What are the treatment options for sarcopenia?

Treatment of Sarcopenia

The cornerstone treatment for sarcopenia is progressive resistance training combined with adequate protein intake of at least 1.2 g/kg/day, as this combination directly addresses both muscle mass loss and functional decline that define this condition. 1, 2

First-Line Treatment: Exercise Interventions

Resistance training should be implemented as the primary therapeutic intervention, consisting of 2-3 sessions per week with progressive overload 1, 3. The optimal prescription includes:

• Upper and lower body exercises performed at relatively high effort for 1-3 sets of 6-12 repetitions 3
• Combination with aerobic activity (150-300 minutes of moderate-intensity or 75-150 minutes of vigorous-intensity weekly) to enhance overall metabolic health 4, 1
• Weight-bearing exercises to prevent concurrent bone loss 1

The evidence supporting resistance training is particularly strong—it directly counteracts the fundamental pathophysiology of sarcopenia by stimulating muscle protein synthesis and improving neuromuscular function 3. While studies in healthy older adults are robust, evidence specifically in sarcopenic populations is more limited, though the biological rationale remains sound 3.

Nutritional Management

Protein intake must exceed 1.0 g/kg body weight daily, with optimal targets of 1.2-1.5 g/kg/day 1, 2. Critical implementation details include:

• Distribute protein throughout the day with 20-30g per meal to maximize muscle protein synthesis 1
• Include leucine-rich protein sources (chicken, fish, eggs, nuts, lentils, soy) as leucine is essential for skeletal muscle protein synthesis 4, 2
• Add a late evening snack containing protein and at least 50g of complex carbohydrates to prevent overnight catabolism 4
• Ensure total energy intake reaches 35 kcal/kg/day in patients with cirrhosis or critical illness 4

Special Population: Cirrhosis and Sarcopenia

For patients with cirrhosis-related sarcopenia (prevalence 40-70%), nutritional requirements are more stringent 4:

• Protein intake of 1.2-2.0 g/kg ideal body weight/day in critically ill patients 4
• Avoid fasting periods exceeding 4-6 hours due to rapid transition to catabolic states 4
• Consultation with specialized nutritionist is preferred given the complexity of managing sarcopenic obesity in this population 4

Screening and Case-Finding

Before initiating treatment, appropriate screening identifies candidates:

• SARC-F questionnaire (score ≥4) or calf circumference (<34 cm men, <33 cm women) for initial screening 2
• Handgrip strength (<28 kg men, <18 kg women) or 5-time chair stand test (≥12 seconds) confirms "possible sarcopenia" 2
• CT-based skeletal muscle index can quantify severity (SMI <38.5 cm²/m² women, <52.4 cm²/m² men at L3-L4) 4

Pharmacologic Considerations

Currently, no medications are approved specifically for sarcopenia treatment 2, 5. However, certain interventions show promise:

• Testosterone replacement may be considered in select men with documented low testosterone to improve muscle mass, though relative contraindications include history of hepatocellular carcinoma, other malignancy, or thrombosis 4
• Vitamin D supplementation should be provided if deficient, as it supports muscle health 5
• Investigational agents (myostatin antibodies, selective androgen receptor modulators) remain in clinical trials 5, 6

Critical Pitfalls to Avoid

Do not focus solely on weight loss in older adults with obesity without addressing muscle preservation, as this accelerates sarcopenia 1. The combination of obesity and sarcopenia (sarcopenic obesity) produces worse outcomes than either condition alone 1.

Do not prescribe inadequate protein during weight loss attempts—this is a common error that dramatically accelerates muscle loss 1.

Do not neglect resistance training in favor of aerobic exercise alone—while both are beneficial, resistance training is essential for maintaining and building muscle mass 1, 3.

Avoid intense/strenuous exercise in patients with active inflammatory conditions (such as active IBD), as this can induce systemic inflammation and exacerbate disease 4. In these populations, exercise intensity must be carefully modulated to baseline characteristics 4.

Synergistic Approach

Exercise and nutrition work synergistically—nutritional supplementation should be combined with exercise intervention for optimal results 2, 7. Physical exercises, especially resistance training, not only promote muscle protein synthesis independently but enhance the effectiveness of nutritional strategies when combined 7.

Prognosis and Outcomes

Sarcopenia is associated with severe adverse outcomes including increased mortality, postoperative complications (OR 6.1), falls, fractures, and functional decline 4. In cirrhotic patients, sarcopenia independently predicts higher 1-year mortality and acute-on-chronic liver failure development 4. Therefore, aggressive treatment is warranted to improve morbidity, mortality, and quality of life outcomes.