Which is best syrup to increase appetite in normal patient assessed per Harrison
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I now have the full, direct Harrison's answer. Here is what it says:
Appetite Stimulants per Harrison's Principles of Internal Medicine (22nd Edition, 2025)
Important framing first: Harrison's does NOT discuss appetite stimulant "syrups" for healthy/normal patients. The coverage is specifically for patients with anorexia and cachexia - primarily in the context of cancer or serious illness. For a truly "normal" patient with no underlying disease, Harrison's does not recommend pharmacologic appetite stimulants.
For patients with anorexia/cachexia (e.g., cancer-related), here is what Harrison's says:
First-Line Agent: Olanzapine (NOT a syrup)
- Recommended as the first-line agent with "good evidence of benefit without potentially serious harm."
- In the largest RCT (124 solid tumor patients), olanzapine 2.5 mg at bedtime led to ≥5% weight gain in 60% of patients vs. only 9% in the placebo group (p <0.001).
- Given as a low-dose oral tablet at bedtime.
Other Agents Harrison's Mentions:
| Drug | Harrison's Comment |
|---|---|
| Megestrol acetate | Does increase appetite and cause some weight gain, but has untoward side effects (thromboembolism, hyperglycemia, edema) and does not improve survival. Not first-line. |
| Corticosteroids | Also increase appetite and cause some weight gain, but same caveats - side effects and no survival benefit. |
| Mirtazapine | Commonly prescribed but shown to be ineffective in a large RCT. Harrison's says it should NOT be used. |
| Dietary counseling | Recommended as a reasonable non-pharmacologic option; modest weight gain benefit. |
| Ponsegromab (anti-GDF-15 monoclonal antibody) | Investigational - promising phase 2 RCT data for cachexia, but not yet FDA approved. |
What Harrison's Explicitly Does NOT Recommend:
- Enteral feeding tubes and IV nutrition - not recommended routinely.
- Mirtazapine - explicitly stated as ineffective.
- No commercial "appetite syrup" (cyproheptadine syrups, etc.) is listed as evidence-based in Harrison's.
Bottom Line
Per Harrison's 22e (2025), olanzapine 2.5 mg at bedtime is the only appetite stimulant with strong RCT evidence and an acceptable safety profile. Megestrol acetate is a second option that works but carries significant risks. The concept of giving an "appetite syrup" to a normal/healthy patient is outside Harrison's scope - it does not endorse this practice, and the evidence-base for over-the-counter appetite syrups (like cyproheptadine-based preparations) is not addressed in this reference.
- Harrison's Principles of Internal Medicine 22E, p. 552 (Anorexia and Cachexia - Treatment)
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