Appetite Loss

Top tips:

  1. Appetite loss and reduced caloric intake (anorexia) are common in cirrhosis
  2. Consider contributory causes and consider treatment if appropriate depending on patient’s goals of care
  3. If active treatment indicated, consider non-pharmacological therapies first. These include nutrition therapy and exercise.
  4. 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.

ACCORDION 1.1

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:

  1. Food should be treated as medication- consider setting alarms as reminders to eat
  2. Smaller, more frequent high calorie meals and snacks (q3-4 hourly)
  3. Limit fluid intake when eating to reserve room for food
  4. Avoid drinks that reduce appetite and provide little nutrition such as coffee, tea and water
  5. Liquid nutritional supplements are useful high calorie liquid snacks
  6. Limit intake of spicy, acidic or overly sweet foods
  7. 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.
ACCORDION 1.2
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.

Additional Content:

For a comprehensive review on breathlessness, please refer to the links below.

  1. Goals of care
  2. Frailty and Malnutrition
  3. Physical Activity
  4. Nutrition Therapy
  5. Constipation
  6. Depression

References:

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

References:

  1. Bruera E. ABC of palliative care. Anorexia, cachexia, and nutrition. BMJ 1997;315:1219
  2. Bunchorntavakul C, Reddy KR. Review article: malnutrition/sarcopenia and frailty in patients with cirrhosis. Aliment Pharmacol Ther 2020;51:64-77
  3. Sevastianos VA, Dourakis SP. J Nutr Food Sci 2016;6:2.
  4. Guillaume Economos et.al. What is the evidence for mirtazapine in treating cancer-related symptomatology? A systematic review Supportive Care in Cancer (2020) 28:1597–1606
  5. Zheng , Zheng. The effects of megestrol acetate on nutrition, inflammation and quality of life in elderly haemodialysis patients.  International Urology and Nephrology[0301-1623] yr:2019 vol:51 iss:9 pg:1631-1638
  6. Ruiz García, V . Megestrol acetate for cachexia-anorexia syndrome. A systematic review. Journal of Cachexia, Sarcopenia and Muscle[2190-5991] yr:2018 vol:9 iss:3 pg:444-452
  7. Bolen JC, Andersen RE, Bennett RG. Deep vein thrombosis as a complication of megestrol acetate therapy among nursing home residents. J Am Med Dir Assoc. 2000 Nov-Dec;1(6):248-52
  8. Ruiz Garcia V, López-Briz E, Carbonell Sanchis R, Gonzalvez Perales JL, Bort-Martí S. Megestrol acetate for treatment of anorexia-cachexia syndrome. Cochrane Database of Systematic Reviews 2013, Issue 3. Art. No.: CD004310. DOI: 10.1002/14651858.CD004310.pub
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