amp Cachexia Hong Phuc Tran MD 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 ID: 677451
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Slide1
Palliative Care:Anorexia & Cachexia
Hong-
Phuc
Tran, M.D.
g013Slide2
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 cachexiaSlide3
DefinitionsAnorexia: 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
caloriesSlide4
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 Slide5
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 denturesSlide6
Metabolic disordersThyroid problemsDiabetesAdrenal insufficiency
Altered taste and smell
Odors (e.g. certain smells of food)
Generalized weakness, lethargySlide7
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 & familiesSlide8
Some Examples of Causes of Cachexia
Cancer
AIDS
Chronic obstructive pulmonary disease
Chronic renal insufficiency
Congestive heart failure
Cirrhosis
Dementia
Chronic infections
Autoimmune diseaseSlide9
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 lossSlide10
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 supplementsSlide11
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 prognosisSlide12
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 snacksSlide13
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
DexamethasoneSlide14
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 slowlySlide15
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, neurotoxicitySlide16
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 effectiveSlide17
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 cachexiaSlide18
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)Slide19
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, counselingSlide20
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 patientsSlide21
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, caringSlide22
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;12:601607.
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 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.Slide23
Effective response to caregivers’ fears that loved ones are “starving” to death
Listen and assess for feelings of guilt
Ask about cultural and religious values
Explain physiologic differences between starvation and anorexia-cachexia
Explain artificial nutrition nor increased oral intake will not likely improve survival or weight gain in end stage disease
All of the aboveSlide24
Answer ESlide25
Primary anorexia –cachexia differs from starvation in that
Less protein synthesis occurs in anorexia cachexia due to decreased production of acute phase
Decreased
cortisol
levels suggest a chronically altered
neuroendocrine
state
Proinflamatory
cytokines are commonly involved, causing immune dysfunctionSlide26
Answer CAnorexia cachexia MORE protein synthesisCortisol
levels do not reflect changeSlide27
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.
Insert NG tube and start tube feedings
Reassure the family his weight loss is normal
Complete a history and physical
Order
nystatin
suspension swish and swallow tidSlide28
Answer CComplete a H and P first to assess any reversible causes for anorexia cachexiaThen consider possible treatments