the efficacy of appatite stimulant in patient undergoing

7212019 The Efficacy of Appatite Stimulant in Patient Undergoing

httpslidepdfcomreaderfullthe-efficacy-of-appatite-stimulant-in-patient-undergoing 134

The efficacy of appetite stimulant in

patient undergoing chemotherapy

drSeptimanSurgical Oncology Division Department of SurgeryWahidin Sudirohusodo Hospital

Makassar



bull The indication of chemotherapy have expandedover the past decade for malignant disorders

bull Chemotherapy is a risk for several complications

bull Recognition and management ofchemotherapy toxicity has gained increasingimportance as indication undergo a detailedevaluation including anamnesis about history ofdisease physical examination and laboratorium

for management Chemoterapy of malignantdisorders



Chemotherapy is a risk for several complicationsincluding conditioning chemotherapy relatedtoxicities

I Haematological toxicityII Gastrointestinal toxicity

III Skin toxicity

IV Organ toxicity

V Sensory toxicityVI Metabolic toxicity

VII Other toxicity



Other side effects of cancer treatment such asStomatitisMouth soresInfection and Dry mouth

Dysphagia and mouth painChanges in taste and smellFatigueDepressionAnorexia

DyspepsiaNausea and vomitingConstipationDiarrhea





Changes in appetite

bull is common with cancer and cancer

treatmentbull is problem for several complications in

management chemotherapy

bull We routinely encounter the problem

before and after chemotherapy



bull Appetite loss may ndash eat less than usual

ndash not feel hungry at all ndash feel full after eating only a small amount

bull Ongoing appetite loss may lead to ndash weight loss

ndash

not getting the nutrients from food that thebody needs

ndash loss of muscle mass and strength



bull Physiologic changes that can increasethe toxicity of chemotherapy are

decreased stem cell reserves decreasedability to repair cell damage progressiveloss of body protein and accumulation ofbody fat

bull The outcome of chemotherapy is oftenclosely related to how well thesecomplication are managed



Causes

Some types of cancers ndash may cause a loss of appetite usually by

affecting a persons metabolism which is the process of the body breaking down food and turning itinto energy

Ovarian cancer

Pancreatic cancer

stomach cancer

Advanced cancer

Spleenomegali some cancers may cause the spleen to become larger it can push on the

stomach creating a feeling of fullness

Ascites that may create a feeling of fullness even after eating a small amount of food

Medications including chemotherapy immunotherapy and drugs called sedatives that cause

feelings of calmness or sleepiness

Radiation treatment or surgery to any part of the gastrointestinal organs such as

the stomach or intestines



Factors That Affect Appetite





III Skin toxicity

IV Organ toxicity


VII Other toxicity











Stergios Boussiosa George PentheroudakIoannina University Hospital Ioannina Greece



Stergios Boussiosa George PentheroudakIoannina University Hospital Ioannina GreeceAnnals of Gastroenterolo 2012 25 106-118



Managing Loose AppetiteProper nutrition helps your body fight disease and cope with the effects of cancer treatment Your healthcare team cansuggest ways to help you manage loss of appetite You can also try the following

Keep mealtimes and snacks flexiblebull Worrying about not eating can further affect the appetite

bull Do the best to include variety and choice in diet

bull Try not to skip meals

bull Try eating small meals and snacks throughout the day

bull Some people may have a better appetite in the morning so eat a

large breakfast

bull Try eating a bedtime snack

Make meals appealing and funbull Appetite affected by how food looks and the eating

environment Try to help make meals appealing and fun change the form of food Try a variety of new tastesand textures to find those that are most appealing

bull Explore different ways of presenting food Put smallportions on the plate

bull Have meals with family and friend or invite special guests ifthe person feels up to it Make fun rituals around meals

