Megestrol

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Megestrol
Names
Trade namesMegace, others
Other namesMegestrol acetate, MGA; BDH-1298; NSC-71423; SC-10363; 17α-Acetoxy-6-dehydro-6-methylprogesterone; 17α-Acetoxy-6-methylpregna-4,6-diene-3,20-dione
  • [(8R,9S,10R,13S,14S,17R)-17-acetyl-6,10,13-trimethyl-3-oxo-2,8,9,11,12,14,15,16-octahydro-1H-cyclopenta[a]phenanthren-17-yl] acetate
Clinical data
Drug classProgestogen; Progestin
Main usesCachexia, breast cancer, endometrial cancer[1]
Side effectsWeight gain, vaginal bleeding, nausea, high blood pressure, high blood sugar, rash[1]
Pregnancy
category
  • US: X (Contraindicated)
Routes of
use		By mouth (tablets, suspension)
External links
AHFS/Drugs.comMonograph
Legal
Legal status
  • In general: ℞ (Prescription only)
Pharmacokinetics
Bioavailability100%[2]
Protein binding82% to albumin,[3] no affinity for SHBG or CBG[2][4]
MetabolismLiver (hydroxylation, reduction, conjugation)[5]
Elimination half-lifeMean: 34 hours[6]
Range: 13–105 hours[6]
ExcretionUrine: 57–78%[5]
Feces: 8–30%[5]
Chemical and physical data
FormulaC24H32O4
Molar mass384.516 g·mol−1
3D model (JSmol)
  • CC1=C[C@@H]2[C@H](CC[C@]3([C@H]2CC[C@@]3(C(=O)C)OC(=O)C)C)[C@@]4(C1=CC(=O)CC4)C
  • InChI=1S/C24H32O4/c1-14-12-18-19(22(4)9-6-17(27)13-21(14)22)7-10-23(5)20(18)8-11-24(23,15(2)25)28-16(3)26/h12-13,18-20H,6-11H2,1-5H3/t18-,19+,20+,22-,23+,24+/m1/s1
  • Key:RQZAXGRLVPAYTJ-GQFGMJRRSA-N

Megestrol (MGA), sold under the brand name Megace among others, is a medication mainly used as an appetite stimulant to treat wasting syndromes such as cachexia.[1] It is also used to treat breast cancer and endometrial cancer, and has been used in birth control.[1][7] MGA is generally formulated alone, though has been combined with estrogens in birth control.[1][7] It is usually taken by mouth.[1]

Common side effects include weight gain, vaginal bleeding, nausea, high blood pressure, high blood sugar, and rash.[1] Other side effects may include blood clots.[1] Use during pregnancy or breastfeeding may harm the baby.[1] It is a manufactured progestin.[1] How it brings about weight gain is unclear.[1]

Megestrol was patented in 1959 and introduced for medical use, specifically in birth control pills, in 1963.[7][8] It is available as a generic medication.[1] In the United Kingdom 30 tablets of 160 mg costs the NHS about £20 as of 2021.[9] This amount in the United States costs about 23 USD.[10] It is sold in many countries globally.[11]

Medical uses

MGA is used mainly as an appetite stimulant to promote weight gain in a variety of situations.[12][13][14] When given at very high dosages, it can substantially increase appetite in most individuals, even those with advanced cancer, and is often used to boost appetite and induce weight gain in patients with cancer or HIV/AIDS-associated cachexia.[12] In addition to its effects on appetite, MGA appears to have antiemetic effects.[15][16] MGA is also used as an antineoplastic agent in the treatment of breast cancer and endometrial cancer.[12][17] It is significantly inferior to aromatase inhibitors in both clinical effectiveness and tolerability as a second-line therapy for breast cancer after tamoxifen failure.[18] MGA was formerly used in combined oral contraceptives in combination with ethinylestradiol or mestranol,[7][19][20] and has been used in a combined injectable contraceptive in combination with estradiol as well.[21]

Although it has not been approved for these uses, MGA has been studied and/or used off-label for a variety of indications including menopausal hormone therapy[22][23][24] and the treatment of hot flashes,[25][26][27][28] gynecological/menstrual disorders,[29][30] endometriosis,[31] endometrial hyperplasia,[32] ovarian cancer,[33][34][35][36] prostate cancer,[37][38][39][40][41][42][43] benign prostatic hyperplasia,[44][45] male breast cancer,[46] and precocious puberty.[5][47][48] MGA can also be used to treat pattern hair loss in men, but its side effects generally make it unacceptable for this purpose.[49]

Appetite stimulation is achieved with MGA with oral dosages of 400 to 800 mg/day.[50] The optimal dosage with maximum effect for appetite stimulation has been determined to be 800 mg/day.[51] The recommended oral dosage of MGA for breast cancer is 40 mg four times per day (160 mg/day total), while the medication is used at an oral dosage of 40 to 320 mg/day in divided doses for endometrial cancer.[50][6] It has been used at far lower dosages (e.g., 1–5 mg/day oral, 25 mg/month i.m.) in combination with an estrogen for contraceptive purposes.[7][19][20][21]

Available forms

See also: Estradiol/megestrol acetate and Ethinylestradiol/megestrol acetate

MGA is available as 5 mg, 20 mg, and 40 mg oral tablets and in oral suspensions of 40 mg/mL, 125 mg/mL, 625 mg/5 mL, and 820 mg/20 mL.[50][52] It was used at doses of 1 mg, 2 mg, 4 mg, and 5 mg in combined oral contraceptives.[7][19][20][21] MGA is formulated at a dose of 25 mg in combination with a dose of 3.75 mg estradiol in a microcrystalline aqueous suspension for use as a once-monthly combined injectable contraceptive in women.[21]

