Anorexia/ Cachexia

Wasting syndromes are characterized by lack of appetite (anorexia) and weight loss (cachexia) and are frequently accompanied by generalized fatigue (asthenia). More that 80% of patients develop cachexia before death. The effects of cachexia include: decreased survival; increased complications of surgery, radiation, chemotherapy; weakness, anorexia and chronic nausea; psychological distress. Patients and their loved ones need to be educated that anorexia and cachexia is a common part of the dying process. Natural endorphins prevent the dying patient from experiencing hunger and education regarding this phenomenon may ease their loved ones anxiety and concern. Anorexia and cachexia are signs of disease progression and are not generally reversible.

COMMON CAUSES
The causes are not well understood, making treatment difficult. However, there are many different mechanisms likely to occur, including:

  • the effects of hormonal and humoral mediators;
  • host-tumor interactions;
  • alterations in metabolism;
  • greater energy expenditure from illness than supply.

ASSESSMENT
Diagnosis is straightforward and includes:

  • detailed patient history;
  • documentation of substantial weight loss;
  • physical examination.

Plasma albumin concentration is usually decreased.

Measurement of triceps or subscapular skin folds and arm muscular circumference are useful to monitor changes when body weight is unreliable and difficult to assess.

MANAGEMENT
Treatable causes of anorexia and cachexia include:

  • chronic pain;
  • mouth conditions such as dryness, mucositis, and infections;
  • gastrointestinal motility problems (i.e. constipation);
  • reflux esophagitis.

It is important to keep in mind that cachexia is a "normal" part of dying.

Once treatable causes have been ruled out, symptomatic management of cachexia at the end of life may include both non-pharmacological and pharmacological interventions.

(O'Neill and Fallon, Principles of palliative care and pain control)

Non-Pharmacological Interventions
It is important to note that aggressive feeding in cancer patients with cachexia may actually increase discomfort.

Teach family caregivers about the pathophysiology of anorexia/cachexia and to replace the "need to feed" with behaviours to alleviate symptoms (i.e. moistening lips and mouth).

Eliminate dietary restrictions and offer small amounts of food as the patient desires.

Pharmacological Interventions
Pharmacologic therapy should be considered an adjunct to the non-pharmaceutical approaches suggested above. 

Corticosteroids:

Research has shown that steroids may improve appetite and sense of well being.  Mechanisms of action are not completely clear: may be related to euphoria effects and/or to their ability to inhibit prostaglandin metabolism.

Side effects: mood swings, sleep disturbance, hyperglycemia, edema, delirium, weakness, osteoporosis and cataracts (long term) and immunosuppression.

Consider:
Dexamethasone (Decadron) is used more often because once daily dosing can be used due to its long half-life and because it lacks mineralocorticoid effects. However, any steroid will have the same effects on appetite

  • The effect may diminish after 4-6 weeks of use.

Progesteronal Drugs

Mechanism of action is not completely clear. It has been postulated that it works by inhibiting macrophage production of cachexin and TNF and by acting as an appetite stimulant

Side effects include: nausea and edema, cushinoid appearance, hypercalcemia, and perhaps decreased survival

Consider:
Megastrol (Megace)
Some evidence for using a combination of megastrol acetate and ibuprofen for cancer cachexia.

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This page was last updated: March 8th, 2005 at 5:30pm.