Anorexia-Cachexia CBM and Oxford Flashcards
What is anorexia?
- Anorexia: Loss of appetite
What the symptoms of anorexia/cachexia?
Symptoms:
- anorexia
- fatigue
- depression
- early satiety
- reduced function
- weight loss
What are the “biological” features?
- increased resting energy expenditure
- High CRP
- High LDH
- low albumin (late finding)
- low testosterone
What is the difference between primary and secondary cachexia?
Primary Cachexia
- host-tumour liason
- wasteful consumption of energy
- Resetting of metabolic processes in fat, muscle and organs
- muscle and fat loss
Secondary Cachexia
- potentially treatable causes from reduced nourishment
- muscle and fat loss
List causes of secondary cachexia
Psychological
- anxiety
- depression
- family distress
- spiritual distress
Eating problems
- appetitie
- disturbed taste or smell
Oral problems
- dentures
- thrush
- mucositis/ulceration
- dry mouth
Swallowing problems
Stomach problems
- gastric reflux
- early satiety
- nausea and vomiting
Bowel problems
- Obstruction
- Constipation
- Diarrhea
Malabsorption
- Pancreas
- Fistulas
- short gut syndrome (ileostomy, etc)
Fatigue
- sleep disturbance
- physical limitations
- motivation
- cognitive fatigue
Function
Pain
Metabolic disorders
- diabetes
- adrenal insufficiency
- hypogonadism
- thyroid insufficiency
Which cancers are more likely to cause anorexia-cachexia?
- upper GI
- pancreas
- lung
Unusual in :
- breast
- heme
How does a chronic inflammatory state cause cachexia?
- Strong immune response
- unknown trigger
- Neutrophils, lymphocytes and macrophages invade tumour
- produce inflammatory chemokines and cytokines
- cytokines activate tumour oncogenes –> further stimulates inflammatory actions of immune cells
- Cytokines:
- IL-1B, IL-6, IL-8 and MIC-1
Muscle loss
- inflammatory activity activates genes that stimulate proteolytic system (normally balances muscle synthesis and breakdown)
- ubiquitin-proteosome system
- muscle tissue is catabolized
- Inflammtory cytokines blcok anabolic effects of growth hormone and insulin growth factor, induce insulin resistance.
- reduced muscle synthesis
- Myostatin upregulatation
- increased proteolysis
- Muscle synthesis decreases
- reduced intake of protein, increased resting expenditure
Anorexia pathophysiology
Appetite mediation
- Hypothalamus
- cytokines activate POMC (pro-opiomelanocortin system)
- reduces appetite
- increases energy expenditure that cannot be met via:
- alpha-melanocyte-stimulating hormone binds to type 4 melanocortin recptor
- Solitary tract nucleus (STN)
- brainstem
- appetite and gastric motility
Fat Loss
- Lipolysis increases
- fat synthesis decreases
- increased catecholamine activity
- upregulated zinc alpha 2 glycoprotein (ZAG)
Assessemnt of anorexia-cachexia
- Initial weight and height (BMI) kg/m2
- BMI < 18.5 underweight
- Patient recorded information
- ESAS
- PG SGA
- Test of function
- 6 minute walk test
- sit to stand time
- gait speed
- steps measured
- imaging (DEXA or CT scans)
What lab tests are helpful for anorexia-cachexia?
- CRP ( > 10 mg/L)
- acute phase protein
- produced by liver
- powerful prognosticator
- Albumin
- not a reliable early marker
- advanced cachexia only
What is a framework for treating anorexia-cachexia?
- Decide if at significant risk (grade 3-4 weight loss, BMI < 18.5, reduced appetite, evidence of muscle mass)
- Decide if primary vs secondary
- Treat secondary causes
- Use interdisciplinary team
- Address family concerns
- Emply specific tools and protocols for assessment and treatment
- Consider exercise program (resistance ideal)
- strong antiinflammatory effects
- single best therapy for fatigue
- Relevant anti-inflammatory medications
- NSAIDS (ibuprofren 400 mg po tid)
- EPA/DHA (1.5-2.0 g/day)
What dietary advice would you give?
- enquire about specific atypical diets
- Broad balanced diet
-
Total protein intake 1.5 g/kg/day
- meats, eggs, dairy, protein supplements
- Improve taste
- spices
- flavouring with lemon, orange, juices, pickles
- sugar
- marinate meats
- meat aversion common
- sparkling water
- Improve food presentation
- Eat aware from odours
- Small portions, more frequently
- Social meals with atmosphere
What about dietary supplements?
- Can complement regular food intake
- Omega 3 fatty acids (oily fish)
- suppress IL-6 production, stop lipolysis
- EPA 2-2.5 g/ day
- DHA (inflammatory reducing)
- may prevent platelet aggregation , incr bleeding risk?
- 2007 cochrane review and 2021 systematic review : insufficient data.
- Maybe more beneficial for pancreatic cancer
- Vit D.
- muscle function and synthesis
- 1000 IU daily
- NOT IN HYPERCALCEMIA
- Vit C / multivitamin
- if malnourished
- check with oncology if chemotherapy