Contraindications

Contraindications of MGA include hypersensitivity to MGA or any component of its formulation, known or suspected pregnancy, and breastfeeding.[53] MGA is a teratogen in animals and may have the potential to cause fetal harm, such as decreased fetal weight and feminization of male fetuses.[53]

Side effects

The most common side effect of MGA is weight gain, with an incidence of 15 to 70% at the high dosages used to treat breast cancer.[6][5] Other side effects include vaginal bleeding (7–8%), nausea (7%), and edema (5%), as well as others such as dizziness and shortness of breath.[6][5][54] MGA can cause hypogonadism and associated symptoms like diminished secondary sexual characteristics, sexual dysfunction, osteoporosis, and reversible infertility in men and premenopausal women.[55][56][57] Combining MGA with an androgen/anabolic steroid like oxandrolone, nandrolone decanoate, or testosterone in men can alleviate MGA-associated symptoms of hypoandrogenism as well as further increase appetite and weight gain.[56][58][59][60] Less common but more serious side effects of MGA include cardiovascular/thromboembolic complications such as thrombophlebitis.[6] It may also cause glucocorticoid side effects such as Cushing syndrome-like symptoms, steroid diabetes, and adrenal insufficiency at high dosages.[61][62][63] Case reports of deep vein thrombosis, pulmonary embolism, jaundice, intrahepatic cholestasis, and meningiomas in association with high-dosage MGA have been published.[64][65][66][67] In older patients who take MGA, one in 23 will have an adverse event leading to death.[68]

Overdose

MGA has been studied at very high dosages of as much as 1,600 mg/day with no serious adverse effects observed.[53][69] No clear increase in rate or severity of side effects have been observed up to 1,600 mg/day MGA except for weight gain, mild increases in blood pressure, and some fluid retention.[69] In post-marketing experience, limited reports of overdose have been received.[53] Signs and symptoms described in these reports have included diarrhea, nausea, abdominal pain, shortness of breath, cough, unsteady gait, listlessness, and chest pain.[53] There is no specific antidote for overdose of MGA.[53] Treatment should be supportive and based on symptoms.[53] MGA has not been assessed for dialyzability.[53] However, due to its low solubility, it is thought that dialysis would not be useful for treating MGA overdose.[53]

Interactions

Interactions of MGA include significantly decreased exposure to indinavir, which may necessitate an increased dosage of the medication.[53] When MGA is co-administered with zidovudine and rifabutin, there is no significant change in exposure to these medications and no dosage adjustment is necessary.[53]

Pharmacology

(Proposed) megestrol acetate mechanism for weight gain (and side-effects.)[70]

Pharmacodynamics

MGA has progestogenic activity, antigonadotropic effects, weak partial androgenic activity, and weak glucocorticoid activity.[2][4][71]

Relative affinities (%) of megestrol acetate
Compound PR AR ER GR MR SHBG CBG
Megestrol acetate 65 5 0 30 0 0 0
Notes: Values are percentages (%). Reference ligands (100%) were promegestone for the PR, metribolone for the AR, estradiol for the ER, dexamethasone for the GR, aldosterone for the MR, dihydrotestosterone for SHBG, and cortisol for CBG. Sources:[2][4][71]
Relative affinities (%) of antiandrogens at steroid-hormone receptors
Antiandrogen AR PR ER GR MR
Cyproterone acetate 8–10 60 <0.1 5 1
Chlormadinone acetate 5 175 <0.1 38 1
Megestrol acetate 5 152 <0.1 50 3
Spironolactone 7 0.4a <0.1 2a 182
Trimethyltrienolone 3.6 <1 <1 <1 <1
Inocoterone 0.8 <0.1 <0.1 <0.1 <0.1
Inocoterone acetate <0.1 <0.1 <0.1 <0.1 <0.1
Flutamide <0.1 <0.1 <0.1 <0.1 <0.1
Hydroxyflutamide 0.5–0.8 <0.1 <0.1 <0.1 <0.1
Nilutamide 0.5–0.8 <0.1 <0.1 <0.1 <0.1
Bicalutamide 1.8 <0.1 <0.1 <0.1 <0.1
Notes: (1): Reference ligands (100%) were testosterone for the AR, progesterone for the PR, estradiol for the ER, dexamethasone for the GR, and aldosterone for the MR. (2): Tissues were rat prostate (AR), rabbit uterus (PR), mouse uterus (ER), rat thymus (GR), and rat kidney (MR). (3): Incubation times (0°C) were 24 hours (AR, a), 2 hours (PR, ER), 4 hours (GR), and 1 hour (MR). (4): Assay methods were different for bicalutamide for receptors besides the AR. Sources: See template.

