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Management of cancer cachexia. Cancer cachexia Anorexia, chronic nausea, asthenia, psychological stress. Poor survival and decreased tolerance to both

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  • Management of cancer cachexia

  • Cancer cachexiaAnorexia, chronic nausea, asthenia, psychological stress.Poor survival and decreased tolerance to both radiotherapy and chemotherapy.No evidence : nutritional or pharmacological intervention improve survival.Exception : GI obstruction from malignancy. Lancet Oncolo 2000;1:138-47

  • Goals Ideal : reverse syndrome completely eliminate tumor mass impossible Reasonable : Improving general comfort.Relieving of symptoms : anorexia, nausea, asthenia.Improve level of functioning. Lancet Oncolo 2000;1:138-47

  • Management approachNutritionPharmacological interventionPsychological and behavioral therapyLancet Oncolo 2000;1:138-47

  • NutritionNutritional counseling improve the daily caloric intake.Maximize oral intake by allowing the patient flexibility in type, quantity and timing if meals.Disease progresses decrease nutritional support. Adequate mouth care and small amount of ice chips or sips of cold beverages may be adequateIn dehydration : use hypodermoclysis

    Lancet Oncolo 2000;1:138-47

  • ESPEN guideline 2006

  • Hypodermoclysis A family member can do hypodermoclysis at home after one lesson from the doctor Using hypodermoclysis, a family member can give the sick person about 90 ounces of fluid a day by giving 45 ounces of fluid in two different places. American Family Physician Nov 1,2001

  • Pharmacological interventionsMain purpose :AnorexiaChronic nauseaNot affect psychological distress from a negative body image : no weight gain. Lancet Oncolo 2000;1:138-47

  • Pharmacological interventionsProven efficacyCorticosteroidProgesteroneMetoclopramide

    No proven efficacyCyproheptadineHydrazine sulphateThalidomideMelatoninB2-agonistAnabolic steroidGHCannabinoid NSAIDsEicosapentanoic acid(EPA)Branched chain amino acid

    Lancet Oncolo 2000;1:138-47

  • CA Cancer J Clin 2002;52:72-91

  • Corticosteroid MechanismInhibition of synthesis and/or release of proinflammatory cytokines (TNF-,IL-1), anorexigenic mediators(leptin, CRF, serotonin)Enhance NPY levels in hypothalamus.XXLancet Oncolo 2000;1:138-47

  • CorticosteroidImproving appetite, food intake, sensation of well-being, performance status.No significant weight gain.Dose : 20-40 mg of prednisolone Risk : peptic ulcer, etc.

    Lancet Oncolo 2000;1:138-47

  • Progesterone MechanismStimulate NPY in the hypothalamusModulation of Ca channel in VMH(satiety center)Inhibition of proinflammatory cytokinesXXLancet Oncolo 2000;1:138-47

  • ProgesteroneImprove appetite, caloric intake, sensation of well-being.Significant weight gain (mostly fat) .Dose : megestrol acetate 160-1600 mg , optimum dose : 800 mgResponse can be seen in 1 week. Risk : thromboembolism, breakthrough bleeding, peripheral edema, hyperglycemia, hypertension, Cushing syndrome, alopecia, adrenal insufficiency.

    Lancet Oncolo 2000;1:138-47

  • Metoclopramide MechanismAntidopaminergic drug Central antiemetic Gastroprokinetic : improve gastric emptying XXLancet Oncolo 2000;1:138-47

  • MetoclopramideImprove in appetite, food intake.Dose : 10 mg before meals and bedtime.Risk : minimal

    Lancet Oncolo 2000;1:138-47

  • Cyproheptadine MechanismAntiserotoninergicRCT mild increase appetite, food intake.No weight gain.Risk : sedation XLancet Oncolo 2000;1:138-47

  • Hydrazine sulphateMechanismInhibit gluconeogenesisPilot study improve appetite and nutritional status.No weight gain.Substantial side effects and deterioration of QOL scalesXLancet Oncolo 2000;1:138-47

  • ThalidomideMechanism Inhibit production of TNF-Pilot studyImprove appetitie, well-being, nausea, insomniaXLancet Oncolo 2000;1:138-47

  • MelatoninMechanismDecrease circulating concentration of TNF-Preliminary studies Weight loss > 10% fewer than best supportive care XLancet Oncolo 2000;1:138-47

  • Beta-adrenoreceptor agonistClenbuterol Mechanism Decrease protein catabolism. Positive effect on muscle mass in tumor-bearing rats.Risk : nervousness, tachycardia, tremor, headache. XLancet Oncolo 2000;1:138-47

  • Anabolic steroid MechanismDecrease protein catabolismRCT Less effective than dexamethasone/megestrol acetate in appetite and nutritional variables.

    XLancet Oncolo 2000;1:138-47

  • Growth hormoneMechanismStimulate muscle protein synthesis.No trial in cancer cachexia. XLancet Oncolo 2000;1:138-47

  • CannabinoidMechanismStimulate appetite No trial in cancer cachexia.Risk : somnolence, confusion, perceptual disturbance.XLancet Oncolo 2000;1:138-47

  • NSAIDsMechanismInhibit the production of cytokineStimulate appetite Preliminary studies : Ibuprofen Weight gain Decrease production of CRP XXLancet Oncolo 2000;1:138-47

  • EPA(Eicosapentanoic acid)Omega 3 fatty acidMechanismInhibition of lipolysis and muscle protein degradation Eicosapentanoic acid decrease production of IL-6RCT : controversy in efficacyXXXLancet Oncolo 2000;1:138-47

  • Psychological and behavioral therapyMultidisciplinary approachOncologistNursesDieticiansPatient and family Secondary depression. Relaxation, hypnosis, group psychotherapy.Lancet Oncolo 2000;1:138-47

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