Cover up tastes and smellsbull Cancer treatment can change foods taste try with

different foods to help cover up tastes and smells

bull Try new spices such as basi l cinnamon curry coriandermint oregano or rosemary Spices make the mouth water and change the taste of food

bull Serve food cold or at room temperature reduce strongtastes and smells

Make every calorie countbull You can help prevent weight loss by increasing the nutritional value

of the food you eat especially with calories and protein

bull Eat whatever you want whenever you want it

bull Keep healthy high-protein high-calorie snacks available ready toeat when appetite returns

bull Eat foods high in calories and protein when the appetite is poor

bull Increase the protein and calorie content of milk products

Use a feeding tubebull If loss of appetite becomes severe and there is a risk of

malnutrition may suggest using a feeding tube Once the tubeis in place liquid nutritional supplements are delivered through it(enteral feeding)

bull Feeding tubes can help nutritional needs when it is too difficultto eat ordrink or you have losta lot of weight

Use appetite stimulantsbull Prescribe drugs to stimulate appetite These drugs may include

megestrol or corticosteroids

bull Some people claim that marijuana helps increase their appetiteTo date studies havenrsquot shown for certain that marijuana caneffectively improve appetite Find out more about medicalmarijuana and cannabinoids



Effects of megestrol acetate in patients with canceranorexia-cachexia syndrome a systematic reviewand meta-analysis

W Lesniak M Bala R Jaeschke and M Krzakowski

Review published 2008

Systematic review of the treatment of cancer-associatedanorexia and weight loss

T Yavuzsen MP Davis D Walsh S LeGrand and R Lagman


Nutritional support for head and neck cancer patients

receiving radiotherapy a systematic review

S Garg J Yoo and E Winquist


Expert Opin Pharmacother 2007 Jun8(8)1085-90

Pharmacological options for advanced cancer patients with

loss of appetite and weight

Behl D1 Jatoi A

Cochrane Database Syst Rev 2013 Mar 283CD004310 doi

10100214651858CD004310pub3

Megestrol acetate for treatment of anorexia-cachexia

syndrome

Ruiz Garcia V1 Loacutepez-Briz E Carbonell Sanchis R Gonzalvez

Perales JL Bort-Marti S

Cochrane Database Syst Rev 2005 Apr 18(2)CD004310Megestrol acetate for the treatment of anorexia-

cachexia syndrome

Berenstein EG1 Ortiz Z

Semin Oncol 1990 Dec17(6 Suppl 9)2-7

Appetite stimulation and weight gain with megestrol

acetate

Aisner J1 Parnes H Tait N Hickman M Forrest A Greco

FA Tchekmedyian NS

Drugs 1992 Apr43(4)499-506

Cancer-associated anorexia and cachexia Implications

for drug therapy

Loprinzi CL1 Goldberg RM Burnham NL

Standards Options and Recommendations for the use of

appetite stimulants in oncology (2000)J C Desport1 G Gory-Delabaere2 M P Blanc-Vincent2 P Bachmann3 J Beacuteal4 R Benamouzig5 V Colomb6 D Kere7 J C

Melchior8 G Nitenberg9 B Raynard10 S Schneider11 and P Senesse7

Author information Article notes Copyright and License i nformation



Management

bull Relieving side effects mdash also called symptommanagement palliative care or supportivetreatment for conditions (may help improveappetite) such asbull mouth sores

bull dry mouth

bull pain

bull depression

bull Treatments for appetite loss and associatedweight loss may includebull medications that increase appetitebull medications that help move food through the

intestine



Increase appetitebull Megestrol acetate or medroxyprogesterone are

forms of the progesterone hormone that can improve appetite and weight gain

bull Steroid medications can increase appetite improve a persons sense of well-being and helpwith nausea weakness or pain Because of serious side effects steroids should only be used for ashort time

bull Metoclopramide (Reglan) can prevent feeling full before eating enoughfood

bull Dronabinol (Marinol) a cannabinoid made in the laboratory may stimulateappetite

bull Other medications are being studied to help peoplewith cancer improve their appetite and gain weight

Medications that help food move through the intestine

bull nutritional supplement drinksbull tube feeding which is the use of a tube that passes through the nose into the

stomach can also be helpful



Standards Options and Recommendations for the useof appetite stimulants in oncology (2000)J C Desport1 G Gory-Delabaere2 M P Blanc-Vincent2 P Bachmann3 J Beacuteal4 R Benamouzig5 V Colomb6 D Kere7 J C Melchior 8 GNitenberg9 B Raynard10 S Schneider 11 and P Senesse7