Progestogenic activity

MGA is a progestogen, or an agonist of the progesterone receptor (PR).[2][71][72] It has about 65% of the affinity of promegestone and 130% of the affinity of progesterone for the PR.[71][72] Like other progestogens, MGA has functional antiestrogenic effects in certain tissues such as the endometrium and has antigonadotropic effects.[2][12][73] The total endometrial transformation dose of MGA is 50 mg per cycle.[73]

Parenteral potencies and durations of progestogens
Progestogen Form Major brand names Class TFD
(14 days)		 POIC-D
(2–3 months)		 CIC-D
(month)		 Duration
Algestone acetophenide Oil solution Perlutal, Topasel, Yectames Pregnane ? – 75–150 mg 100 mg ≈ 14–32 days
Cyproterone acetate Oil solution Androcur Depot Pregnane ? – – 300 mg ≈ 20 days
Dydrogesteronea Aqueous suspension – Retropregnane ? – – 100 mg ≈ 16–38 days
Gestonorone caproate Oil solution Depostat, Primostat Norpregnane 25–50 mg – – 25–50 mg ≈ 8–13 days
Hydroxyprogesterone acetatea Aqueous suspension – Pregnane 350 mg – – 150–350 mg ≈ 9–16 days
Hydroxyprogesterone caproate Oil solution Delalutin, Proluton, Makena Pregnane 250–500 mgb – 250–500 mg 65–500 mg ≈ 5–21 days
Levonorgestrel butanoatea Aqueous suspension – Gonane ? – – 5–50 mg ≈ 3–6 months
Lynestrenol phenylpropionatea Oil solution – Estrane ? – – 50–100 mg ≈ 14–30 days
Medroxyprogesterone acetate Aqueous suspension Depo-Provera Pregnane 50–100 mg 150 mg 25 mg 50–150 mg ≈ 14–50+ days
Megestrol acetate Aqueous suspension Mego-E Pregnane ? – 25 mg 25 mg ≈ >14 daysc
Norethisterone enanthate Oil solution Noristerat, Mesigyna Estrane 100–200 mg 200 mg 50 mg 50–200 mg ≈ 11–52 days
Oxogestone phenylpropionatea Oil solution – Norpregnane ? – – 100 mg ≈ 19–20 days
Progesterone Oil solution Progestaject, Gestone, Strone Pregnane 200 mgb – – 25–350 mg ≈ 2–6 days
Aqueous suspension Agolutin Depot Pregnane 50–200 mg – – 50–300 mg ≈ 7–14 days
Note: All by intramuscular or subcutaneous injection. All are synthetic except for P4, which is bioidentical. P4 production during the luteal phase is ~25 (15–50) mg/day. The OID of OHPC is 250 to 500 mg/month. Footnotes: a = Never marketed by this route. b = In divided doses (2 × 125 or 250 mg for OHPC, 10 × 20 mg for P4). c = Half-life is ~14 days. Sources: Main: See template.

Antigonadotropic and anticorticotropic effects

MGA has antigonadotropic effects in humans at sufficient doses, capable of profoundly suppressing circulating androgen and estrogen concentrations.[12][40][74][75][76][77] The antigonadotropic effects of MGA are the result of activation of the PR, which suppresses the secretion of the gonadotropins—peptide hormones responsible for signaling the body to produce not only progesterone but also the androgens and the estrogens—from the pituitary gland as a form of negative feedback inhibition, and hence downregulates the hypothalamic–pituitary–gonadal axis (HPG axis), resulting in decreased levels of the sex hormones and interference with fertility.[78] As such, MGA has functional antiandrogenic and antiestrogenic effects as well as contraceptive effects via its antigonadotropic effects.[47]

The precise ovulation-inhibiting dosage of MGA is unknown.[73][79] However, doses of 1 to 5 mg MGA were previously used in combined birth control pills in combination with the estrogen ethinylestradiol or mestranol.[7][19][20] MGA is an effective contraceptive by itself at dosages of 0.35 to 0.5 mg/day, but is not effective at a dosage of 0.25 mg/day.[47] MGA alone does not inhibit ovulation at a dosage of 0.5 mg/day, nor does it fully inhibit ovulation at a dosage of 0.7 mg/day or even at a dosage of 5 mg/day.[47][29][80] The combination of 2 to 5 mg/day MGA and 100 μg/day mestranol has been found to consistently inhibit ovulation, whereas either medication alone did not completely inhibit ovulation in all women.[29][81]

Suppression of testosterone levels by MGA is responsible for its effectiveness in the treatment of conditions like prostate cancer and benign prostatic hyperplasia.[47][82] In one study, 120 to 160 mg/day MGA suppressed testosterone levels in men by 72%.[76] However, a recovery or "escape" of testosterone levels, gradually returning to near-normal values, has been observed in most men after 2 to 6 months of MGA therapy, and this has limited the usefulness of the medication.[12][83][84][85] The combination of a lower dosage of MGA (40–80 mg/day) and a low oral dosage of an estrogen such as estradiol (0.5–1.5 mg/day), diethylstilbestrol (0.1–0.2 mg/day) or ethinylestradiol (50 µg/day) is able to suppress testosterone levels into the castrate range in men, maintain this suppression long-term, and achieve equivalent effectiveness to high-dosage estrogen monotherapy in the treatment of prostate cancer with comparatively greatly reduced toxicity and side effects.[47][12][40][41][83][86][87][88][89] In spite of these results, however, this combination has been very rarely used to treat prostate cancer in the United States.[83]

The antigonadotropic as well as anticorticotropic effects of MGA may be involved in its effectiveness in the treatment of postmenopausal breast cancer via substantially decreasing gonadal and adrenal production of sex steroids and by extension circulating levels of estrogens, by about 80%.[90][91][92]

