8.5 (10.5) Etiology, classification, assessment, and treatment of the anorexia-cachexia syndrome Flashcards
What are two negative balances associated with anorexia-cachexia syndrome?
What are two major drivers of the syndrome?
Negative energy + protein balance
Driven by reduced food intake + abnormal metabolism due to inflammation generated in brain, tumor, tissues by tumor, diversity of host cells
List four patient conditions that will exacerbate muscle loss in the cachexia syndrome
old age (age-related sarcopenia)
physical deconditioning
nutritional deficiency
pulmonary disease (COPD)
chronic renal failure
hypogonadism
insulin resistance
drugs
medical interventions (including all major cancer therapies: surgery, radiotherapy and chemotherapy)
FS:
- Old age
- Physical deconditioning
- Poor intake
- Chronic comorbidities (COPD, CKD, diabetes)
- Drugs/medical txs
What are FOUR complications of cachexia syndrome? (medical and non medical)
decreased physical function
decreased immune function
increased morbidity
increased mortality
psychosocial isolation
increased health service utilization
What defines grade three weight loss according to the subjective global assessment?
Grade 1-month loss 6-month loss
0 0–1.9% 0–1.9%
1 2.0–2.9% 2.0–5.9%
2 3.0–4.9% 6.0–9.9%
3 5.0–9.9% 10.0–19.9%
4 ≥ 10% ≥ 20%
What defines grade 4 weight loss according to the subjective global assessment
≥ 10% over one month ≥ 20% over 6 months
Define cachexia syndrome
a MULTIFACTORIAL SYNDROME characterized by an ongoing loss of SKELETAL muscle mass (with or without loss of fat mass) that cannot be fully REVERSED by conventional nutritional support and which leads to progressive functional impairment
What three findings might suggest that a patient is at risk of anorexia-cachexia syndrome?
weight loss (grade 3-4, BMI <18.5)
reduced food intake (< 1500 kcal/day)
systemic inflammation (serum CRP > 10 mg/L)
poor performance status
aggressive malignancy
FS:
Store - weight loss (grade 3-4, BMI <18.5)
Intake <1500kcal/day + Inflammation CRP >10
Performance (PPS)
Potential (minimal with advanced ca)
When clinically assessing for anorexia cachexia syndrome what four MAJOR initial elements need to be assessed?
SIPP
nutritional Stores
Intake
Performance/psychosocial impact
catabolic drivers/Potential for reversal
When creating treatment plan for patients with anorexia cachexia, what factors do you have to consider
Type of anorexia cachexia (pre-cachexia, cachexia, refractory cachexia)
Performance status
Prognosis
Expectations (GOC)
FS:
Stores – S+I = type of anorexia
Intake – S+I = type of anorexia
Performance, PPS, prognosis, GOC
Potential to reverse
A patient with breast cancer is assessed for the anorexia-cachexia syndrome. They are found to have at lost 2% of their body weight in the last six months, are eating 1600kcal/day and are receiving maintenance letrozole for hormone positive cancer. There is no evidence of progression at this time. The patient reports decreased intake due to dysguesia. What recommendation do you make?
“Pre-cachexia” –> Monitor + Preventative intervention
Ask patient to F/U if further weight loss/decrease intake
Dysguesia assessment/treatment
A patient with PANCREATIC CANCER is assessed for the anorexia-cachexia syndrome. They are found to have at lost 35% of their body weight in the last six months, are eating 500kcal/day and are admitted to PCU for symptom mgmt. They are not receiving chemo x 4 weeks with no further tx options. What recommendation do you make?
“Refractory cachexia”
Symptomatic management ie steroids, megace + rule out malabsorption from pancreatic enzyme deficiency, DM
Ethical discussion around nutritional support
Psychosocial support
normalize as consequence of advanced illness
FS:
Education - normalize as result of advanced cancer
Diet - eating for comfort, discuss nutritional support ethics
Tx reversible - e.g. malabsorption (pancreatic enzyme), DM
Tx symptoms - Dex, megace
—-
Tx source (anorexia = OT/PT)
Tx symptoms
Tx complications
Educator
Refractory cachexia due to rapidly progressive cancer unresponsive to therapy is associate with what prognosis?
