What are the recommendations for a patient with anorexia and weight loss?

Recommendations for Patients with Anorexia and Weight Loss

For patients with anorexia and weight loss, a comprehensive nutritional intervention approach is recommended, including dietary counseling, oral nutritional supplements, and in select cases, pharmacological appetite stimulants such as corticosteroids or progestins for short-term use. 1

Assessment and Nutritional Support

• Regular nutritional assessment should begin at diagnosis and be repeated at every visit to initiate nutritional intervention early, before the patient's general status becomes severely compromised 1
• Inadequate nutritional intake is considered present if a patient cannot eat for more than a week or if estimated energy intake is <60% of requirement for more than 1-2 weeks 1
• Provide individualized dietary counseling and oral nutritional supplements (ONS) to improve nutritional intake, quality of life, and stabilize body weight 1
• When oral food intake is inadequate despite counseling and ONS, supplemental enteral nutrition should be provided, or if not possible, parenteral nutrition 1
• In patients with chronic insufficient dietary intake and/or uncontrollable malabsorption, home enteral nutrition or parenteral nutrition is recommended for suitable patients 1

Non-Pharmacological Interventions

• Implement physical activity recommendations consisting of supervised or home-based moderate-intensity training (50-75% of baseline maximum heart rate), three sessions per week, for 10-60 minutes per exercise session 1
• Suggest individualized resistance exercise in addition to aerobic exercise to maintain muscle strength and muscle mass 1
• Serve energy-dense meals to help patients meet nutritional requirements without increasing meal volume 2
• Provide oral nutritional supplements when food intake is between 50-75% of usual intake 2
• Offer protein-enriched foods and drinks to improve protein intake 2
• Create a relaxed, comfortable environment during meals with emotional support and adequate feeding assistance 2

Pharmacological Interventions

• Consider corticosteroids to increase appetite in anorectic patients with advanced disease for a restricted period (1-3 weeks), but be aware of side effects (e.g., muscle wasting, insulin resistance, infections) 1
• Consider progestins (megestrol acetate 400-800 mg/day) to increase appetite in anorectic patients with advanced disease, but be aware of potentially serious side effects (e.g., thromboembolism) 1, 2
• Dexamethasone (2-8 mg/day) offers faster onset of action, making it suitable for patients with shorter life expectancy 2
• Mirtazapine (7.5-30 mg at bedtime) can be effective for patients with concurrent depression and appetite loss 3, 2
• In patients with advanced cancer undergoing chemotherapy and at risk of weight loss or malnourished, consider supplementation with long-chain N-3 fatty acids or fish oil to stabilize or improve appetite, food intake, lean body mass, and body weight 1

Special Considerations

• For patients with dementia, drugs to stimulate appetite are NOT recommended due to limited evidence and potential risks 1, 2
• In cancer patients, the anorexia-cachexia syndrome is multifactorial and may involve chronic pain, depression, anxiety, altered taste and smell, early satiety, gastrointestinal malfunction, metabolic alterations, and cytokine action 4
• Recognize that anorexia nervosa as a psychiatric disorder requires a different approach focused on normalization of dietary patterns and cognitive behavioral therapy 5, 6, 7
• Lower starting doses of pharmacological agents should be used for elderly patients with close monitoring for side effects 2
• Regular reassessment is essential to evaluate benefit versus harm of pharmacological interventions 2

Important Caveats

• Corticosteroids have a transient antianorectic effect that disappears after a few weeks when myopathy and immunosuppression become manifest; insulin resistance is an early metabolic adverse effect 1
• Progestins increase appetite and body weight but not fat-free mass; they may induce impotence, vaginal spotting, thromboembolism, and in some cases, death 1
• Bupropion is the only antidepressant consistently shown to promote weight loss, making it unsuitable for patients with appetite loss 3, 8
• Fluoxetine can cause significant weight loss, especially in underweight patients, and should be used with caution in patients with anorexia 9