Androgenic and antiandrogenic activity

MGA is a weak partial agonist of the androgen receptor (AR).[93][94][95] It has been reported to bind to this receptor with 5% of the affinity of the anabolic steroid metribolone.[2][4][71] Despite its weak intrinsic activity at the AR, at clinical doses in humans, MGA appears to behave, for all intents and purposes, purely as an antiandrogen.[96] This is based on the fact that no virilizing side effects have been observed with the use of MGA in patients of either sex at dosages up to as high as 1,600 mg per day, the highest that has been assessed.[96] Furthermore, MGA produces detectable androgenic effects in animals only at a dose that is the equivalent of approximately 200 times that typically used for the treatment of prostate cancer in men.[97] However, the medication does have moderate androgenic effects on serum lipids in humans, causing a significant reduction of HDL and LDL cholesterol levels and no change in triglyceride levels at a dosage of only 5 mg/day.[2] Conversely, MGA does not decrease SHBG levels.[98] The weak but significant androgenic activity of MGA may serve to limit its clinical effectiveness in the treatment of prostate cancer.[94][95][99][100]

Glucocorticoid activity

MGA is an agonist of the glucocorticoid receptor (GR), the biological target of glucocorticoids like cortisol.[2][4][71] It has been found to possess 30% of the affinity of the corticosteroid dexamethasone for this receptor.[2][4][71] MGA shows the lowest ratio of PR affinity to GR affinity of a broad selection of marketed progestins, suggesting that it may have among the highest relative glucocorticoid effect of the progestins used in medicine.[2] MGA produces observable glucocorticoid effects, with one study finding that, in the dose range tested, it possessed about 50% of the eosinopenic and hyperglycemic activity (markers of glucocorticoid activity) of an equal amount of medroxyprogesterone acetate and about 25% that of hydrocortisone.[101] Accordingly, manifestations of its glucocorticoid activity, including symptoms of Cushing's syndrome, steroid diabetes, and adrenal insufficiency, have been reported with the use of MGA in the literature, albeit sporadically.[61]

Appetite stimulation

MGA is frequently used as an appetite stimulant to promote weight gain.[12][13][14] The direct mechanism of appetite enhancement is unclear, but it is known that MGA induces a variety of downstream changes to cause the effect, including stimulation of the release of neuropeptide Y in the hypothalamus, neurosteroid-like modulation of calcium channels in the ventromedial hypothalamus,[102] and inhibition of the secretion of proinflammatory cytokines including interleukin 1α, interleukin 1β, interleukin 6, and tumor necrosis factor α, all of which have been implicated in facilitation of appetite.[103][104][105] Increased levels of insulin-like growth factor 1 (IGF-1) may also be involved, specifically in its anabolic effects.[106] Studies of MGA in elderly patients who experience weight loss are limited and of poor quality with most showing minimal or no weight gain, with no nutritional or clinically significant beneficial outcomes observed. In patients who take MGA, one in 12 will have an increase in weight.[68]

Miscellaneous

Unlike the case of the AR, MGA has no significant affinity for the ER.[2][4][71] As such, it does not possess the capacity to directly activate the ER.[2][4][71] Furthermore, unlike antiandrogens such as spironolactone and bicalutamide but similarly to cyproterone acetate, there is relatively little risk of indirectly mediated estrogenic side effects (e.g., gynecomastia) with MGA.[107] This is because MGA strongly suppresses both androgen and estrogen levels at the same time.[12][40][74][75][76][77] Similarly to the case of the ER, MGA has negligible affinity for the mineralocorticoid receptor (MR), and hence does not possess mineralocorticoid or antimineralocorticoid activity.[2][4][71]

MGA has been found to dose-dependently increase total and free IGF-1 levels up to a dosage of 120 mg/day.[106] Total IGF-1 levels were described as "profoundly" increased, gradually increasing, significantly by 3 days of treatment, up to a maximum of 2.66-fold by 5 to 6 months of treatment.[106] Free (readily dissociable) concentrations of IGF-1 were increased to a smaller extent, by 1.23–2.15-fold, and were described as increasing "moderately".[106] It was suggested that the increase in IGF-1 levels with high-dosage MGA therapy may explain the anabolic effects of MGA in patients with cachexia.[106]

Pharmacokinetics

The oral bioavailability of MGA is approximately 100%.[2] After a single low oral dose of 4 mg MGA, peak serum concentrations of MGA were about 7 ng/dL (18 nmol/L) and occurred after 3 hours.[2] Following a single high oral dose of 160 mg micronized MGA in men, peak circulating levels of MGA were 125 ng/mL (325 nmol/L) and occurred after 6.3 hours.[108][109][110] This study found that micronized MGA at this dose showed considerably improved absorption relative to its conventional tablet form.[108][109][110] In terms of plasma protein binding, MGA is bound mostly to albumin (82.4%) and is not bound to sex hormone-binding globulin or to corticosteroid-binding globulin.[2][3][4] MGA metabolized in the liver mainly by hydroxylation of the C21, C2α, and C6 positions, as well as by reduction and conjugation.[2][5] Its elimination half-life is 34 hours on average, with a range of 13 to 105 hours.[6] MGA is excreted 57 to 78% in urine and 8 to 30% in feces.[5]

At high doses, MGA appears to have far greater bioavailability and potency than medroxyprogesterone acetate, regardless of whether the route of administration of the latter is oral or parenteral.[5][111][112] Following oral administration of 80 to 160 mg MGA or 500 to 1,000 mg medroxyprogesterone acetate, circulating levels of MGA were 2- to 10-fold higher than those of medroxyprogesterone acetate.[5][111][112] Similar findings have been found for oral MGA relative to medroxyprogesterone acetate administered via intramuscular injection.[5] MGA also reaches steady-state levels more quickly than medroxyprogesterone acetate.[112] The improved potency of MGA compared to medroxyprogesterone acetate may be due to increased resistance to metabolism of MGA afforded by its C6(7) double bond (medroxyprogesterone acetate being identical to MGA in structure except lacking this feature).[5][113][114]

