A randomized controlled clinical trial will be conducted to assess the efficacy of the FDA approved drug , mirtazapine , in treatment of cancer associated anorexia cachexia syndrome.

Two arms will be compared . Arm A will involve 50 patients with confirmed advanced cancer receiving mirtazapine 15 mg once daily for 8 weeks & Arm B will involve another 50 patients with confirmed advanced cancer receiving placebo for 8 weeks.

Both arms will be compared to assess efficacy of mirtazapine in appetite stimulation primarily and to assess other outcomes secondarily which will be discussed later in details.

• A Written consent is to be obtained from all patients before being enrolled in the study.

• Baseline Complete Blood Count , Liver function tests and kidney function tests will be obtained to assess safety to start the drug and to assess its dose adjustment.

• Two arms will be compared : mirtazapine oral 15mg daily versus placebo. This will be conducted on a double-blinded basis.

• Oral mirtazapine ( REMERON , RD , 30 mg tablets , Organon ) will be the original FDA approved drugs that will be used in the study.

• Treatment allocation will be concealed from patients, investigators, and study coordinators enrolling the participants.

• All patients will be counseled and given dietary advice by a dietician at baseline.

• Patients will be permitted to continue treatment at the same dose as scheduled as long as weight was stabilized (no loss greater than 10 % of body weight at baseline).

• Duration of therapy : Patients will remain on protocol for a duration of 8 weeks as long as they did not develop serious concurrent illness preventing further treatment, unacceptable adverse events (grade 3 or higher), the patient decides to withdraw from study, or the investigator judges that it is in the patient's best interest to discontinue treatment due to general or specific health conditions.

• Demographic data will include performance status, tumor type, sex, age, and percentage weight loss.

• The ESAS scale (Edmonton Symptom Assessment Scale ) will be used to assess the following 10 symptoms experienced by patients with cancer during the previous 24 hours:

  1. pain.
  2. Fatigue.
  3. Nausea.
  4. Depression.
  5. Anxiety.
  6. Drowsiness.
  7. Dyspnea.
  8. Anorexia.
  9. Sleep disturbance.
  10. And feelings of well-being.

The severity of each symptom is rated on a numerical scale of 0 to 10 (0_no symptom, 10_worst possible severity). The ESAS is both valid and reliable in the assessment of the intensity of symptoms in patients with cancer.

• The FAACT questionnaire ( Functional Assessment of Anorexia\Cachexia Therapy ) with anorexia \ cachexia subscale will be used to assess quality of life among the studied patients , in a form of questionnaire including :

  1. Physical well-being.

  2. Social well-being.

  3. Emotional well-being.

  4. Functional well-being.

  5. Additional concerns.

     The patient rates the answer on a scale of 0 to 4. The FACIT - Pal scale is internally consistent , reliable and valid as a measure of health-related quality of life for persons with advanced cancer.

     We will contact their website to get the licence to use the questionnaire and to get its translated version.

• Anthropometric measures to assess efficacy of mirtazapine in weight gain :

  1. Assessment of weight of the patient .
  2. Assessment of muscle strength ( via hand grip dynamometry , using the device named Lite 200 lb , Fabrication Enterprises Incorporated Company).
  3. Assessment of lean ( via bioimpedance analysis , using the device named BF100 , Beurer Company ).

• Biological methods to assess efficacy of mirtazapine in modulating inflammatory cytokine media : quantitative c-reactive protein (CRP) and comparative analysis by enzyme-linked immunoassay (ELISA) will be performed on IL-6 ( Interleukin - 6 ) , and YKL-40 serum levels according to availability. They will be obtained at baseline (day 1 of treatment, immediately before first dose) and at week 8.

• Evaluation of safety and tolerability Patients who will receive at least one dose of study medication will be done.

• A traditional definition of dose-limiting toxicity (DLT) within the first cycle Will be used (any grade 3 non-hematologic or grade 4 hematologic toxicity within 4 weeks and assessed as being at least possibly related to study drug).

• A toxicity questionnaire will be done at baseline and then at 14-day intervals until day 28.

To fully assess the toxicity profile of the drug, the safety evaluation period in the trial will be extended 30 days from the date of the last dose of study drug.

Inclusion Criteria:

• Patients with confirmed advanced cancer.
• Patients with appetite score equal or more than 4 on a 0 to 10 scale (10 _ worst appetite).
• Patients with weight loss more than 5 % of body weight over 6 months . Or : Patients with any degree of weight loss more than 2 % associated with BMI ( body mass index ) of less than 20.
• Patients able to take pills orally and not dependent on tube feeding (no oral mucosal inflammation interfering with oral intake or dysphagia as determined by clinical examination).
• Eastern Cooperative Oncology Group (ECOG) performance status of 0-2.
• Normal organ function (creatinine ≤2× upper limit of normal, bilirubin ≤2; upper limit of normal).
• Ability to understand and willingness to sign written informed consent.
• Patients could be receiving concurrent chemotherapy or radiation therapy.
• Patients with an expected life span of at least 3 months.

Exclusion Criteria:

• Patients with weight gain for known cause , e.g. , ascites.
• Premenopausal women with childbearing potential with a positive pregnancy test.
• Patients unable to maintain oral intake .
• Patients with dementia or delirium.
• Patients with uncontrolled symptoms that could impact appetite or caloric intake such as nausea, pain, or depression will be excluded until their symptoms had stabilized for at least 2 weeks.
• Because improvement in anorexia and/or weight in depressed individuals could be due to an antidepressant effect of mirtazapine, rather than to a direct effect on anorexia, patients with moderate to severe depressive symptoms will be also excluded. the screening instrument will be a single-item interview assessing depressed mood of the Schedule for Affective Disorders and Schizophrenia (SADS) instrument which is validated and highly accurate in screening for depression when compared to the gold standard of semistructured diagnostic interviews, and is rated on a 6-point Likert scale, where 0 = no depression and 6 = extreme feelings of depression. Patients with a score of 4 or more will be excluded from the study as they are considered to be at high risk for depression.
• No treatment with antipsychotic agents such as risperidone, quetiapine, clozapine, phenothiazine, or butyrophenone for 30 days prior to or during protocol therapy.
• Patients with untreated vitamin B12 deficiency or endocrine abnormalities that could affect appetite, such as thyroid dysfunction and hypoadrenalism.
• Patients on supplements or medications with potential appetite-stimulating activity, such as megestrol acetate, corticosteroids, or thalidomide, will be excluded unless they are put on a stable dose for more than 2 weeks and continue to experience poor appetite.

All data will be kept in records at clinical oncology department at Kasr Al Ainy NEMROCK to be available at anytime and shared with other researchers

• Treatment allocation will be concealed from patients, investigators, and study coordinators enrolling the participants.
• The pills used in the study ( either remeron or placebo ) will be kept into opaque containers , in order to be concealed from patients , investigators and study coordinators.