<3 months
A patient with ovarian cancer is assessed for the anorexia-cachexia syndrome. They are found to have at lost 11% of their body weight in the last six months, are eating 1400kcal/day and are living at home receiving 3rd line chemotherapy with further options for if/when this fails. What recommendation do you make?
“Cachexia” –> Multimodal management:
dietician consult
physio consult (exercise)
treat secondary causes
treating cachexia weight loss (steroid, megace, dronabinol, ghrelin)
anti-inflammatory (NSAID or EPA)
FS:
- Education
- Diet + exercise (consult dietician and PT)
- Symptomatic tx
- Tx reversible
What are the 4 major treatment considerations for a patient with anorexia cachexia syndrome who is not at EOL and is not bed bound
dietician consult
physio consult (exercise to maintain skeletal muscles)
treat secondary causes
treating cachexia (steroid, megace, dronabinol, ghrelin)
anti-inflammatory (NSAID or EPA)
FS:
Education
Diet + exercise (dietician and PT)
Tx symptom
Tx source
List medications that can be used to treat cachexia
- 2 recommended
- 2 insufficient evidence
- 1 not recommended
Corticosteroids (for patients with short life expectancy - improves appetite but not weight gain)
Progestins (eg megace - improves weight gain and appetite, risk of DVT))
Dronabinol, CBD (poor evidence)
Ghrelin (ie hunger hormone)
Uptodate:
Potentially beneficial agents - steroid, megace
Insufficient evidence - mirtazapine, olanzapine, ghrelin, NSAIDs
Not recommended - cannabinoids
What are 4 SECONDARY CAUSES of reduced intake that can contribute to reduced energy intake for those who are losing weight?
Oral problems: dentures, mouth sores, thrush, dry mouth, dysphagia/odynophagia
GI: early satiety, N/V, obstruction, constipation, diarrhea, abdo pain
Metabolic: diabetes, malabsorption (both common associations with advanced pancreatic cancer) and which if not managed with insulin/pancreatic enzyme supplements will result in continuing weight loss independent of any nutritional intervention
Side effects of drugs
Fatigue: sleep disturbance, physical limitation, motivation, cognitive fatigue
Psychological factors: anxiety, depression, family or spiritual distress
FS: use vindicatenp for DDX
What are 2 key basics in dietary advice you can give to patients with cancer?
- Avg daily calorie deficit in weight losing cancer patient is 250-400kcal/day
- Vital to maintain high protein intake (1-1.5g/kg of BODY WEIGHT/day) to maintain muscle mass
2 approaches to treat inflammation (although evidence not great)
NSAIDs
Dietary fish oil
A patient’s has refractory anorexia-cachexia syndrome and the family is concerned about the patient’s weight loss. What are three things you will review with them when discussing the syndrome?
discuss patients expectations concerning future benefit of any intervention
Burden of intervention (eg daily oral supplements) needs to match what patient is willing to go through for minimal gains
Frame as consequence of advanced cancer
Suggest symptomatic tx (ie. dex)
FS:
- Education: consequence of advanced cancer
- Diet: discuss burden of intervention + expectation of minimal gains
- Symptomatic tx (e.g. Dex)
What are the two major classes of medication for cancer associated cachexia? How does each one result in weight gain?
corticosteroids - increased appetite, reduced inflammation?
progestins - increased appetite, increased caloric intake
What are 3 major side effects of megesterol acetate
DVT/lower extremity edema
sleep disturbance
sexual side effects
How does cannabinoid help with anorexia cachexia (mechanism)
chemosensory alteration - ie increasing patient’s ability to taste and smell -> increase food palatability
List 4 conditions for the use of artificial nutrition in the setting of cancer/palliative care
Unable to maintain nutrition via oral route
Relatively long life expectancy (at least 3 months)
Undergoing active treatment for life limiting illness
Defined end point
What is the main cause of decreased food intake in advanced illness
primary cachexia (CNS) not secondary causes
