Anorexia

Short Answer

A. Incorrect. A feeding tube would be premature, is unlikely to affect the course of illness, and should be inserted only after a full discussion of risks and benefits. A trial of megestrol acetate would be appropriate in this case.

B. Incorrect. This dose is too low to impact appetite. 200 mg po q6-8h would be more appropriate.

C. Correct! Megestrol acetate is often effective in this situation, and improving this patient[base ']s appetite might impact her quality of life.

D. Incorrect. Dexamethasone is a second-line treatment for anorexia, and might be problematic in a patient with a history of diabetes. Megestrol acetate would probably be better tolerated.

E. Incorrect. Anorexia and cachexia are common in many advanced illnesses, not just cancer. Evaluation for malignancy is probably unnecessary. A trial of megestrol acetate would be appropriate.


Long Answer

The correct answer is C. Trial of megestrol acetate, 200 mg po q6-8h.

Anorexia and cachexia are common in many advanced illnesses, not just cancer. Anorexia and cachexia may result in significant distress, especially for caregivers. Caregivers are often concerned that lack of eating and weight loss is contributing to the underlying illness, but the reverse is typically the case. Adequate feeding rarely reverses the cause of advanced disease in patients with poor functional status and limited prognosis, even with artificial feeding. However, feeding may be beneficial in selected situations, including patients with good functional status, malabsorption, temporary unconsciousness, sepsis, and for symptom control where true hunger exists. The decision not to place an artificial feeding tube may be considered ethical if the burdens outweigh the benefits and the options have been discussed with the patient and/or family and they agree with the plan. It is important to consider conditions that may exacerbate loss of appetite and weight loss. The table below shows a mnemonic for the differential diagnosis of treatable causes and treatments of anorexia: Cause...Treatment<br>
A: Aches and pains...Improve pain management

N: Nausea and GI dysfunction (dysphagia, odynophagia)...See nausea/vomiting, Question 3. Evaluate whether invasive diagnostics are appropriate

O: Oral candidiasis/Oral lesions...For candidiasis: nystatin 5 ml (500,000 U) swish and swallow qid; hold in mouth 2-5 minutes. Evaluate for herpes simplex, etc.

R: Reactive/organic depression, anticipatory grief...Antidepressives/social work, spiritual intervention

E: Evacuation problems (constipation)...See constipation, Question Four

X: Xerostomia (dry mouth)...Artificial saliva with mucin

I: Iatrogenic--Chemo, Radiation, Medications, Feeding problems, Infections...Reevaluate risks and benefits of treatment. Stop if unnecessary, especially anticholinergics. Ensure that caregivers are adequately helping with feeding if necessary, and that desirable foods are offered. Evaluate risks and benefits of treatment, patient goals

A: Acid: GERD, PUD Antacids, H2 blockers


You have evaluated the patient for each of these causes, and found no clear source that you can treat. Caregivers may often complain about anorexia, when their real concern is that they now realize that the patient is dying. Although improving appetite will not alter the course of the disease, resumption of eating for enjoyment and a restored sense of normalcy may improve patient and caregiver well-being.

At times, anorexia and cachexia are more bothersome to the caregiver than to the patient. Reassuring the caregiver that they are not doing anything wrong and that this is the natural course of the disease is appropriate in this situation. Suggesting other activities to engage both the caregiver and the patient (such as talking together, reading together, making tape recordings for family members) can provide great satisfaction to both the patient and caregiver. Other management options include discontinuation of dietary restrictions imposed for management of long-term complications of hypertension and diabetes, reduction of portion sizes, and counseling of family members to avoid pressuring the patient to eat.

Ntritional supplements, while expensive and sometimes difficult to tolerate, can assist with caloric intake, although providing ice cream or milkshakes may be just as effective. Small doses of alcohol are sometimes reasonable to stimulate appetite. Megestrol acetate is another option to stimulate appetite in patients who would like to eat for pleasure, although it is expensive. The initial dose is 200mg po q6-8h, titrating up (maximum daily dose 800 mg). Medical administration of cannabinoids is not legal in all states, but may have some benefit. Dexamethasone, starting at a dose of 2mg qd and titrated up to 20mg qd, may also be of benefit. Androgens may be of some benefit in patients with AIDS.

Last update: 7/13/02; 4:19:15 PM.