The pharmacokinetics of MGA have been reviewed.[2][73][115]

Chemistry

See also: List of progestogens, Progestogen ester, List of progestogen esters, Steroidal antiandrogen, and List of steroidal antiandrogens

MGA, also known as 17α-acetoxy-6-dehydro-6-methylprogesterone or as 17α-acetoxy-6-methylpregna-4,6-diene-3,20-dione, is a synthetic pregnane steroid and a derivative of progesterone.[11][116] It is specifically a derivative of 17α-hydroxyprogesterone with a methyl group at the C6 position, a double bond between the C6 and C7 positions, and an acetate ester at the C17α position.[11][116] MGA is the C17α acetate ester of megestrol, which, in contrast to MGA, was never marketed.[11][116] Analogues of MGA include other 17α-hydroxyprogesterone derivatives such as acetomepregenol, anagestone acetate, chlormadinone acetate, cyproterone acetate, hydroxyprogesterone caproate, medroxyprogesterone acetate, and nomegestrol acetate.[11][116] MGA differs from medroxyprogesterone acetate only by its C6(7) double bond.[117] Close analogues of MGA that were never marketed include cymegesolate (megestrol acetate 3β-cypionate) and megestrol caproate.[118][119][120]

Synthesis

Chemical syntheses of MGA have been published.[121][122]

History

MGA was synthesized at Syntex in 1959.[73] It was derived from medroxyprogesterone acetate, which had been synthesized at Syntex in 1957.[8][73] MGA was the third synthetic derivative of progesterone to be developed for use as a medication, following hydroxyprogesterone caproate in 1954 and medroxyprogesterone acetate in 1957.[73] The medication was introduced for medical use in combination with ethinylestradiol (EE) as an oral contraceptive in 1963 by British Drug Houses in the United Kingdom under the brand name Volidan (4 mg MGA and 50 μg EE tablets),[7][19] and this was followed by Serial 28 (1 mg MGA and 100 μg EE tablets) and Volidan 21 (4 mg MGA and 50 μg EE tablets) in 1964 and Nuvacon (2 mg MGA and 100 μg EE tablets) in 1967, all by British Drug Houses also in the United Kingdom.[20] It was also marketed under the brand name Delpregnin (5 mg MGA and 100 μg mestranol tablets) by 1965, among others.[111][123][124][125] MGA-containing birth control pills were withdrawn after reports in the early 1970s of a high incidence of venous thromboembolism with the preparations.[98]

In the early 1970s, MGA was found to be associated with mammary tumors in beagle dogs, and along with several other progestogens, was withdrawn as an oral contraceptive from several markets including the United Kingdom, Canada, and Germany.[126][127][128] It was also under investigation for use as a contraceptive in the United States, but development was discontinued in 1972 following the mammary toxicity findings in dogs, and MGA was never marketed as an oral contraceptive in the United States.[128][129][130] Subsequent research, such as monkey studies, revealed that there is no similar risk in humans.[5][131] Following its withdrawal from the market, MGA was eventually reintroduced for the treatment of hormone-sensitive cancers.[130] In addition, MGA was marketed for veterinary use in dogs in 1969 in the United Kingdom and in 1974 in the United States.[132][133][134]

Progesterone was first found to be effective in the treatment of endometrial hyperplasia in 1951,[5] and progestins were first found to be effective in the treatment of endometrial cancer in 1959.[135] MGA was reported to be effective in the treatment of endometrial hyperplasia in the mid-1960s.[5] It first started to be studied as a treatment for endometrial cancer in 1967, with findings published in 1973.[5][136][137] MGA was reportedly introduced for the treatment of endometrial cancer in the United States in 1971.[47] Progesterone was studied in the treatment of breast cancer in 1951 and 1952, but with relatively modest results.[138][139][140] MGA was first studied in the treatment of breast cancer in 1967, and was one of the first progestins to be evaluated for the treatment of this disease.[5][17][141] A second study was conducted in 1974.[5][142] A "breakthrough" and surge of interest in progestins for breast cancer occurred in 1978 when a study using a massive dosage of medroxyprogesterone acetate to treat breast cancer was published.[138][143] A third study of MGA for breast cancer was published in 1980, and this was followed by additional studies in the 1980s and beyond.[5][144][145] MGA was approved for the treatment of breast cancer in the United States by at least 1983.[5]

Progestogens, including progesterone and ethisterone, were studied in the treatment prostate cancer in 1949.[5][146] MGA was first studied in the treatment of prostate cancer in 1970.[5][147] Additional studies were conducted in 1975 and 1978, followed by others thereafter.[5][47][38][42] However, results of MGA therapy for prostate cancer have been "disappointing",[148] and the medication has not been approved for the treatment of prostate cancer in the United States or elsewhere.[83]

