Download 18. Anorexia and Cachexia

Palliative Care:
Anorexia & Cachexia
Hong-Phuc Tran, M.D.g013
Learning Objectives
• Identify reversible causes of anorexia
• Learn management of anorexia
• Explain features of cachexia
• Understand that cachexia is often caused by same
factors that cause anorexia
• Understand that increased calories, and enteral /
parenteral nutrition cannot reverse cachexia
Definitions
• Anorexia: loss of appetite and reduced caloric
intake
• Cachexia: involuntary loss of more than 10% of
premorbid weight and loss of muscle, visceral
protein and lipolysis
• Starvation: loss of weight and loss of needed
calories
Anorexia: Introduction
• Anorexia is a decrease or loss of appetite
• Can be a symptom of a terminal disease process, such as
cancer & end-stage CHF
• Prevalence of anorexia is 66% in patients with advanced
cancer.
• Anorexia may occur in isolation or as part of anorexiacachexia syndrome
• Management involves evaluating for reversible causes
Causes of Anorexia
• Medication side effects:GI causes
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Constipation, fecal Impaction
Nausea, vomiting
GERD, gastritis, gastro paresis
Malabsorbtion: Pancreatic ca, diarrhea
• Dysphagia
• Depression, anxiety
• Oral problems: dry mouth, candidiasis,
stomatitis, dental pain, ulcers, poorly fitting
dentures
• Metabolic disorders
▫ Thyroid problems
▫ Diabetes
▫ Adrenal insufficiency
• Altered taste and smell
• Odors (e.g. certain smells of food)
• Generalized weakness, lethargy
Cachexia: Introduction
• A wasting syndrome characterized by disproportionate
loss of skeletal muscle over fat
• Primary cause of death in about 20% of all patients with
cancer
• Often occurs concomitantly with anorexia, as it caused
by same factors that cause anorexia
• Multi-factorial etiology not clearly understood, but
chronic inflammation is core mechanism
• Tends to be very distressing for patients & families
Some Examples of Causes of Cachexia
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Cancer
AIDS
Chronic obstructive pulmonary disease
Chronic renal insufficiency
Congestive heart failure
Cirrhosis
Dementia
Chronic infections
Autoimmune disease
Cachexia: Biochemical markers
• Biochemical markers may be helpful in assessing
cachexia
– Primary cachexia/anorexia is associated with high
CRP, low albumin
– Increasing levels of CRP provide a measure of
chronic inflammation
– Anemia & decreased lymphocyte count often
present
– In patients with weight loss, normal albumin &
normal/slightly elevated CRP raise concerns for
other causes of weight loss
Dietary habits in dying people
• Prospective study 151 advanced cancer patients
dietary records aprox 7 mo before death
▫ Even patients with highest intakes had weight loss
▫ Frequency of eating was important in total energy
intake
▫ Patients preferred typical foods over supplements
Anorexia-Cachexia from Cancer
• Distinct from other secondary causes of anorexia-cachexia
– Includes correctable problems, including pain, infection,
emotional disorder, obstruction, constipation
• Not reversible with aggressive feeding / increased calories
– Enteral and parenteral nutrition offer no significant benefits & do
not improve survival or comfort
– Weight loss correlates with cytotoxic effects of & poor tumor
response to chemotherapy
• Often present at diagnosis of certain cancers
– Non-small cell lung, upper GI, pancreatic
• Concomitant presence of anxorexia carries a poorer prognosis
Management of Anorexia
• Identify and treat reversible causes
• Educate families, caregivers on natural
progression of disease
• Evaluate whether anorexia is bothersome to
patient
▫ Anorexia may be more bothersome to families &
caregivers than to patient
• Offer favorite foods
• Smaller, frequent meals and snacks
Supplements and Medications
• Nutritional supplements
– Oral protein shakes, protein powders
 Take in ADDITION to food not instead of meals
– Calorie dense supplement (Benecalorie)
 Add to pureed foods, adds calories, no nutrition
• Appetite stimulants
– Megesterol acetate
– Marinol
– Dexamethasone
Megesterol acetate (Megace)
• Improves appetite and weight gain
– Most of weight gain is from fat not lean muscle
– Best absorbed when taken with high-fat meal
• Start with 400mg/day. If appetite not better in 2 weeks, then increase to
600-800mg/day.
• Takes a few weeks to take effect but longer duration of benefit than steroids
• Side effects: Increase risk of venous thromboembolism, fluid retention
• Contradictions: history of DVT , thrombophlebitis
• Do not discontinue abruptly if used more than 3 weeks (adrenal
suppression); taper off slowly
Cannabinoids
• Marinol (tetrahydrocannabinol, THC) improves weight
gain and appetite in patients with AIDs & cancer
• Start with small dose and up titrate to effect and
tolerability
• 7.5mg to 15mg /day
• Example dosing: Marinol 2.5mg po TID one hour after
meals
• Adverse side effects: anxiety, somnolence, neurotoxicity
Corticosteroids
• Stimulates appetite short-term
• Dexamethasone preferred over other corticosteroids for appetite
stimulation due to its relative lack of mineralocorticoid effect
• Rapid effect, long half life but effect limited 2-6 weeks
• Doses of 2-16 mg/day dexamethasone
• Side effects: fluid retention, increased infection risk, gastritis, insomnia,
proximal muscle wasting with prolonged treatment, steroid psychosis
• Consider 1 week trial
– If no improvement, then discontinue
– If helps, then reduce to lowest effective dose.
