From the Guidelines
Cachexia should be managed with a combination of nutritional support, medications, and exercise, with a focus on early intervention to prevent progression and improve quality of life. Cachexia is a complex metabolic syndrome characterized by severe weight loss, muscle wasting, and loss of appetite that occurs in patients with chronic illnesses, including cancer, chronic heart failure, chronic kidney disease, COPD, and AIDS 1. It differs from simple malnutrition because it involves inflammatory processes and cannot be fully reversed by nutritional support alone. Management includes treating the underlying condition while providing nutritional support through high-protein, high-calorie diets (aim for 1.2-1.5g protein/kg/day) 1.
Medications that may help include megestrol acetate (400-800mg daily), which has been shown to improve appetite and weight gain in patients with cancer-related anorexia/cachexia 1. Dronabinol (2.5mg twice daily) and corticosteroids like dexamethasone (2-4mg daily) may also be used for short-term appetite stimulation, although their effectiveness is limited compared to megestrol acetate 1. A combination therapy approach, including medroxyprogesterone, megestrol acetate, eicosapentaenoic acid, and L-carnitine supplementation, and thalidomide, may yield the best possible outcomes for patients with cancer cachexia 1.
Exercise, particularly resistance training, can help preserve muscle mass when tolerated. A multidisciplinary approach involving physicians, dietitians, physical therapists, and palliative care specialists is essential for effective management. Early intervention is crucial as cachexia becomes increasingly difficult to reverse as it progresses, with inflammation-driven metabolic changes causing continued tissue breakdown despite nutritional interventions 1.
Some key points to consider in managing cachexia include:
- Identifying and addressing reversible causes of anorexia, such as oropharyngeal candidiasis and depression 1
- Relieving symptoms that interfere with food intake, such as pain, constipation, and nausea/vomiting 1
- Using appetite stimulants, such as megestrol acetate, dexamethasone, and olanzapine, in patients with months-to-weeks or weeks-to-days life expectancy, if increased appetite is an important aspect of quality of life 1
- Considering combination therapy, including nutritional support, medications, and exercise, to yield the best possible outcomes for patients with cancer cachexia 1.
From the FDA Drug Label
The appetite stimulant effect of dronabinol capsules in the treatment of AIDS-related anorexia associated with weight loss was studied in a randomized, double-blind, placebo-controlled study involving 139 patients. A statistically significant difference between dronabinol capsules and placebo was seen in appetite as measured by the visual analog scale at weeks 4 and 6
- Cachexia is a condition characterized by weight loss, muscle atrophy, and loss of appetite.
- The study shows that dronabinol capsules have an appetite stimulant effect in patients with AIDS-related anorexia associated with weight loss.
- Key findings include:
- Statistically significant difference in appetite between dronabinol capsules and placebo at weeks 4 and 6.
- Trends toward improved body weight and mood, and decreases in nausea.
- Based on the study, dronabinol capsules may be effective in treating cachexia associated with AIDS-related anorexia and weight loss 2.
From the Research
Definition and Characteristics of Cachexia
- Cachexia is a complex multi-factorial syndrome characterized by anorexia, inflammation, body, and skeletal muscle wasting 3.
- It is a multiorgan, multifactorial and often irreversible wasting syndrome associated with cancer and other serious, chronic illnesses including AIDS, chronic heart failure, chronic kidney disease and chronic obstructive pulmonary disease 4.
- Cancer cachexia demonstrates the same pathology as cachexia found in patients with disease-associated malnutrition presenting with inflammation 5.
Treatment and Management of Cachexia
- Early diagnosis and intervention via a multimodal approach combining nutritional counseling, exercise, and pharmacological agents is advisable 3.
- Treatment of the patient with cachexia is currently targeted to correcting the two underlying features of the condition: anorexia and metabolic disturbances 4.
- Several classes of drugs are under active development for cachexia including drugs acting on hormone receptors or cytokine receptors, myostatin/activin pathway antagonists, beta-adrenoceptor agonists and cannabinoids 4.
- Anamorelin hydrochloride, an endogenous ligand for the growth hormone release-promoting factor receptor, has been developed to treat weight loss accompanied by anorexia and is expected to bring new advancements into the field of clinical oncology as an effective therapeutic drug for cancer cachexia 5.
- Agents showing promising results in managing cachexia include Anamorelin and Enobosarm, with Anamorelin at 50 or 100 mg per day for 12 weeks showing a consistent benefit across all studies and resulting in significant improvement in weight as compared to baseline among cancer patients 6.
Guidelines and Recommendations for Cachexia Management
- The European Society for Medical Oncology (ESMO) provides key recommendations for managing cancer-related cachexia, covering screening, assessment and multimodal management of cancer cachexia 7.
- Recommendations are based on available scientific data and expert opinion, and are compiled by a multidisciplinary group of experts 7.