![Page 1: Palliative Care: Anorexia & Cachexia Hong-Phuc Tran, M.D.g013](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649da05503460f94a8c2ee/html5/thumbnails/1.jpg)
Palliative Care:Anorexia & CachexiaHong-Phuc Tran, M.D.g013
![Page 2: Palliative Care: Anorexia & Cachexia Hong-Phuc Tran, M.D.g013](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649da05503460f94a8c2ee/html5/thumbnails/2.jpg)
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
![Page 3: Palliative Care: Anorexia & Cachexia Hong-Phuc Tran, M.D.g013](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649da05503460f94a8c2ee/html5/thumbnails/3.jpg)
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
![Page 4: Palliative Care: Anorexia & Cachexia Hong-Phuc Tran, M.D.g013](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649da05503460f94a8c2ee/html5/thumbnails/4.jpg)
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 anorexia-cachexia syndrome
• Management involves evaluating for reversible causes
![Page 5: Palliative Care: Anorexia & Cachexia Hong-Phuc Tran, M.D.g013](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649da05503460f94a8c2ee/html5/thumbnails/5.jpg)
Causes of Anorexia
•Medication side effects:GI causes▫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
![Page 6: Palliative Care: Anorexia & Cachexia Hong-Phuc Tran, M.D.g013](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649da05503460f94a8c2ee/html5/thumbnails/6.jpg)
•Metabolic disorders▫Thyroid problems▫Diabetes▫Adrenal insufficiency
•Altered taste and smell•Odors (e.g. certain smells of food)•Generalized weakness, lethargy
![Page 7: Palliative Care: Anorexia & Cachexia Hong-Phuc Tran, M.D.g013](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649da05503460f94a8c2ee/html5/thumbnails/7.jpg)
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
![Page 8: Palliative Care: Anorexia & Cachexia Hong-Phuc Tran, M.D.g013](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649da05503460f94a8c2ee/html5/thumbnails/8.jpg)
Some Examples of Causes of Cachexia•Cancer•AIDS•Chronic obstructive pulmonary disease•Chronic renal insufficiency•Congestive heart failure•Cirrhosis•Dementia•Chronic infections•Autoimmune disease
![Page 9: Palliative Care: Anorexia & Cachexia Hong-Phuc Tran, M.D.g013](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649da05503460f94a8c2ee/html5/thumbnails/9.jpg)
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
![Page 10: Palliative Care: Anorexia & Cachexia Hong-Phuc Tran, M.D.g013](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649da05503460f94a8c2ee/html5/thumbnails/10.jpg)
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
![Page 11: Palliative Care: Anorexia & Cachexia Hong-Phuc Tran, M.D.g013](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649da05503460f94a8c2ee/html5/thumbnails/11.jpg)
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
![Page 12: Palliative Care: Anorexia & Cachexia Hong-Phuc Tran, M.D.g013](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649da05503460f94a8c2ee/html5/thumbnails/12.jpg)
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
![Page 13: Palliative Care: Anorexia & Cachexia Hong-Phuc Tran, M.D.g013](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649da05503460f94a8c2ee/html5/thumbnails/13.jpg)
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
![Page 14: Palliative Care: Anorexia & Cachexia Hong-Phuc Tran, M.D.g013](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649da05503460f94a8c2ee/html5/thumbnails/14.jpg)
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
![Page 15: Palliative Care: Anorexia & Cachexia Hong-Phuc Tran, M.D.g013](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649da05503460f94a8c2ee/html5/thumbnails/15.jpg)
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
![Page 16: Palliative Care: Anorexia & Cachexia Hong-Phuc Tran, M.D.g013](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649da05503460f94a8c2ee/html5/thumbnails/16.jpg)
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
![Page 17: Palliative Care: Anorexia & Cachexia Hong-Phuc Tran, M.D.g013](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649da05503460f94a8c2ee/html5/thumbnails/17.jpg)
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
![Page 18: Palliative Care: Anorexia & Cachexia Hong-Phuc Tran, M.D.g013](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649da05503460f94a8c2ee/html5/thumbnails/18.jpg)
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)
![Page 19: Palliative Care: Anorexia & Cachexia Hong-Phuc Tran, M.D.g013](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649da05503460f94a8c2ee/html5/thumbnails/19.jpg)
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
![Page 20: Palliative Care: Anorexia & Cachexia Hong-Phuc Tran, M.D.g013](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649da05503460f94a8c2ee/html5/thumbnails/20.jpg)
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
![Page 21: Palliative Care: Anorexia & Cachexia Hong-Phuc Tran, M.D.g013](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649da05503460f94a8c2ee/html5/thumbnails/21.jpg)
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
![Page 22: Palliative Care: Anorexia & Cachexia Hong-Phuc Tran, M.D.g013](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649da05503460f94a8c2ee/html5/thumbnails/22.jpg)
References & Suggested Readings• AMA EPEC (Education for Physicians on End-of-Life Care) at
http://www.cancer.gov/cancertopics/cancerlibrary/epeco/selfstudy/module-3/module-3b-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;12:601 607.• 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 anorexia-
cachexia 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.
![Page 23: Palliative Care: Anorexia & Cachexia Hong-Phuc Tran, M.D.g013](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649da05503460f94a8c2ee/html5/thumbnails/23.jpg)
Effective response to caregivers’ fears that loved ones are “starving” to deatha. Listen and assess for feelings of guilt b. Ask about cultural and religious valuesc. Explain physiologic differences between
starvation and anorexia-cachexiad. Explain artificial nutrition nor increased
oral intake will not likely improve survival or weight gain in end stage disease
e. All of the above
![Page 24: Palliative Care: Anorexia & Cachexia Hong-Phuc Tran, M.D.g013](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649da05503460f94a8c2ee/html5/thumbnails/24.jpg)
•Answer E
![Page 25: Palliative Care: Anorexia & Cachexia Hong-Phuc Tran, M.D.g013](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649da05503460f94a8c2ee/html5/thumbnails/25.jpg)
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
![Page 26: Palliative Care: Anorexia & Cachexia Hong-Phuc Tran, M.D.g013](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649da05503460f94a8c2ee/html5/thumbnails/26.jpg)
•Answer C
▫Anorexia cachexia MORE protein synthesis▫Cortisol levels do not reflect change
![Page 27: Palliative Care: Anorexia & Cachexia Hong-Phuc Tran, M.D.g013](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649da05503460f94a8c2ee/html5/thumbnails/27.jpg)
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
![Page 28: Palliative Care: Anorexia & Cachexia Hong-Phuc Tran, M.D.g013](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649da05503460f94a8c2ee/html5/thumbnails/28.jpg)
•Answer C
•Complete a H and P first to assess any reversible causes for anorexia cachexia
•Then consider possible treatments