Appetite loss and reduced caloric intake (anorexia) are common in cirrhosis
Consider contributory causes and consider treatment if appropriate depending on patient’s goals of care
If active treatment indicated, consider non-pharmacological therapies first. These include nutrition therapy and exercise.
There is no cirrhosis specific data in support of pharmacological therapy
Follow this step by step process when dealing with Anorexia in cirrhosis.
Step 1: Consider potential contributing causes and treat appropriately
Anorexia is multifactorial, in part related to pro-inflammatory upregulation as liver disease progresses.
A dietician consult and guidance can help evaluate and improve 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 should be utilized:
- 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: If anorexia persist, consider Pharmacological therapy if consistent with GOC
If non-pharmacological therapy alone fails, the risks and benefits of pharmacological therapy need to be discussed with the patient if in keeping with their goals of care.
There is no data to support the routine use of appetite supplements in the setting of cirrhosis.
In cancer patients, appetite stimulants have shown only short lived effects, with no survival benefit or improved physical function. Notably, these drugs are associated with side effects.
Step 4: Special considerations at End of Life (last few days to weeks)
At End of life, as the patient’s condition deteriorates, anorexia may worsen and may not be amenable to therapy.
If assistance in managing this is required, a consultation from Palliative Care should be obtained.
For a comprehensive review on breathlessness, please refer to the links below.
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: —————–, Dr. Puneeta Tandon
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