Weight Gain in Patients with AIDS-Related Cachexia: Is Bigger Better?

When I was serving recently as the teaching attending in a general medical ward team, the most heated disagreements were about the nutritional support of a patient with the acquired immunodeficiency syndrome (AIDS). He had decreased appetite and oral intake leading to a modest loss of body weight in association with other typical complications of AIDS. He was awaiting—no, demanding—placement of a central venous catheter for hyperalimentation. Aware that weight loss was associated with shortened survival in AIDS, he was adamant about delaying his death by increasing his caloric intake. As an oncologist who works with patients with cancer who have cachexia caused by malignancy and have wasting from multiple disease-related causes, I was aware of the controversies surrounding the level of supportive care of the terminally ill. I was unprepared, however, for the passionate debate that this patient with AIDS engendered among the ward team. What right did this patient have to demand an expensive, complex therapy? How exactly could treatment improve his life? Could the complications of total parenteral nutrition shorten his survival? Where were the data? Although we all had opinions about these medical and ethical issues, we had few data on which to base our opinions about the expenses and the legitimate outcomes of preventing weight loss in this patient.

In this issue, two randomized, placebo-controlled clinical trials [1, 2] are reported in which high doses of megestrol acetate were given to patients with AIDS. The most common side effect of progestational agents in patients with metastatic breast cancer is weight …