Clinical studies of very high dosages of MGA for breast cancer conducted in the 1980s observed markedly increased appetite and weight gain in treated patients despite them having advanced cancer.[149][150] This led to potential interest in MGA as an appetite stimulant,[149] and in 1986, a paper was published proposing the study and potential use of MGA in cachexia.[150][151][152] MGA was subsequently studied for this indication[153] and, following completion of phase III clinical trials, was approved as an oral suspension for the treatment of anorexia–cachexia syndrome due to cancer and other chronic conditions such as HIV/AIDS in the United States in 1993.[154][155] Thereafter, the branded product, Megace ES, has been heavily promoted by its maker, Par Pharmaceutical, for treatment of unintentional weight loss in elderly patients, especially those living in long-term care facilities. In March 2013, Par settled a $45 million federal and multi-state criminal and civil lawsuit in which the company was accused of promoting the branded version of MGA, over the generic version, for use in treating non-AIDS-related geriatric wasting. This use was not approved as safe and effective by the Food and Drug Administration (FDA), and not covered by federal health care programs. The lawsuit claimed that Par marketed the product as effective for this use, despite having conducted no well-controlled studies to support a claim of greater efficacy for Megace ES, and prior knowledge of the severe adverse side effects for geriatric patients, including deep vein thrombosis, toxic reactions with impaired renal function, and mortality.[156]

Society and culture

Generic names

Megestrol acetate is the generic name of the drug and its INNM, USAN, USP, and BANM, while megestrol is the INN and BAN and mégestrol the DCF of megestrol, the free alcohol form of MGA.[157]ref name="IndexNominum2000"/>[158][116] The medication is also known by its developmental code names BDH-1298, NSC-71423, and SC-10363.[157][11][158][116]

Brand names

MGA is marketed under a variety of brand names throughout the world but is most commonly sold under the brand name Megace.[11][158][116] It is also available under the brand name Megace ES in the United States and under the brand name Megace OS in Canada.[158] For use in veterinary medicine, MGA is sold as Ovaban in the United States and as Ovarid in the United Kingdom.[158]

In Bangladesh and India, megestrol is marketed under the trade name Megestol by Ziska Pharmaceuticals, Mezest by Beacon Pharmaceuticals, and under the trade name Varigestrol by Laboratorio Varifarma, Argentina.

Availability

See also: List of progestogens available in the United States

MGA is available widely throughout the world, including in the United States, Canada, the United Kingdom, Ireland, elsewhere throughout Europe, Australia, New Zealand, Latin America, Asia, and a few African countries.[11][158] It does not appear to be marketed in Germany, Russia, South Africa, Japan, India, or Mexico, among other countries.[158]

Generation

Progestins in birth control pills are sometimes grouped by generation.[159][160] While the 19-nortestosterone progestins are consistently grouped into generations, the pregnane progestins that are or have been used in birth control pills are typically omitted from such classifications or are grouped simply as "miscellaneous" or "pregnanes".[159][160] In any case, based on its date of introduction in such formulations of 1963, MGA could be considered a "first-generation" progestin.[161]

Research

MGA has been studied in men in combination with testosterone as a male hormonal contraceptive to suppress spermatogenesis.[47][162]

Veterinary use

MGA has been used in veterinary medicine under the brand name Ovaban in the treatment of medical conditions in cats and dogs.[11][163] Due to its ability to suppress testosterone levels, MGA can control sexually dimorphic traits in males.[164][165] As a result, MGA has been used to reduce dominance, inter-male aggression, mounting, urine spraying, and roaming in male dogs and cats.[164][165]

