

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