___________________________________________ Palliative Care and Pain Management at the End of Life
PHARMACOLOGIC MANAGEMENT OF ANOREXIA AND CACHEXIA
Drug
Dose Range
Findings
FDA Approval
Megestrol acetate
200–600 mg/day
Increased appetite, food intake, and weight
For the treatment of anorexia, cachexia, or unexplained weight loss in patients with AIDS For anorexia associated with weight loss in people with AIDS
Dronabinol
2.5–20 mg, twice daily (before lunch and dinner)
Stimulated appetite and improved body weight
Metoclopramide
10 mg, 3 times daily Enhanced appetite in people with early satiety
For nausea and vomiting
Recombinant human growth hormone
0.1 mg/kgSC at bedtime (max: 6 mg)
Increased lean body mass and improved physical endurance and quality of life among people with HIV-related cachexia Increased body weight and lean body mass in cachexia related to HIV and COPD
For HIV-related wasting or cachexia (with concomitant antiretroviral therapy) Adjunctive therapy to promote weight gain after weight loss following extensive surgery, chronic infection, or severe trauma and for some patients without a definitive pathophysiologic cause of weight loss
Oxandrolone (anabolic steroid)
5–20 mg/day
Ghrelin
Not defined
Increased lean body mass in people with end-stage renal disease, COPD, and heart failure
Not approved
AIDS = acquired immune deficiency syndrome, COPD = chronic obstructive pulmonary disease, HIV = human immunodeficiency virus, SC = subcutaneous. Source: [310; 326; 349; 351; 352; 353; 354; 355; 356]
Table 17
The anabolic steroid oxandrolone (Oxandrin) is FDA approved as adjunctive therapy to promote weight gain after weight loss following extensive surgery, chronic infection, or severe trauma and for some patients without a definitive pathophysiologic cause of weight loss [252]. The drug has shown benefit in increasing body weight and lean body mass in cachexia related to HIV and COPD [355; 356]. The drug is safe and well toler- ated, but more studies are needed to determine its risk-benefit ratio before it can be used more widely [357]. Ghrelin has been evaluated for the treatment of cachexia, and its anti-inflammatory properties may address the proposed role of inflammation in the development of cachexia [358]. The results of small studies have demonstrated that ghrelin increases lean body mass in people with end-stage renal disease, COPD, and heart failure [354]. A 2018 systematic review found insufficient evidence to either support or refute the use of ghrelin for the treatment of cachexia [359]. Again, more research is needed before this agent can become part of clinical practice. For people with a limited life expectancy (weeks to days), the clinician should provide education and emotional support to the patient, family, and/or caregiver regarding the natural his- tory of anorexia and cachexia, and what to expect with disease progression. This can alleviate distress that sometimes leads to well-meaning but futile attempts to pressure or coerce the
patient into increased feedings. It may be helpful to discuss with patient and family the following points in reference to end-of-life feeding [310]: • Absence of hunger and thirst and the wish to suspend the effort required for feeding are part of the disease process itself, to be expected near the end of life. • Nutritional support eventually will not maintain weight nor reverse weight loss. • There are risks associated with artificial nutrition and hydration (e.g., fluid overload, infection, hastened death); intravenous feedings rarely improve outcomes. • Symptoms like dry mouth should be treated with local measures. • Discontinuing previously initiated enteral/parenteral nutrition near the end of life is appropriate, ethically permissible, and may improve some symptoms. DIARRHEA Diarrhea is characterized by the frequent passage of loose, watery stools, usually defined as more than three unformed stools within a 24-hour period [360]. Diarrhea is most often acute, lasting for a few days; diarrhea is chronic when it persists for more than three weeks [360]. Left unchecked, diarrhea can result in dehydration, electrolyte imbalance, and fatigue.
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MDCA1525
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