See also

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 "Megestrol Monograph for Professionals". Drugs.com. Archived from the original on 25 February 2021. Retrieved 15 November 2021.
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  92. ↑ Lønning PE (2009). "Additive endocrine therapy for advanced breast cancer - back to the future". Acta Oncol. 48 (8): 1092–101. doi:10.3109/02841860903117816. PMID 19863216. S2CID 26081050.
  93. ↑ Eil C, Edelson SK (July 1984). "The use of human skin fibroblasts to obtain potency estimates of drug binding to androgen receptors". The Journal of Clinical Endocrinology and Metabolism. 59 (1): 51–5. doi:10.1210/jcem-59-1-51. PMID 6725525.
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  96. ↑ 96.0 96.1 Farrar DJ (March 1999). "Megestrol acetate: promises and pitfalls". AIDS Patient Care and STDs. 13 (3): 149–52. doi:10.1089/apc.1999.13.149. PMID 10375262.
  97. ↑ Tisell LE, Salander H (February 1975). "Androgenic properties and adrenal depressant activity of megestrol acetate observed in castrated male rats". Acta Endocrinologica. 78 (2): 316–24. doi:10.1530/acta.0.0780316. PMID 1172901.
  98. ↑ 98.0 98.1 El Makhzangy MN, Wynn V, Lawrence DM (January 1979). "Sex hormone binding globulin capacity as an index of oestrogenicity or androgenicity in women on oral contraceptive steroids". Clinical Endocrinology. 10 (1): 39–45. doi:10.1111/j.1365-2265.1979.tb03031.x. PMID 571314. S2CID 7262495.
  99. ↑ Timothy L. Ratliff; William J. Catalona (6 December 2012). Genitourinary Cancer: Basic and Clinical Aspects. Springer Science & Business Media. pp. 171–. ISBN 978-1-4613-2033-3. Archived from the original on 15 November 2021. Retrieved 31 October 2021.
  100. ↑ Labrie C, Cusan L, Plante M, Lapointe S, Labrie F (October 1987). "Analysis of the androgenic activity of synthetic "progestins" currently used for the treatment of prostate cancer". J. Steroid Biochem. 28 (4): 379–84. doi:10.1016/0022-4731(87)91054-5. PMID 2444770.
  101. ↑ Briggs MH, Briggs M (October 1973). "Glucocorticoid properties of progestogens". Steroids. 22 (4): 555–9. doi:10.1016/0039-128x(73)90011-1. PMID 4747450.
  102. ↑ Martine El-Etr; Michaël Schumacher; Etienne-Emile Baulieu (10 November 1999). "Effects of Progesterone and Related Steroids in the Brain". In Régine Sitruk-Ware; Daniel R. Mishell (eds.). Progestins and Antiprogestins in Clinical Practice. Taylor & Francis. pp. 15–58. ISBN 978-0-8247-8291-7. Archived from the original on 15 November 2021. Retrieved 31 October 2021. Specific actions of neurosteroids on ion transport across the neuronal plasma membrane have been described (see Fig. 2[10). In hippocampal CA1 neurons, Ffrench Mullen et al. (76) observed an inhibition by PREG, PREGS, and 3α,5β-TH PROG (but not PROG) of both the N- and L-type calcium channel currents, mediated by a pertussis toxin-sensitive G protein mechanism, associated with the activation of protein kinase C. PROG still has no effect on calcium channels of hypothalamic neurons from the ventromedial nucleus; however, the synthetic progestin megestrol acetate inhibits some high-threshold Ca2+ channel currents: not the N-type nor the P-type Ca2+ channel currents, but the residual current. Appetite enhancement induced by megestrol acetate might be partly due to the inhibition of these Ca2+ channel currents, and the attenuation of the firing of ventromedial nucleus neurons, involved in satiety mechanisms (77).
  103. ↑ Ann M. Berger; John L. Shuster; Jamie H. Von Roenn (6 October 2006). Principles And Practice of Palliative Care And Supportive Oncology. Lippincott Williams & Wilkins. p. 128. ISBN 978-0-7817-9595-1. Archived from the original on 27 May 2013. Retrieved 27 May 2012.
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  105. ↑ David S. Ettinger (11 November 2008). Supportive Care in Cancer Therapy. Springer. p. 61. ISBN 978-1-58829-941-3. Archived from the original on 27 May 2013. Retrieved 27 May 2012.
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  107. ↑ Kenneth A. Foon (1998). Biological and Hormonal Therapies of Cancer. Springer. p. 73. ISBN 978-0-7923-9997-1. Archived from the original on 27 May 2013. Retrieved 2 June 2012.
  108. ↑ 108.0 108.1 Stanczyk FZ (September 2002). "Pharmacokinetics and potency of progestins used for hormone replacement therapy and contraception". Rev Endocr Metab Disord. 3 (3): 211–24. doi:10.1023/A:1020072325818. PMID 12215716. S2CID 27018468.
  109. ↑ 109.0 109.1 Goletiani NV, Keith DR, Gorsky SJ (October 2007). "Progesterone: review of safety for clinical studies". Exp Clin Psychopharmacol. 15 (5): 427–44. doi:10.1037/1064-1297.15.5.427. PMID 17924777.
  110. ↑ 110.0 110.1 Farinha A, Bica A, Tavares P (May 2000). "Improved bioavailability of a micronized megestrol acetate tablet formulation in humans". Drug Dev Ind Pharm. 26 (5): 567–70. doi:10.1081/ddc-100101270. PMID 10789071. S2CID 24952875.
  111. ↑ 111.0 111.1 111.2 Harry W. Rudel; Fred A. Kincl; Milan R. Henzl (1973). Birth Control; Contraception and Abortion. Macmillan. ISBN 9780024044105. Archived from the original on 2021-11-15. Retrieved 2021-10-31.
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  113. ↑ Gerald Litwack (2 December 2012). Biochemical Actions of Hormones. Elsevier. pp. 330–. ISBN 978-0-323-15344-7. Archived from the original on 15 November 2021. Retrieved 31 October 2021.
  114. ↑ David A. Williams; William O. Foye; Thomas L. Lemke (2002). Foye's Principles of Medicinal Chemistry. Lippincott Williams & Wilkins. pp. 699–. ISBN 978-0-683-30737-5. Archived from the original on 2021-11-15. Retrieved 2021-10-31.
  115. ↑ Die Gestagene. Springer-Verlag. 27 November 2013. p. 281. ISBN 978-3-642-99941-3. Archived from the original on 15 November 2021. Retrieved 31 October 2021.
