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Referral and warning signs
When to refer
Need for specialist palliative care input for complex symptom management. Consideration of appetite stimulants beyond short-course steroids. Need for nutritional support assessment in specific situations (requires careful consideration of goals of care).
Red flags
- Rapid, unintentional weight loss.
- Complete inability to tolerate oral intake (may indicate obstruction or other acute issue).
- Signs of severe dehydration.
- Underlying reversible cause requiring urgent treatment (e.g., severe hypercalcaemia).
Signs and symptoms
- Reduced desire to eat (anorexia).
- Weight loss (especially muscle mass).
- Fatigue.
- Weakness.
- Early satiety.
Risk factors
- Advanced cancer.
- Chronic organ failure (heart, kidney, liver).
- Chronic infections (HIV/AIDS, TB).
- Symptoms interfering with intake (nausea, vomiting, constipation, pain, sore mouth, malodour).
- Metabolic abnormalities (hypercalcaemia, uraemia).
- Medications.
- Depression.
Diagnosis
Clinical assessment
History of appetite changes, weight loss, food intake patterns. Assess for potentially reversible causes (constipation, nausea, depression, oral problems, medication side effects). Assess nutritional status (weight, muscle mass).
Investigations
- Targeted based on suspected reversible causes:
- - Blood tests: Electrolytes, Calcium, Urea, Creatinine, LFTs.
- - Assess for infections.
- - Assess for depression.
Diagnostic criteria
Clinical assessment of reduced appetite and/or significant weight/muscle loss in the context of advanced illness.
Management
Non-pharmacological management
- Treat underlying reversible causes (e.g., manage constipation, nausea, oral thrush, depression).
- Dietary Advice: Small, frequent, energy-dense meals. Limit fat if causing early satiety. Avoid extremes of taste/smell. Focus on patient preference and enjoyment.
- Pleasant mealtime environment, social eating.
- Nutritional Counselling: Focus on quality of life, managing expectations.
- Counsel patient and family: If prognosis poor (<2 months), help adjust to reduced appetite as part of the disease process. Aggressive nutritional support often unhelpful in established cachexia.
Pharmacological treatment
- Appetite Stimulants (Limited role, short-term use, specialist supervision):
- - Corticosteroids: Short course (e.g., 7 days) may improve appetite temporarily. Prednisolone 15-40mg OD OR Dexamethasone 2-6mg OD (morning dose).
- - Progestogens (e.g., Megestrol acetate): Specialist use, potential side effects (VTE risk).
- Manage associated symptoms (nausea, pain etc.) pharmacologically.
Monitoring
Monitor appetite, food intake, enjoyment of food. Monitor weight (less emphasis in advanced cachexia). Assess quality of life. Monitor for side effects of corticosteroids if used.
Complications
- Progressive weight loss and muscle wasting.
- Weakness, fatigue, functional decline.
- Increased susceptibility to infection.
- Pressure ulcer risk.
- Distress for patient and family.
Prevention
- Early identification and management of factors contributing to poor intake (nausea, pain, etc.).
- Nutritional counselling tailored to stage of illness.
Patient education
- Explain anorexia/cachexia as part of the illness.
- Focus on quality of life and enjoyment of food, rather than quantity.
- Small, frequent meals may be better tolerated.
- Manage expectations regarding weight gain in advanced disease.
- Importance of treating other symptoms (nausea, pain) that affect appetite.
- Role of family support during mealtimes.
Uganda-specific notes
Anorexia and cachexia are very common in advanced HIV/AIDS, TB, and cancer. Focus on managing reversible causes and providing practical dietary advice. Corticosteroids may be used short-term under supervision. Parenteral/enteral nutrition rarely appropriate or available for cachexia in this context.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 13, Section 13.2.5