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Anorexia, Cachexia, Nausea and Vomiting Are Common in Advanced Cancer

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Anorexia, Cachexia, Nausea and Vomiting Are Common in Advanced Cancer ARTICLE RUNNING HEAD CHANGE ON MASTER What’s new ? Anorexia, cachexia, nausea • Low-dose levomepromazine, 6–25 mg/24 hours, has and vomiting become more widely used and in some centres is prescribed before hyoscine butylbromide in inoperable Robert Twycross chronically obstructed patients • Although not available as an injection, olanzapine has been used in patienst with refractory nausea and vomiting, particularly when the much cheaper levomepromazine causes unacceptable sedation Anorexia, cachexia, nausea and vomiting are common in advanced cancer. Although evidence from randomized controlled trials is limited, a rational approach to management is possible provided Appetite stimulants are helpful in some patients. They should the doctor is: be stopped if no benefit is seen after 1 week. A corticosteroid • aware of the common causes (e.g. prednisolone, 15–30 mg o.d., dexamethasone, 2–4 mg o.d.) • able to work from basic knowledge of anatomy, physiology and is sometimes useful, but the effect may last only a few weeks. pharmacology. A progestogen (e.g. medroxyprogesterone acetate, 400 mg o.d., megestrol, 160 mg o.d.) may have an effect lasting months and is generally associated with weight gain. Anorexia Appetite stimulants are inappropriate in patients with early Anorexia may be primary (as in cachexia–anorexia syndrome) or satiety without concurrent anorexia. secondary to one or more other conditions (Figure 1). Although anorexia and early satiety are often linked, early satiety also occurs Causes of poor appetite in advanced cancer without concomitant anorexia (“Although I look forward to my meals, I feel full up after a few mouthfuls and can’t eat any more”). Early satiety without anorexia is associated with a small stomach Causes Management possibilities (post-gastrectomy), gastric stasis, hepatomegaly and gross ascites. • Unappetizing food Choice of food by patient Patients are often more accepting of anorexia than their families. • Too much food provided Small meals Management – helping the patient and family accept and ad- • Altered taste Adjust diet to counter taste just to reduced appetite is often the focus of management. changes • Listen to the family’s fears. • Dyspepsia Antacid, antiflatulent, prokinetic • Explain to the family that, in the circumstances, it is normal drug to be satisfied with less food; and with a fickle appetite they can • Nausea and vomiting Anti-emetics help by providing food when the patient is hungry (a microwave • Early satiety ‘Small and often’, snacks rather oven is useful). • Fatigue } than meals • A small helping looks better on a smaller plate. • Gastric stasis Prokinetic drug • Offer specific dietary advice, particularly for patients with early • Constipation Laxative satiety. • Sore mouth Mouth care • Lightly spiced food helps taste, and mild alcohol (e.g. wine) • Pain Analgesics moistens food. • Malodour Treatment of malodour • Discourage the ‘he-must-eat-or-he-will-die syndrome’ by • Biochemical emphasizing that a balanced diet is unnecessary at this stage in Hypercalcaemia Correct hypercalcaemia the illness (“Just give little of what he fancies”, “I shall be happy Hyponatraemia Demeclocycline, 300mg b.d. to even if he just takes fluids”). q.d.s., if caused by syndrome • Recognize the ‘food-as-love’ and ‘feeding-him-is-my-job’ syn- of inappropriate antidiuretic dromes, and use them as an opportunity to discuss the progressive hormone secretion impact of the illness with the spouse/partner. Uraemia Anti-emetic • Eating is a social habit, and people generally eat better at a • Secondary to treatment table and when dressed. Drugs Modify drug regimen Radiotherapy Anti-emetic Chemotherapy } • Disease process Appetite stimulant Robert Twycross is Emeritus Clinical Reader in Palliative Medicine at the • Anxiety Anxiolytic University of Oxford, UK. His interests include palliative care, and pain • Depression Antidepressant and symptom management. He is Head of the WHO Collaborating Centre for Palliative Care. 1 MEDICINE 9 © 2004 The Medicine Publishing Company Ltd ARTICLE RUNNING HEAD CHANGE ON MASTER Cachexia Causes of cachexia in advanced cancer Cachexia (marked weight loss and muscle wasting) is generally Paraneoplastic associated with anorexia. It is a paraneoplastic phenomenon that • Cytokines produced by host cells and tumour (e.g. tumour is exacerbated by various factors (Figure 2) and occurs in more necrosis factor, interleukin-6, interleukin-1) than 80% of patients with advanced cancer. The incidence is • Proteolysis-inducing factor → abnormal metabolism of highest in gastrointestinal and lung cancers. It may antedate the protein, carbohydrate clinical diagnosis, and