INTRODUCTION

Anorexia is the involuntary loss of appetite or desire to eat that results in reduced caloric intake and is often associated with weight loss.

Cachexia is a multifactorial syndrome defined by ongoing loss of skeletal muscle mass (with or without loss of fat mass) that cannot be fully reversed by conventional nutritional support and leads to progressive functional impairment.

Anorexia-cachexia syndrome is characterised by loss of lean tissue, a decline in performance status due to fatigue, variations in energy expenditure, and loss of appetite. It impacts on quality of life and causes distress to patients and carers. Associated stressors include chronic nausea, change in body image, psychological distress and dyspnoea.

Common causes in cancer patients:

• Cancer related
• Oral ulcers/candidiasis
• Reduced food intake
• Impaired gastro-intestinal absorption
• Early satiety, gastroparesis, delayed gastric emptying
• Bowel obstruction
• Metabolic abnormalities
• Loss of protein (e.g. repeated ascitic drainage or nephrotic syndrome)
• Catabolic state – tumour derived factors
• Uncontrolled symptoms – breathlessness, pain, constipation, nausea and vomiting, foul odours, fungating wounds, fistulae

• Treatment related
• Chemotherapy and radiotherapy related side-effects such as oral mucositis, xerostomia, oesophagitis, dysphagia, nausea and vomiting, constipation,
• Radical surgery – Oesophagectomy, gastrectomy (total or subtotal), Whipples surgery, small bowel resection, colectomy

• Other conditions
• Altered taste
• Psychological issues – depression, delirium, anxiety
• Chronic infection
• Hyperthyroidism
• CCF / liver cirrhosis
• Poorly controlled diabetes

ASSESSMENT

• Assessment must determine the underlying aetiology of anorexia-cachexia, effectiveness of treatment and impact on quality of life for the patient and his/her family (refer to the Guideline – Symptom assessment)
• Clinical history to identify relevant aetiology, evidence of weight loss and focused physical
• Simple measurements – arm circumference
• Laboratory investigations (as appropriate to identify any reversible causes)
• Serum albumin, C-reactive protein, erythrocyte sedimentation rate (ESR). Low serum albumin and high C-reactive protein (CRP) indicates primary anorexia/cachexia

MANAGEMENT

• Management should be individualised based on the stage of the disease, and patient preferences and risks and benefits with treatment
• Correct the correctable
• Identify anorexia/cachexia at an early stage
• Use a multi-disciplinary approach – doctor, nurse, physiotherapist, dietician, social worker, occupational therapist, community volunteer, psychologist, cleric
• The goals of care should depend on the stage of the disease and the likely risks and rewards of investigations and treatments
• Therapeutic options are unlikely to have any impact on survival, but may improve quality of life
• Use both pharmacological and non-pharmacological measures
• If there are signs and symptoms of dehydration, consider subcutaneous administration of fluids
• Enteral feeding can be considered if there is dysphagia and patient experiences hunger
• Consider ‘Limited Time Trial’ feeding with NG or NJ tube if the patient wants to try; if helpful and patient has prognosis of 6 months or more, PEG can be a longer-term option
• Total parenteral nutrition is best avoided as there is no evidence of benefit

Explanation and Education

• Explain what anorexia/cachexia is and the probable causes of the condition
• Explain that decreased oral intake is a natural part of the disease process
• Explain that lack of hunger and thirst is normal in dying patients
• Explain the possible interventions and limitations
• Explain that intravenous administration of fluids is unlikely to alter the course of the illness and may not be beneficial in dying patients
• Explain the risks of intravenous hydration (e.g. fluid overload) in dying patients
• Acknowledge and address the psychological impact on patient/carer
• Educate the family to avoid force-feeding

Correct the correctable

• Address early satiety, gastroparesis, delayed gastric emptying
• Ensure effective symptom management (e.g. nausea and vomiting, pain)
• Treat infections

Non-pharmacological measures

Encourage the patient:

• To consume small, frequent, high caloric meals (e.g. ice cream) tailored to the patient’s preferences and capacity to eat
• To participate in physical activity to the extent possible
• To practice effective oral care
• to manage good skin care -to prevent the development of pressure sores

Pharmacological measures

• Medications prescribed for anorexia/cachexia syndrome may have limited benefits with considerable side-effects
• If life expectancy of the patient is in months and years, progestogens are preferred
• If life expectancy of the patient is in weeks, corticosteroids are preferred (on a short-term basis)
• Progestogens
• Megestrol Acetate
• Starting dose: 80-160mg PO daily
• If initial response is poor, double the dose in 2-3 weeks
• Maximum dose: 800mg/24 hours
• Optimum dose for appetite stimulation: 160mg PO daily
• Side effects include oedema and thromboembolism
• The tablet is large and patients with dysphagia will find it difficult to swallow
• Combination with NSAIDs
• Megestrol Acetate 160mg tid + Ibuprofen400mg tid
• Megestrol Acetate 160mg bd + celecoxib 300mg daily + l-carnitine + antioxidants
• Corticosteroids
• Dexamethasone
• Dose – 2-6mg PO OD (PC) am
• Withdraw if no effect in 7-10 days
• If useful decrease gradually to the lowest effective dose
• Prescribe along with gastroprotectors
• Side effects include cushingoid changes, myopathy, peptic acid disease, insomnia and psychiatric disorders like psychosis, mania, delirium and depression
• Prednisolone
• Dose – 15-40mg PO OD (PC) am
• Withdraw if no effect in 7-10 days
• If useful, decrease gradually to the lowest effective dose
• Side effects (same as with Dexamethasone)
• Prokinetics
• Metoclopramide 10mg PO tid (½ hour AC)
• Domperidone 10mg PO tid (½ hour AC)

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REFERENCES

• Bruggeman, A., Kamal, A., LeBlanc, T., Ma, J.D., Baracos, V., Roeland, E. Cancer Cachexia: Beyond Weight Loss. Journal of Oncology Practice (2016); 12(11): 1163-1172
• Ferraro, D. C., Grant, M., Koczywas, M., Dorr-Uyemura, L.  Management of Anorexia-Cachexia in Late Stage Lung Cancer Patients. Journal of Hospice and Palliative Nursing (2010); 14(6): 1-12
• Nicolini, A., Ferrari, P., Masoni, M.C., Fini, M., Pagani, S., Giampietro, O., Carpi, A. Malnutrition, anorexia and cachexia in cancer patients: A mini-review on pathogenesis and treatment. Biomedicine & Pharmacotherapy (2013); 67: 807-817
• Twycross, R. (2003). Symptom Management II. Introducing Palliative Care. (pp. 105-162)