Palliative Care and Pain Management at the End of Life ___________________________________________
Assessment Guidelines for assessing anorexia and cachexia have been devel- oped for the cancer and HIV settings [310; 348]. According to NCCN guidelines, assessment of anorexia and cachexia in patients with cancer include the following [310]: • Determination of the rate and severity of weight loss • Examination of the oral cavity (the mucous mem- branes, teeth, gingiva, and lips) • Review of the medications list for drugs that interfere with intake • Evaluation of symptoms that have the potential to inter- fere with eating and drinking • Evaluation for endocrine abnormalities that may be an underlying cause • Assessment of social and economic factors The guidelines for the assessment of HIV-related wasting recommend the following [348]: • Thorough and complete history and physical examina- tion, with specific questions related to the patient’s nutritional status, caloric intake, appetite, and gastroin- testinal and physiologic functioning • Measurements of body composition (considering the following factors: age, height, weight, ideal body weight, body cell mass (by bioelectrical impedance analysis), and body mass index • Laboratory tests (plasma HIV RNA, CD4 cell count, free and total serum testosterone, and serum albumin and thyroid function (if clinically warranted) • Psychosocial evaluation • Dietary assessment Management Few evidence-based guidelines for the treatment of anorexia and cachexia are available, primarily because of the lack of studies on these under-recognized conditions and the still- emerging understanding of the causes of cachexia. The first step in managing anorexia is to treat symptoms that interfere with appetite and/or the ability to eat. In addition, nonpharmaco- logic interventions should be directed at improving enjoyment of food, increasing the sense of well-being, and enhancing a sense of normalcy in daily activities. The patient should be encouraged to try favorite foods, to eat small frequent meals, and to drink high-calorie nutritional supplements [310; 347; 349; 350]. Other interventions include an exercise program, consultation with a nutritionist, swallowing evaluation, and psychiatric consultation (if it is determined that the patient has an eating disorder) [310]. For people with end-stage liver disease and an inadequate caloric intake, protein restriction (to prevent hepatic encephalopathy) should be avoided [201]. Two drugs are FDA approved as appetite stimulants for anorexia associated with life-limiting disease ( Table 17 ). Meges- trol acetate is FDA approved for the treatment of anorexia,
cachexia, or unexplained weight loss in patients with AIDS [351]. It has become the most widely used drug for these indications for people with other life-limiting diseases, and a meta-analysis of data from studies (involving people with a variety of life-limiting illnesses) demonstrated that megestrol acetate was beneficial, especially with respect to improving appetite and weight gain in people with cancer [351]. Meta- analysis showed a benefit of megestrol acetate compared with placebo, particularly with regard to appetite improvement and weight gain in cancer, AIDS, and other underlying conditions. There was insufficient information to define the optimal dose, but higher doses were more related to weight improvement than lower doses. Side effects (e.g., edema, thromboembolic phenomena) and deaths were more frequent in patients treated with megestrol acetate compared with placebo [351]. Today, use of megestrol is limited due to the increased risk for throm- boembolism. Dronabinol (Marinol), an oral cannabinoid, is FDA approved for anorexia associated with weight loss in people with AIDS [326]. Because of its effects, dronabinol should be used with caution for people with cardiac disorders, depression, or a history of substance abuse; people taking concomitant sedatives or hypnotics; and older individuals [326]. In addition to appetite stimulants, metoclopramide, a drug approved for treatment of nausea and vomiting, is recom- mended for anorexia related to early satiety in people with cancer [310; 349]. The treatment of cachexia is more challenging because its pathophysiology is poorly understood and because treatments may differ according to the life-limiting disease. According to the guidelines for cachexia related to cancer and HIV infec- tion, management includes improving nutritional intake, treating disease-related causes of cachexia, treating anorexia, and addressing psychosocial or lifestyle issues [310; 348]. Currently, there is no one treatment or combination of treat- ments that is effective for all patients with cachexia [350]. Increasing oral intake alone is not sufficient, and reversal of wasting may not always be possible; the goal should be to prevent or delay further wasting and functional decline [310; 348; 350]. As noted, the use of megestrol acetate is effective in increasing weight, but increased nutrition and weight are not sufficient to effectively manage cachexia, and more research is needed to identify agents to increase body mass and to define a multimodal strategy to stop and/or reverse wasting. These strat- egies may differ according to the underlying chronic disease. Studies have indicated that recombinant human growth hormone (rhGH) significantly increases lean body mass and improved physical endurance and quality of life in people with HIV [352; 353]. In addition, rhGH has shown benefit in cachexia related to pulmonary and cardiac disease [354]. Recombinant somatropin (Serostim) is approved for the treatment of people with HIV with wasting or cachexia; con- comitant antiretroviral therapy is necessary [252]. The drug is contraindicated in active neoplasia [252].
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MDCA1525
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