Poor appetite and intake

Top tips:

  1. Appetite loss and reduced caloric intake (anorexia) are common in cirrhosis
  2. Consider contributing causes and treat if appropriate according to goals of care.
  3. There is no robust cirrhosis specific data evaluating pharmacological therapy
  4. Refer to additional topics under the Healthy Living tab (malnutrition, frailty)
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Step 1: Consider potential contributing causes and treat as appropriate

Anorexia is multifactorial, in part related to changes in pro-inflammatory upregulation and appetite mediators as liver disease progresses.

Potential contributing factors include
  • Poor palatability of prescribed diets– e.g. dietary restriction of sodium ± other restrictions based on clinical diagnoses – see Nutrition section for patient resources. Depending upon the course of the patient’s disease, it may also be relevant to have discussions to understand the potential benefits (e.g. reduction in volume retention) versus burden (e.g. impact on quality of living, ability to enjoy or intake food) of continued sodium restriction.
  • Early satiety, gastroparesis – medications, physical limitations such as ascites
  • Dysgeusia (altered sense of taste) – zinc deficiency – test and treat
  • Medications – culprits include antihistamines, opioids, certain antibiotics, antidepressants
  • Hypogonadism – hypothyroidism, adrenal insufficiency, see sexual dysfunction page
Anorexia may be a manifestation of another symptom such as
A dietician consult and guidance can help evaluate and improve a patient’s nutrition.
Step 2: Consider non-pharmacological therapies

 Interdisciplinary consultation as appropriate – Dietitian, speech language pathologist, occupational therapist, physical therapist 

Practical non-pharmacological therapies can be utilized to increase intake
  • Food should be treated as medication- consider setting alarms as reminders to eat
  • Smaller, more frequent high calorie meals and snacks (q3-4 hourly)
  • Limit fluid intake when eating to reserve room for food
  • Avoid drinks that reduce appetite and provide little nutrition such as coffee, tea and water
  • Liquid nutritional supplements are useful high calorie liquid snacks
  • Limit intake of spicy, acidic or overly sweet foods
  • Cold foods may cause less aversion if nausea is an issue
Initiation of enteral supplementation can be discussed in concert with a Dietitian or Nutrition Specialist. 
Step 3: Pharmacological therapy
Lifestyle modification

There is no data to support the routine use of appetite supplements in the setting of cirrhosis.

In cancer patients, appetite stimulants such as Megesterone acetate have not shown benefits on sarcopenia, physical function or survival. Use is associated with a risk of thrombosis.

 

Special considerations at End of Life (last few days to weeks)
Lifestyle modification

At End of life, as the patient’s condition deteriorates, anorexia will worsen and it will not be amenable to therapy (including enteral/parenteral nutrition). Discussions around eating for pleasure may help patients to be able to balance adverse effects versus benefits at this stage. If anorexia or conversations around the utility of nutritional therapy at end of life are of particular distress for the patient, family or team, a consultation from Palliative Care should be obtained.

 

This section was adapted from content using the following evidence based resources in combination with expert consensus. The presented information is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient’s care.

Authors (Alphabetical): Amanda Brisebois, Sarah Burton-Macleod, Ingrid DeKock , Martin Labrie, Noush Mirhosseini, Mino Mitri, Kinjal Patel, Aynharan Sinnarajah, Puneeta Tandon

Thank you to pharmacists Omer Ghutmy and Meghan Mior for their help with reviewing these pages. 

Helpful Links: 
  1. Goals of care: https://www.albertahealthservices.ca/frm-103547.pdf
  2. Frailty and Malnutrition: https://cirrhosiscare.ca/healthy-living-provider/frailty-and-malnutrition-screening-hcp/
  3. Physical Activity: https://cirrhosiscare.ca/healthy-living-provider/exercise-therapy-hcp/
  4. Nutrition Therapy: https://cirrhosiscare.ca/healthy-living-provider/nutrition-therapy-hcp/ 
  5. Constipation: https://cirrhosiscare.ca/healthy-living-provider/constipation-hcp/
  6. Depression: https://cirrhosiscare.ca/healthy-living-provider/depression-hcp/
References:
  1. Davison SN on behalf of the Kidney Supportive Care Research Group. Conservative Kidney Management Pathway; Available from: https//:www.CKMcare.com.
  2. Bruera E. ABC of palliative care. Anorexia, cachexia, and nutrition. BMJ. 1997 Nov 8;315(7117):1219-22. doi: 10.1136/bmj.315.7117.1219. PMID: 9393230; PMCID: PMC2127742.
  3. Bunchorntavakul C, Reddy KR. Review article: malnutrition/sarcopenia and frailty in patients with cirrhosis. Aliment Pharmacol Ther. 2020 Jan;51(1):64-77. doi: 10.1111/apt.15571. Epub 2019 Nov 8. PMID: 31701570.
  4. Ruiz-García V, López-Briz E, Carbonell-Sanchis R, Bort-Martí S, Gonzálvez-Perales JL. Megestrol acetate for cachexia-anorexia syndrome. A systematic review. J Cachexia Sarcopenia Muscle. 2018 Jun;9(3):444-452. doi: 10.1002/jcsm.12292. Epub 2018 Mar 14. PMID: 29542279; PMCID: PMC5989756
We gratefully acknowledge the Physician Learning Program for their design assistance.

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