Cambridgeshire Palliative Care Guidelines Group Review Date: September 2016 FACTSHEET 19 ON PALLIATIVE CARE THE TREATMENT OF ANOREXIA IN PALLIATIVE CARE Anorexia or loss of appetite is a very common symptom in palliative care patients and can be distressing for both patients and carers. It denies the carer one of the main aspects of care they can provide, i.e. to nourish. This is a frequent cause of tension between patient and carer. Causes Cancer or disease process Pain Oral problems Nausea and vomiting Constipation Dyspnoea Fatigue Depression Cancer treatments Medications Management Explanation and discussion with patient and carer Treat reversible causes – (refer to Factsheet 10 - Nausea & Vomiting, Factsheets 6 & 7 - Pain, Factsheet 12 - Constipation and Factsheet 13 – Mouthcare). Support and nutritional advice. Consider medication if anorexia a major concern Support for Patient and Family Explanation that anorexia and taste changes are common symptoms Give permission to eat less Not to talk about food all the time Gently encourage what the patient can manage Explain ‘healthy’ diet not necessary – focus on what the patient enjoys/tolerates Discuss taste changes Nutritional Advice Maintain fluids Increase nutritional value of food, add butter/cream/cheese where tolerated Frequent nutritious drinks and snacks Use small portions Alcohol (aperitif) Supplementary drinks e.g. home made milkshakes, smoothies where possible Before prescribing supplements (Fortisip, Maxijul etc.) refer to Dietician for dietary review, and consider referral to SALT for advice on consistency of fluids/foods Page 1 of 2 Factsheet 19 Cambridgeshire Palliative Care Guidelines Group Review Date: September 2016 Medication Corticosteroids Established role in short-term improvement of appetite in patients with advanced cancer. May provide a temporary improvement in energy and overall sensation of well being. No significant effect on nutritional status is seen. See corticosteroids guidelines. Duration of response is limited to 2 to 4 weeks therefore short courses which can be repeated may be of more benefit than continuous use. Starting dose dexamethasone 2 to 4mg oral in morning or prednisolone 10 to 30mg oral in morning. Stop after 5 days if no effect. Prokinetics May be helpful for patients with early satiety or feeling of fullness. A risk versus benefit approach must be used– avoid in patients with known cardiac problems. Metoclopramide 10mg three times daily orally or domperidone 10mg three times daily orally 30 minutes before meals can be trialled. Progestogens Progestogens may be trialled although weight gain is likely to be due to increase in fat and fluid retention. There is increased risk of thrombo-embolism in patients on progestogens. Discuss with a specialist (oncologist/palliative care) before prescribing. Starting dose of megestrol acetate 80 - 160mg oral in morning increasing after 2 weeks, maximum recommended dose 800mg daily, medroxyprogesterone acetate 400mg oral in the morning, increasing to twice daily. Anti-depressants Some anti-depressants (tricyclics e.g. amitriptyline; atypical antidepressants e.g. mirtazapine) as well as treating depression may also improve appetite. IF PROBLEMS PERSIST, PLEASE SEEK SPECIALIST ADVICE General palliative care references include: ‘Palliative Care Formulary’, Fourth Edition (PCF4) Edits: Robert Twycross and Andrew Wilcock available via Palliativedrugs.com Palliative Adult Network Guidelines Third Edition (also available as an App) Edits: Max Watson, Caroline Lucas, Andrew Hoy, Ian Back, Peter Armstrong Page 2 of 2 Factsheet 19