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  122. ↑ Cooley G, Kellie AE (October 1964). "Synthesis of [1,2-3H2]medroxyprogesterone acetate (17-alpha-acetoxy-6-alpha-methyl[1,2-3H2]pregn-4-ene-3,20-dione) and [1,2-3H2]megestrol acetate (17-alpha-acetoxy-6-methyl[1,2-3H2]pregna-4,6-diene-3,20-dione)". Biochem. J. 93 (1): 8C–9C. doi:10.1042/bj0930008c. PMID 5320316.
  123. ↑ David P. Rose (1973). Oral Contraceptives: Psychological and Physiological Effects. Ardent Media. pp. 12–. ISBN 978-0-8422-7101-1. Archived from the original on 2021-11-15. Retrieved 2021-10-31.
  124. ↑ Statens seruminstitut (Denmark) (1966). Communications: Extraits. Archived from the original on 2021-11-15. Retrieved 2021-10-31. Each Delpregnin tablet contains 5 mg megestrol acetate + 0.1 mg mestranol.
  125. ↑ Unlisted Drugs. Pharmaceutical Section, Special Libraries Association. 1965. Archived from the original on 2021-11-15. Retrieved 2021-10-31.
  126. ↑ Consolidated List of Products Whose Consumption And/or Sale Have Been Banned, Withdrawn, Severely Restricted Or Not Approved by Governments. United Nations Publications. 1983. pp. 137–. ISBN 978-92-1-130230-1.
  127. ↑ Nelson LW, Weikel JH, Reno FE (October 1973). "Mammary nodules in dogs during four years' treatment with megestrol acetate or chlormadinone acetate". J. Natl. Cancer Inst. 51 (4): 1303–11. doi:10.1093/jnci/51.4.1303. PMID 4126857.
  128. ↑ 128.0 128.1 FDA Consumer. U.S. Department of Health, Education, and Welfare, Public Health Service, Food and Drug Administration. February 1976. Archived from the original on 2021-11-15. Retrieved 2021-10-31. Several foreign countries, including Germany, Canada, and Great Britain, have banned the sale of birth control pills containing megestrol acetate after a study done at FDA's request indicated it caused breast cancer in dogs. Megestrol acetate has never been marketed in the United States as an oral contraceptive. FDA routinely requires long-term animal studies before any drug can be marketed for human use. Following animal studies with megestrol acetate, FDA in the late sixties and early seventies allowed limited studies of the drug in women. In 1972, after noticing a significant number of test dogs developing breast nodules (none of them malignant), FDA ordered that megestrol acetate be discontinued in human oral contraceptive studies.
  129. ↑ United States. Congress. Senate. Committee on Labor and Public Welfare (1976). Hearings, Reports and Prints of the Senate Committee on Labor and Public Welfare. U.S. Government Printing Office. Archived from the original on 2021-11-15. Retrieved 2021-10-31. Megestrol was never marketed in the United States for contraceptive use because in 1972, FDA took prompt action to discontinue investigational studies on megestrol after dogs exposed to the drug for four years In a chronic toxicity study developed benign breast tumors.
  130. ↑ 130.0 130.1 Bakke OM, Wardell WM, Lasagna L (May 1984). "Drug discontinuations in the United Kingdom and the United States, 1964 to 1983: issues of safety". Clin. Pharmacol. Ther. 35 (5): 559–67. doi:10.1038/clpt.1984.78. PMID 6713769. S2CID 7452111.
  131. ↑ Benno Clemens Runnebaum; Thomas Rabe; Ludwig Kiesel (6 December 2012). Female Contraception: Update and Trends. Springer Science & Business Media. pp. 134–. ISBN 978-3-642-73790-9.
  132. ↑ Modern Veterinary Practice. 1971. Archived from the original on 2021-11-15. Retrieved 2021-10-31. Your Q & A concerning megestrol acetate (Oct MVP, p 27), a product containing this compound (Ovarid: Glaxo) has been commercially available for controlling estrus in bitches in the UK for nearly 2 years.
  133. ↑ VM/SAC, Veterinary Medicine/small Animal Clinician. Veterinary Medicine Publishing Company. 1977. Archived from the original on 2021-11-15. Retrieved 2021-10-31. In England, where megestrol acetate has been marketed for eight years, it is recommended to treat false pregnancy and estrogen-dependent mammary tumors in dogs. It has also been used successfully to treat hypersexuality in male dogs, and miliary dermatitis and eosinophilic granulomas in cats. In 1974, megestrol acetate was approved in the United States for postponement of es- trus and treatment of false pregnancy in dogs.
  134. ↑ Upjohn Company (1978). Proceedings of the Symposium on Cheque® for Canine Estrus Prevention, Brook Lodge, Augusta, Michigan, March 13-15, 1978. Upjohn Company. Archived from the original on 2021-06-14. Retrieved 2021-10-31. In 1974, Sobering marketed megestrol acetate3 (Figure 1) under the trade name of Ovaban® (Ovarid® in Europe).
  135. ↑ KISTNER RW (1959). "Histological effects of progestins on hyperplasia and carcinoma in situ of the endometrium". Cancer. 12 (6): 1106–22. doi:10.1002/1097-0142(195911/12)12:6<1106::aid-cncr2820120607>3.0.co;2-m. PMID 14409476.
  136. ↑ Geisler, Hans E. (1973). "The use of megestrol acetate in the treatment of advanced malignant lesions of the endometrium". Gynecologic Oncology. 1 (4): 340–344. doi:10.1016/0090-8258(73)90026-7. ISSN 0090-8258.
  137. ↑ Wait RB (January 1973). "Megestrol acetate in the management of advanced endometrial carcinoma". Obstet Gynecol. 41 (1): 129–36. PMID 4682608.
  138. ↑ 138.0 138.1 Lundgren S (1992). "Progestins in breast cancer treatment. A review". Acta Oncol. 31 (7): 709–22. doi:10.3109/02841869209083859. PMID 1476750.
  139. ↑ Taylor SG, Morris RS (January 1951). "Hormones in breast metastasis therapy". Med. Clin. North Am. 35 (1): 51–61. doi:10.1016/s0025-7125(16)35321-4. PMID 14796108.
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  142. ↑ Ansfield FJ, Davis HL, Ellerby RA, Ramirez G (April 1974). "A clinical trial of megestrol acetate in advanced breast cancer". Cancer. 33 (4): 907–10. doi:10.1002/1097-0142(197404)33:4<907::aid-cncr2820330403>3.0.co;2-y. PMID 4819220.
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  146. ↑ Gutierrez R (August 1949). "New horizons in the surgical management of carcinoma of the prostate gland". Am. J. Surg. 78 (2): 147–69. doi:10.1016/0002-9610(49)90323-2. PMID 18135629.
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