Author information

Article notes

Copyright and License information

Corticosteroids Corticosteroids are appetite stimulants (level of evidence B1) There is insufficient information

available to define the optimal dose and scheduling for their use in this indication(recommendation)

Synthetic progestogens

Megesterol acetate

Megesterol acetate is an appetite stimulant (level of evidence B1) It results in a significantincrease in appetite and there is a beneficial effect on body weight in patients with cancer(standard level of evidence B1) The minimum efficacious dose is 160 thinspmgthinspdayminus1 (level ofevidence B1) If there is no response 480thinspmgthinspdayminus1 which seems to be the optimal dose can beused (recommendation level of evidence C) There is no evidence that doses greater than480thinspmgthinspdayminus1 have a higher efficacy (level of evidence B1)

Medroxyprogesterone acetate (MPA) Medroxyprogesterone acetate is an appetite stimulant (level of evidence B1) It results in a

significant increase in appetite (level of evidence B1) The effect on weight gain has not been

confirmed (level of evidence C) Randomised clinical trials should be undertaken to investigatethe optimal dose and duration of administration of this drug although the minimum dose shownto have a positive effect on appetite in published trials was 200thinspmgthinspdayminus1 (recommendationexpert agreement)

Other drugs Cyproheptadine may be an appetite stimulant but adverse effects have been reported (level

of evidence C) Dronabinol metoclopramide nandrolone and pentoxifylline have not beenshown to have any appetite-stimulating effects (level of evidence C) These drugs should not beused outside the setting of a randomised clinical trial (recommendation expert agreement)



The French Regional Comprehensive Cancer Centres the French Employment andSolidarity Ministry The French association lsquoLigue Nationale Contre le Cancerrsquo and

the French Hospital Federation for their financial support



Conclution





Management strategy appetite stimulants foruse in patients with cancer

No French product licence

Corticosteroids

Megestrol acetate

MPA (French product licence) can be used in the treatment ofanorexia and weight loss in patients with cancer(recommendation level of evidence B1)

Appetite stimulants can be used in combination with or afterfailure of dietetic and oral nutritional management(recommendation expert agreement)

The use of appetite stimulants is particularly warranted inpatients with incurable disease (recommendation level of

evidence C)

Appetite stimulants can be administered to patients with anytype of tumour (recommendation expert agreement) Theoptimal mode of administration for these products is notknown



Anoorexia and cachexia are serious complications

frequently found in patients with cancer (Bozetti1995 Donnelly and Walsh 1995)

Multiple factors are involved in their aetiology(Puccio and Nathanson 1997)

The resultant malnutrition is associated with a

poorer response to anticancer treatment and animpaired quality of life (Holmes and Dickerson1987 Bozetti 1995 De Conno et al 1998)

Many clinical trials have been undertaken toevaluate the efficacy of drugs thought to be

appetite stimulants Developing New Chemotherapy Regimens With

Similar Efficacy But Less Toxicity Should Be a priorityFor Future research



Thank You



Thank You



Standards Procedures or treatments that are considered tobe of benefit inappropriate or harmful byunanimous decision based on the best availableevidence

Options Procedures or treatments that are considered tobe of benefit inappropriate or harmful by amajority based on the best available evidence

Recommendations Additional information to enable the available

options to be ranked using explicit criteria (egsurvival toxicity) with an indication of the level ofevidence

Definiton of Standards Options and Recommendations

Br J Cancer 2003 Aug 89(Suppl 1) S98 ndashS100



Level AThere exist a high-standard meta-analysis or several high-standard randomised clinicaltrials which give consistent results

Level B

There exist good quality evidence from randomised trials (B1) or prospective or

retrospective studies (B2) The results are consistent when considered together

Level C

The methodology of the available studies is weak or their results are not consistent whenconsidered together

Level DEither the scientific data do not exist or there is only a series of cases

Expert agreement

The data do not exist for the method concerned but the experts are unanimous in their judgement

