Anorexia and Cachexia

KEYPOINTS

• Cancer and other diseases, such as HIV/AIDS, can often cause a lack of appetite (anorexia) and weight loss with muscle wasting (cachexia)
• These are often accompanied by fatigue
• The process of anorexia/cachexia is complex and involves numerous metabolic changes
• Anorexia/cachexia is present in up to 80% of patients with cancer

• Children with solid tumours are more likely to develop cachexia than children with haematological malignancies
• Seeing a child not eating may be very distressing for the family

ASSESSMENT

(see Foreword)

• A good history and clinical assessment is important to try and identify any reversible cause of the anorexia/cachexia
  • Assess appetite
  • Assess ability/difficulty in swallowing and chewing
  • Identify any other symptoms such as pain, constipation, depression, or nausea and vomiting that may be causing decreased appetite
  • Examine the mouth for any sores, lesions or infection

• Treatable causes of anorexia/cachexia include:
  • Ongoing pain
  • Nausea and vomiting
  • Depression
  • Oral problems
    • Dry mouth
    • Mucositis secondary to chemotherapy
    • Thrush/candidiasis
    • Oral herpes
  • Gastrointestinal motility problems
    • Reflux oesophagitis
    • Gastric stasis
    • Constipation

• As in adults: evaluate possible correctable conditions that affect appetite and feeding such as nausea, pain, oral conditions, constipation and depression

MANAGEMENT

• Consider treatment of the underlying cause if one is identifiable

Consider if patient is well enough to benefit

Nonpharmacological Approaches

• Patient and family education
• Eliminate dietary restrictions
• Encourage patient to eat their favourite foods

Pharmacological Approaches

• Ensure good pain and nausea/vomiting control, treat constipation
• Stimulate appetite
  • Megestrol acetate 40-240 mg up to four times a day PO or 800 mg once daily PO
  • Dexamethasone 4-8 mg qAM PO

• As in adults: corticosteroids may help appetite. However, because of potential significant adverse side effects they should probably not be used if anorexia/cachexia is the only symptom they might benefit

PITFALLS/CONCERNS

• Increasing calorie intake is unlikely to increase body weight and quality of life in advanced cancer cachexia

PALLIATIVE TIPS

• Despite the appearance of malnutrition, anorexia/cachexia is usually not simply reversed with improved nutrition
• Aggressive feeding can often make symptoms such as nausea, vomiting and pain worse
• Educating the family that wasting is a part of the disease process and not the result of the family not providing enough nutrition for the patient is important
• Anorexia can cause significant anxiety and distress for family members and caregivers who may not understand that loss of appetite is a common symptom of dying
• There is no evidence that providing nutritional support either enterally or parenterally decreases morbidity or mortality in terminally ill patients

• Smaller, more frequent meals of the child’s favourite foods may help
• Small plates and using straws may also help

SOURCES/REFERENCES

1. Del Fabbro E, Dalal S, Bruera E. Symptom control in palliative care - part II: Cachexia/anorexia and fatigue. J Palliat Med 2006;9(2):409-421. http://www.ncbi.nlm.nih.gov/pubmed/16629571
2. Hardy J, Rees E, Ling J, Burman R, Feuer D, Broadley K, Stone P. A prospective survey of the use of dexamethasone on a palliative care unit. Palliat Med 2001;15(1):3-8. http://www.ncbi.nlm.nih.gov/pubmed/11212465
3. Lopez A, Figuls M, Cuchi G, Berenstein E, Pasies B, Alegre M, Herdman M. Systematic review of megestrol acetate in the treatment of anorexia-cachexia syndrome. J Pain Symptom Manage 2004;27(4): 360-369. http://www.ncbi.nlm.nih.gov/pubmed/15050664
4. Nelson KA, Walsh D. The cancer anorexia-cachexia syndrome: a survey of the prognostic inflammatory and nutritional index (PINI) in advanced disease. J Pain Symptom Manage 2002;24(4):424-8. http://www.ncbi.nlm.nih.gov/pubmed/12505211
5. Poole K, Froggatt K. Loss of weight and loss of appetite in advanced cancer: a problem for the patient, the carer, or the health professional? Palliat Med 2002;16(6):499-506. http://www.ncbi.nlm.nih.gov/pubmed/12465697
6. Plonk W, Arnold R. Terminal care: the last weeks of life. J Palliat Med 2005;8(5):1042-1050. http://www.ncbi.nlm.nih.gov/pubmed/16238518
7. Shragge J, Wismer W, Olson K, Baracos V. The management of anorexia by patients with advanced cancer: a critical review of the literature. Palliat Med 2006;20(6):623-629. http://www.ncbi.nlm.nih.gov/pubmed/17060256
8. Strasser F. Eating-related disorders in patients with advanced cancer. Support Care Cancer 2003;11(1):11-20. http://www.ncbi.nlm.nih.gov/pubmed/12527949
9. Strasser F, Bruera ED. Update on anorexia and cachexia. Hematology/Oncology Clinics of North America 2002;16(3):589-617. http://www.ncbi.nlm.nih.gov/pubmed/12170570
10. Sutton LM, Demark-Wahnefried W, Clipp EC. Management of terminal cancer in elderly patients. Lancet Oncol 2003;4(3):149-57. http://www.ncbi.nlm.nih.gov/pubmed/12623360
11. Tomíska M, Tomisková M, Salajka F, Adam Z, Vorlícek J. Palliative treatment of cancer anorexia with oral suspension of megestrol acetate. Neoplasma 2003;50(3):227-33. http://www.ncbi.nlm.nih.gov/pubmed/12937858

Back to top of page Next page Previous page