– Reassess need frequently; discontinue when no longer effective
Other agents
• Psychotropics- Mirtazapine, atypical
antipsychotics
– Mirtazapine can increase appetite , but also may
cause drowsiness, constipation
– Atypical antipsychotics cause weight gain side
effect, caution diabetes, blood sugars
• Fish oil –small study in pancreatic ca patients
showed increase in lean body mass
• Thalidomide 200-400mg/day increased weight
in HIV/AIDS cachexia
Anorexia/Cachexia from Cancer:
Examples of Correctable Causes & Management
(1)
• Emotional disorders
– Anxiolytics, antidepressants, counseling for patients &
families
• Eating issues
– Dietitian referral, multivitamin, zinc / flavoring food
with spices (for disturbed sense of smell or taste)
• Oral problems
– Oral moisturizers, antifungal meds to treat thrush (if
present), change meds that may cause dry mouth
• Swallowing difficulties
– Esophageal dilation, antifungal med for thrush (if
present)
Anorexia/Cachexia from Cancer:
Examples of Correctable Causes & Management
(2)
• Stomach issues
– GERD- proton pump inhibitors
– Gastric stimulants (for early satiety), treat n/v
• Bowel issues
– Treat constipation / obstruction
• Malabsorption
– Pancreatic enzymes
• Fatigue
– anxiolytics, exercise protocol, sleep protocol
• Motivation issues
– methylphenidate, exercise
• Pain
– appropriate analgesics, nerve blocks, counseling
Artificial nutrition and Hydration?
(ANH)
• ANH is a medical treatment
▫ Some states make it more difficult to withdraw
than other life sustaining treatments
• Patients should have goals discussion of risk
benefit regarding long term ANH
▫ Insertion of Gtube, NG tube
▫ Risk aspiration with decline in condition
• Unclear benefits for dying patients
Summary
• Don’t focus on appetite and weight
– Let patient guide new eating habits
– Liberalize dietary restrictions
– Maintain muscle function
• Intervene early in disease
– Nutritional supplements
– Exercise
– Consider medical therapies
• Address patient and families fears
– Identify alternative non food methods of expressing
love, caring
References & Suggested Readings
• AMA EPEC (Education for Physicians on End-of-Life Care) at
http://www.cancer.gov/cancertopics/cancerlibrary/epeco/selfstudy/module-3/module3b-pdf
• Holms S. A difficult clinical problem: diagnosis, impact and clinical management of
cachexia in palliative care. Int J Palliat Nurs. 2009 Jul; 15(7):320, 322-6.
• Lasheen W, Walsh D. The cancer anorexia-cachexia syndrome: myth or reality? Support
Care Cancer. 2010. Feb; 18(2):265-72. doi: 10.1007/s00520-009-0772-6.
• Loprinzi CL, Laurie JA, Wieand HS, et al. Prospective evaluation of prognostic variables
from patient-completed questionnaires. J Clin Oncol. 1994;12:601607.
• McGeer AJ, Detsky AS, O'Rourke K. Parenteral nutrition in cancer patients undergoing
chemotherapy: A meta-analysis. Nutrition. 1990;6:233.
• Morrison RS, Meier DE. Clinical Practice: Palliative Care. N Engl J Med. 2004 Jun
17;350(25):2582-90
• Nelson K, Walsh D, Deeter P, et al. A phase II study of delta-9-tetrahydrocannabinol for
appetite stimulation in cancer-associated anorexia. J Palliat Care. 1994 Spring;10(1):14-8.
• Ruiz GV, Lopez-Briz E, Carbonell SR et al. Megesterol acetate for treatment of anorexiacachexia syndrome. Cochrane Database Syst Rev. 2013 Mar 28;3:CD004310. doi:
10.1002/14651858.CD004310.pub3.
• Shoemaker LK, Estfan B, Induru R, et al. Symptom management: an important part of
cancer care. Cleve Clin J Med. 2011 Jan; 78(1):25-34. doi: 10.3949/ccjm.78a.10053.
Effective response to caregivers’ fears
that loved ones are “starving” to
death
a. Listen and assess for feelings of guilt
b. Ask about cultural and religious values
c. Explain physiologic differences between
starvation and anorexia-cachexia
d. Explain artificial nutrition nor increased oral
intake will not likely improve survival or weight
gain in end stage disease
e. All of the above
• Answer E
Primary anorexia –cachexia differs
from starvation in that
a. Less protein synthesis occurs in anorexia
cachexia due to decreased production of acute
phase
b. Decreased cortisol levels suggest a chronically
altered neuroendocrine state
c. Proinflamatory cytokines are commonly
involved, causing immune dysfunction
• Answer C
▫ Anorexia cachexia MORE protein synthesis
▫ Cortisol levels do not reflect change
Mr. K is a 67 year old male with metastatic colon
ca, referred to hospice. Family is concerned he
had no appetite and continues to lose weight.
a. Insert NG tube and start tube feedings
b. Reassure the family his weight loss is normal
c. Complete a history and physical
d. Order nystatin suspension swish and swallow
tid
• Answer C
• Complete a H and P first to assess any reversible
causes for anorexia cachexia
• Then consider possible treatments