Definition of level of evidence




The French Regional Comprehensive Cancer Centres theFrench Employment and Solidarity Ministry The Frenchassociation lsquoLigue Nationale Contre le Cancerrsquo and the

French Hospital Federation for their financial support



The following tips for getting propernutrition when your appetite is poor Eat five to six small meals a day and snack whenever you are hungry Determine which times of day you are hungry make sure to eat at those times and do not limit how much you

eat Eat nutritious snacks that are high in calories and protein such as dried fruits nuts yogurt cheeses eggs

milkshakes ice cream cereal pudding and granola bars Keep your favorite foods on hand for snacking Add calories and protein to foods by adding sauces gravy butter cheese peanut butter cream and nuts Drink fluids between meals rather than with meals Drinking during a meal may make you feel full too quickly Choose nutritious or filling drinks such as milk or nutritional milkshakes or smoothies Ask family members or friends to get groceries and prepare food for you when you are too tired shop or cook

and consider buying precooked meals Try to eat in pleasant surroundings and eat meals with family or friends Try placing food on smaller plates rather than larger plates If the smell or taste of food makes your nauseous eat food that is cold or at room temperature to decrease its

odor and reduce its taste However if you are having trouble tasting food try adding spices and condiments to foods to make them more

appealing If you have changes in taste such as a metallic taste in your mouth sucking on hard candy like mints or lemon

drops before eating a meal can be helpful

Ask your doctor about ways to relieve gastrointestinal symptoms such as nausea vomiting and constipation or ifyou are having any difficulty with managing pain Try light exercise such as a 20-minute walk about an hour before meals to stimulate your appetite Consult your

health care team before starting an exercise program Exercise also helps maintain muscle mass Meet with a registered dietitian for additional advice on meal planning



Appetite-Enhancing Drugs

bull Appetite-enhancing drugs to preventundesired weight loss in the elderly AIDS andcancer which often result in wasting of thebodys muscle tissue as well as overall weightloss The medical term for these drugs isorexigenic

bull the orexigenic drugs in common use as of 2005

bull they range from antihistamines and antiemetics(drugs given to treat or prevent nausea andvomiting) to antidepressants and synthetichormones



bull The indication of chemotherapy have expandedover the past decade for malignant disorders

bull Chemotherapy is a risk for several complications

bull Recognition and management ofchemotherapy toxicity has gained increasingimportance as indication undergo a detailedevaluation including anamnesis about history ofdisease physical examination and laboratorium

for management Chemoterapy of malignantdisorders





III Skin toxicity

IV Organ toxicity


VII Other toxicity










Changes in appetite











ndash










Causes



Ovarian cancer

Pancreatic cancer

stomach cancer

Advanced cancer















III Skin toxicity

IV Organ toxicity


VII Other toxicity























large breakfast





































Behl D1 Jatoi A


10100214651858CD004310pub3


syndrome




cachexia syndrome




acetate


FA Tchekmedyian NS

Drugs 1992 Apr43(4)499-506


for drug therapy








Management


bull dry mouth

bull pain

bull depression


intestine















Author information

Article notes





Megesterol acetate













Conclution







Corticosteroids

Megestrol acetate




evidence C)














Thank You



Thank You












Level B



Level C



Expert agreement





























III Skin toxicity

IV Organ toxicity


VII Other toxicity










Changes in appetite











ndash










Causes



Ovarian cancer

Pancreatic cancer

stomach cancer

Advanced cancer















III Skin toxicity

IV Organ toxicity


VII Other toxicity























large breakfast





































Behl D1 Jatoi A


10100214651858CD004310pub3


syndrome




cachexia syndrome




acetate


FA Tchekmedyian NS

Drugs 1992 Apr43(4)499-506


for drug therapy








Management


bull dry mouth

bull pain

bull depression


intestine















Author information

Article notes





Megesterol acetate













Conclution







Corticosteroids

Megestrol acetate




evidence C)














