Wasting Syndrome
Treatment Advocacy Issues

Appetite Stimulation:
Medicinal Marijuana, Marinol, and Megace
by Nelson Vergel and Michael Mooney (Issue # 7, October, 1998)

Appetite stimulants can be an important part of the optimal approach to increasing lean body mass in HIV. However, all appetite stimulants are not equal in their effects on your overall health and well-being. The first drug used for appetite in the early years of AIDS was Megace. The Medibolics article on Megace showed us that Megace should probably be relegated to the status of the problematic dinosaur drug that it is.

Recently, noted AIDS researcher Dr. Marc Hellerstein conducted a study to see if he could mitigate the negative effects Megace has on body composition by providing testosterone to males at 200 mg every two weeks with a standard 800 mg daily dose of Megace. What he found was that even testosterone's powerful effect on metabolism could not inhibit the effects that Megace has of increasing body fat and decreasing libido.

Although we support the use of marijuana for medicinal purposes, we are concerned with the damage that marijuana smoke can do to lungs. While marijuana's effects on appetite and nausea are noteworthy, marijuana smoke contains over 400 unusual compounds, including fungi and carcinogens. HIV(+) people who smoke marijuana have been documented as having an increased incidence of both fungal infections in the lungs and bacterial pneumonia. Furthermore, studies have shown that HIV(+) people who smoke marijuana may progress towards AIDS more rapidly, with a tendency towards increased opportunistic infections, including Kaposi's Sarcoma.1-3 Smoking marijuana has also been shown to significantly reduce the ability of the immune components in the lungs to kill fungi, bacteria, and tumor cells, as well as decrease the lung tissue's ability to produce protective cytokines.4

While marijuana can also contain herbicides that are immunosuppressive, perhaps most problematic is the fact that marijuana contains about 30 percent more tar than tobacco, and marijuana smoking can decrease blood oxygen by about 50 percent more than tobacco.5 Cancer thrives in low oxygen environments, so the tar and cancer-promoting potential of tobacco smoke should make any HIV(+) person avoid smoking marijuana. If you do choose to use marijuana to increase appetite or reduce nausea, eat it, do not smoke it. See official recommendations for investigation of medical marijuana.

Marinol (dronabinol) is the other well-known pharmaceutical appetite stimulant that is prescribed for HIV. Chemically, it is a pure version of the most well-known active ingredient in marijuana called THC (delta-9-tetrahydracannabinol). Unlike marijuana, Marinol is an oral drug that can be prescribed by the doctor in three different dosages (2 , 5, and 10 mg capsules), so your doctor can titrate the dosage to maximize benefits while minimizing the rather benign side effects that can occur, including sleepiness, thinking abnormalities, and euphoria. (Not a bad side effect.)

In studies, Marinol treatment significantly improved appetite in people with HIV, while trends toward improved body weight and mood, and decreases in nausea and vomiting were also seen.6 (Marinol has recently been approved to treat nausea in cancer.) It can, however, take from 20 to 40 minutes to get enough absorption of the drug in the blood stream to feel the benefits. That is why it is generally agreed that if you're having severe nausea that is unpredictable, you may want to use one of the standard anti-enemics, because they can work more quickly. However, if your nausea is predictable (as when Crixivan is taken on a empty stomach), you should consider Marinol.

Marinol has not been observed to decrease sex drive, decrease testosterone, or cause any of the adverse effects produced by Megace. However, there are a few things you should know when starting this therapy so that benefits can be maximized while minimizing side effects.

If you are considering starting Marinol to improve your appetite, it is generally recommend that you begin on a Friday night so that you have the weekend to acclimate to the effects of the drug in case you do experience side effects. For most people side effects subside after about three days. Most physicians will start you at 2.5 mg twice a day, to be taken 1 hour before lunch and 1 hour before dinner. If side effects like feeling stoned do not decrease during the first three days, the dosage should be reduced to 2.5 mg once per day, usually taken 1 hour before dinner. This can also make it easier to sleep after dinner.

We have also known a few rare people for whom the 2.5 milligram (mg) dose is too much, so they poke a hole in the capsule with a pin and squeeze out half of the dose. This works to give them the right dose for improved appetite and more restful sleep.

The appetite-stimulating effect can last for over 10 hours, so you will probably have a good dinner and wake up feeling hungry for breakfast, too. We also tell PoWeR clients who want to start this therapy to try not to eat junk food when your appetite increases. Make sure to stock your kitchen cupboards with nutritious high-protein snacks so that you have healthy bodybuilding foods handy when this happens. Marinol will help you gain good-quality lean body mass optimally if it is combined with a healthy, whole-foods diet that is high in protein, regular exercise as weight-training, and hormonal therapies like testosterone, when appropriate. With the greater appetite that Marinol can give you, if you do not lift weights to stimulate muscle growth and burn calories you may very well increase your body fat instead of muscle.

Easy Access
Another advantage Marinol has over marijuana is that Marinol is easily accessed because it can be paid for by your own insurance, Medicaid, most state drug assistance programs, and by Roxane Laboratories' Compassionate Use Program (1-800-274- 8651).

1. Denning, DW, et al. Pulmonary Aspergillosis in AIDS. N Eng J Med (1991) 324:654-662.
2. Tindall, B, et al. The Sidney AIDS Project: development of acquired immunodefficiency syndrome in a group of HIV seropositive homosexual men. Aust N Z J Med (1988) 18:8-15.
3. Caiffa, WT, et al. Drug smoking, Pneumocystis carinii pneumonia, and immunosuppression increase risk of bacterial pneumonia in human immunodeficiency virus-seropositive drug users. Am J Respir Crit Care Med (1994) 150:1493-1498.
4. Sherman, MP. Anti-microbial respiratory burst characteristics of pulmonary alveolar macrophages recovered from smokers of marijuana alone, smokers of tobacco alone, smokers of marijuana and tobacco, and nonsmokers. Am Rev Respir Dis (1991) 144:1351-1356.
5. Schwartz, RH, et al. Marijuana to prevent nausea and vomiting in cancer patients: a survey of clinical oncologists. South Med J (1997) 90(2):167-172.
6. Beal, JE, et al. Dronabinol as a treatment for anorexia associated with weight loss in patients with AIDS. J Pain Sympt Man (1995) 10:89-97.


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