can occur in patients with a small primary • Altered fat metabolism neoplasm. Cytokine production suggests a chronic inflammatory • Increased metabolic rate → increased energy expenditure component and explains the beneficial effect of non-steroidal anti- • Nitrogen trap by the tumour inflammatory drugs (NSAIDs) in some patients. Impaired oral intake Clinical features – the principal features of cachexia–anorexia • Dry mouth (xerostomia) syndrome are: • Sore mouth (stomatitis) • marked weight loss • Altered taste • anorexia • Dysphagia, odynophagia • weakness • Nausea and vomiting • fatigue. • Bowel obstruction Associated physical features include altered taste, loose dentures • Severe pain, dyspnoea causing pain and difficulty eating, pallor (anaemia), oedema • Depression (hypoalbuminaemia) and decubitus ulcers. Psychosocial con- • Cognitive impairment (delirium, dementia) sequences include ill-fitting clothes (increased feelings of loss and • Social and financial difficulties displacement), altered appearance (engenders fear and isolation), Impaired gastrointestinal absorption and difficulties in social and family relationships. • Malabsorption Management – efforts should aimed at ameliorating the social • Chronic diarrhoea consequences and physical complications. • Frequent drainage of ascites • Do not weigh the patient routinely. • Loss of proteins • Educate the patient and family about the risk of decubitus ulcers • Ulceration and the importance of skin care. • Haemorrhage or pleural effusion • If affordable, encourage the patient to buy new clothes to • Nephrotic syndrome enhance self-esteem. Catabolic states • Reline dentures to improve chewing and facial appearance; as • Acute or chronic infection a temporary measure, this can be undertaken at the bedside and • Hyperthyroidism lasts about 3 months. Debilitating treatment • Supply equipment to help maintain personal independence • Surgery (e.g. raised toilet seat, commode, walking frame, wheelchair). • Radiotherapy Aggressive dietary supplementation via a nasogastric tube • Chemotherapy or intravenous hyperalimentation is of little value in reversing cachexia in advanced cancer because of the increased metabolic rate and abnormal metabolism. However, dietary advice is impor- 2 tant, particularly if there are associated changes in taste. Some patients benefit psychologically from powdered or liquid nutritional Corticosteroids are anti-emetics; they possibly act by reducing supplements, and a few gain weight. the permeability of the chemoreceptor trigger zone (area postrema) A trial of therapy with an appetite stimulant may help some and of the blood–brain barrier to emetogenic substances, and by patients. However, progestogens are expensive and should be reducing the neuronal content of γ-aminobutyric acid (GABA) in used selectively. The effect of progestogens may be enhanced by the brain stem. Corticosteroids also reduce leu-enkephalin release concurrent use of ibuprofen, 1200 mg/day, or another NSAID. in the brain stem and gastrointestinal tract. Gastric stasis (delayed gastric emptying) accounts for about 25% Nausea and vomiting of cases of nausea and vomiting. Gastric stasis, intestinal obstruction, drugs and biochemical fac- Clinical features range from mild dyspepsia and anorexia to tors account for most cases of nausea and vomiting in advanced persistent severe nausea and large-volume vomiting (Figure 4). cancer; raised intracranial pressure accounts for less than 5%. It is Gastric stasis is generally functional and is associated with one or important to identify the most likely cause in each patient, because more of the following conditions: treatment depends on the cause. On the basis of putative sites of • dysmotility dyspepsia (often longstanding) action, it is possible to determine the anti-emetic drug of choice • constipation in various situations (Figure 3). The initial choice is generally • drugs (e.g. opioids, antimuscarinics, aluminium hydroxide, metoclopramide, haloperidol, hyoscine butylbromide (or glyco- levodopa) pyrronium) or cyclizine (or dimenhydrinate or promethazine). • cancer of the head of the pancreas (disrupts duodenal trans- Other drugs may be necessary in some patients. it) © 2004 The Medicine Publishing Company Ltd 10 MEDICINE ARTICLE RUNNING HEAD CHANGE ON MASTER Management of nausea and vomiting in palliative care 1 After clinical evaluation, document the most likely cause of the 5 Review anti-emetic dose every 24 hours, taking note of p.r.n. use nausea and vomiting in the patient’s case notes (e.g. gastric and the patient’s diary. stasis, intestinal obstruction, biochemical, drugs, raised 6 If there is little benefit despite optimization of the dose, has the intracranial pressure). correct cause been identified? 2 Ask the patient to record symptoms and response to treat- • If no, change to an alternative anti-emetic
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