The recent articles by Von Roenn and colleagues [1] and Oster and associates [2] showed that megestrol acetate treatment resulted in significant weight gain and improvement in "well-being" in patients with cachexia related to AIDS. Only megestrol's prohibitively high cost precludes its use in all patients with AIDS-related wasting syndrome. As pointed out in the editorial by Haller [3], the cost of megestrol at a dose of 800 mg/d is between $3000 and $4400 per year [3]. This may be affordable for some but not most patients with AIDS.

On the basis of clinical experience, prednisone at a dose of 10 mg/d is at least as effective as megestrol and is far less expensive (approximately $5 per month). We have used this dose in patients with the wasting syndrome in whom we could identify no other infectious cause to explain the weight loss (for example, Mycobacterium avium complex or cytomegalovirus infection). The clinical response is uniformly dramatic: weight gain associated with increased appetite and subjective improvement in well-being. The inhibitory effect of corticosteroids on the synthesis of tumor necrosis factor (cachectin) may be partially responsible for the effect [4]. We have noted no substantial rate of side effects with this dose, and the incidence of opportunistic infections has not been higher than expected in this group of patients. The fact that most of these patients are already receiving prophylactic medications for various opportunistic infections may explain why the medication is so well tolerated.

Perhaps trials similar to the ones by Von Roenn and colleagues and Oster and associates should be done to examine whether an inexpensive agent (prednisone) is as effective as an expensive one (megestrol acetate).