Thank You



Thank You












Level B



Level C



Expert agreement


































Changes in appetite











ndash










Causes



Ovarian cancer

Pancreatic cancer

stomach cancer

Advanced cancer















III Skin toxicity

IV Organ toxicity


VII Other toxicity























large breakfast





































Behl D1 Jatoi A


10100214651858CD004310pub3


syndrome




cachexia syndrome




acetate


FA Tchekmedyian NS

Drugs 1992 Apr43(4)499-506


for drug therapy








Management


bull dry mouth

bull pain

bull depression


intestine















Author information

Article notes





Megesterol acetate













Conclution







Corticosteroids

Megestrol acetate




evidence C)














Thank You



Thank You












Level B



Level C



Expert agreement






























ndash










Causes



Ovarian cancer

Pancreatic cancer

stomach cancer

Advanced cancer















III Skin toxicity

IV Organ toxicity


VII Other toxicity























large breakfast





































Behl D1 Jatoi A


10100214651858CD004310pub3


syndrome




cachexia syndrome




acetate


FA Tchekmedyian NS

Drugs 1992 Apr43(4)499-506


for drug therapy








Management


bull dry mouth

bull pain

bull depression


intestine















Author information

Article notes





Megesterol acetate













Conclution







Corticosteroids

Megestrol acetate




evidence C)














Thank You



Thank You












Level B



Level C



Expert agreement
































Causes



Ovarian cancer

Pancreatic cancer

stomach cancer

Advanced cancer















III Skin toxicity

IV Organ toxicity


VII Other toxicity























large breakfast





































Behl D1 Jatoi A


10100214651858CD004310pub3


syndrome




cachexia syndrome




acetate


FA Tchekmedyian NS

Drugs 1992 Apr43(4)499-506


for drug therapy








Management


bull dry mouth

bull pain

bull depression


intestine















Author information

Article notes





Megesterol acetate













Conclution







Corticosteroids

Megestrol acetate




evidence C)














Thank You



Thank You












Level B



Level C



Expert agreement
































III Skin toxicity

IV Organ toxicity


VII Other toxicity























large breakfast





































Behl D1 Jatoi A


10100214651858CD004310pub3


syndrome




cachexia syndrome




acetate


FA Tchekmedyian NS

Drugs 1992 Apr43(4)499-506


for drug therapy








Management


bull dry mouth

bull pain

bull depression


intestine















Author information

Article notes





Megesterol acetate













Conclution







Corticosteroids

Megestrol acetate




evidence C)














Thank You



Thank You












Level B



Level C



Expert agreement















































large breakfast





































Behl D1 Jatoi A


10100214651858CD004310pub3


syndrome




cachexia syndrome




acetate


FA Tchekmedyian NS

Drugs 1992 Apr43(4)499-506


for drug therapy








Management


bull dry mouth

bull pain

bull depression


intestine















Author information

Article notes





Megesterol acetate













Conclution







Corticosteroids

Megestrol acetate




evidence C)














Thank You



Thank You












Level B



Level C



Expert agreement








































Behl D1 Jatoi A


10100214651858CD004310pub3


syndrome




cachexia syndrome




acetate


FA Tchekmedyian NS

Drugs 1992 Apr43(4)499-506


for drug therapy








Management


bull dry mouth

bull pain

bull depression


intestine















Author information

Article notes





Megesterol acetate













Conclution







Corticosteroids

Megestrol acetate




evidence C)














Thank You



Thank You












Level B



Level C



Expert agreement



























Management


bull dry mouth

bull pain

bull depression


intestine















Author information

Article notes





Megesterol acetate













Conclution







Corticosteroids

Megestrol acetate




evidence C)














Thank You



Thank You












Level B



Level C



Expert agreement







































Author information

Article notes





Megesterol acetate













Conclution







Corticosteroids

Megestrol acetate




evidence C)














Thank You



Thank You












Level B



Level C



Expert agreement































Conclution







Corticosteroids

Megestrol acetate




evidence C)














Thank You



Thank You












Level B



Level C



Expert agreement































Corticosteroids

Megestrol acetate




evidence C)














Thank You



Thank You












Level B



Level C



Expert agreement





































Thank You



Thank You












Level B



Level C



Expert agreement



























Thank You












Level B



Level C



Expert agreement




































Level B



Level C



Expert agreement

























the efficacy of appatite stimulant in patient undergoing

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