The efficacy of appetite stimulant in

patient undergoing chemotherapy

dr.Septiman
Surgical Oncology Division, Department of Surgery
Wahidin Sudirohusodo Hospital
Makassar

The indication of chemotherapy have expanded

over the past decade for malignant disorders
Chemotherapy is a risk for several complications
Recognition and management of
chemotherapy toxicity has gained increasing
importance as indication undergo a detailed
evaluation including anamnesis about history of
disease, physical examination and laboratorium
for management Chemoterapy of malignant
disorders

Chemotherapy is a risk for several complications

including conditioning chemotherapy related
toxicities
I.
Haematological toxicity
II. Gastrointestinal toxicity
III. Skin toxicity
IV. Organ toxicity
V. Sensory toxicity
VI. Metabolic toxicity
VII. Other toxicity

Other side effects of cancer treatment, such as:

Stomatitis
Mouth sores
Infection and Dry mouth
Dysphagia and mouth pain
Changes in taste and smell
Fatigue
Depression
Anorexia
Dyspepsia
Nausea and vomiting
Constipation
Diarrhea

Changes in appetite
is common with cancer and cancer
treatment
is problem for several complications in
management chemotherapy
We routinely encounter the problem
before and after chemotherapy

Appetite loss may

eat less than usual

not feel hungry at all
feel full after eating only a small amount

Ongoing appetite loss may lead to

weight loss
not getting the nutrients from food that the
body needs
loss of muscle mass and strength

Physiologic changes that can increase

the toxicity of chemotherapy are
decreased stem cell reserves, decreased
ability to repair cell damage, progressive
loss of body protein, and accumulation of
body fat
The outcome of chemotherapy is often
closely related to how well these
complication are managed

Causes

Some types of cancersmay cause a loss of appetite, usually by

affecting a person's metabolism, which is the process of the body breaking down food and turning it
into energy
Ovarian cancer
Pancreatic cancer
stomach cancer

Advanced cancer
Spleenomegali, some cancers may cause the spleen to become larger, it can push on the
stomach, creating a feeling of fullness

Ascites, that may create a feeling of fullness even after eating a small amount of food
Medications, including chemotherapy, immunotherapy, and drugs called sedatives that cause
feelings of calmness or sleepiness

Radiation treatment or surgery to any part of the gastrointestinal organs, such as

the stomach or intestines

Factors That Affect Appetite

Chemotherapy is a risk for several complications

including conditioning chemotherapy related
toxicities
I.
Haematological toxicity
II. Gastrointestinal toxicity
III. Skin toxicity
IV. Organ toxicity
V. Sensory toxicity
VI. Metabolic toxicity
VII. Other toxicity

Stergios Boussiosa, George Pentheroudak

Ioannina University Hospital, Ioannina, Greece

Stergios Boussiosa, George Pentheroudak

Ioannina University Hospital, Ioannina, Greece
Annals of Gastroenterology (2012) 25, 106-118

Managing Loose Appetite

Proper nutrition helps your body fight disease and cope with the effects of cancer treatment. Your healthcare team can
suggest ways to help you manage loss of appetite. You can also try the following.

Keep mealtimes and snacks flexible Make every calorie count

Worrying about not eating can further affect the appetite.

Do the best to include variety and choice in diet.

Try not to skip meals.

Try eating small meals and snacks throughout the day.

Some people may have a better appetite in the morning, so eat a

large breakfast.

Try eating a bedtime snack.

Make meals appealing and fun

Use a feeding tube

Appetite affected by how food looks and the eating

environment. Try to help make meals appealing and fun.
change the form of food. Try a variety of new tastes
and textures to find those that are most appealing.

Explore different ways of presenting food. Put small

portions on the plate.
Have meals with family and friend or invite special guests if
the person feels up to it Make fun rituals around meals.

Cover up tastes and smells

You can help prevent weight loss by increasing the nutritional value
of the food you eat, especially with calories and protein.
Eat whatever you want, whenever you want it.
Keep healthy, high-protein, high-calorie snacks available ready to
eat when appetite returns.
Eat foods high in calories and protein when the appetite is poor.
Increase the protein and calorie content of milk products.
If loss of appetite becomes severe and there is a risk of
malnutrition may suggest using a feeding tube. Once the tube
is in place, liquid nutritional supplements are delivered through it
(enteral feeding).
Feeding tubes can help nutritional needs when it is too difficult
to eat or drink or you have lost a lot of weight

Use appetite stimulants

Cancer treatment can change foods taste try with

different foods to help cover up tastes and smells

Try new spices, such as basil, cinnamon, curry, coriander,

mint, oregano or rosemary Spices make the mouth water
and change the taste of food.
Serve food cold or at room temperature reduce strong
tastes and smells.

Prescribe drugs to stimulate appetite. These drugs may include

megestrol or corticosteroids.
Some people claim that marijuana helps increase their appetite.
To date, studies havent shown for certain that marijuana can
effectively improve appetite. Find out more about medical
marijuana and cannabinoids.

Effects of megestrol acetate in patients with cancer

anorexia-cachexia syndrome: a systematic review
and meta-analysis
W Lesniak, M Bala, R Jaeschke, and M Krzakowski.
Review published: 2008.

Systematic review of the treatment of cancer-associated

anorexia and weight loss
T Yavuzsen, MP Davis, D Walsh, S LeGrand, and R Lagman.
Review published: 2005.
Nutritional support for head and neck cancer patients
receiving radiotherapy: a systematic review
S Garg, J Yoo, and E Winquist.
Review published: 2010.

Cochrane Database Syst Rev. 2005 Apr 18;(2):CD004310.

Megestrol acetate for the treatment of anorexiacachexia syndrome.

Berenstein EG1, Ortiz Z.

Semin Oncol. 1990 Dec;17(6 Suppl 9):2-7.

Appetite stimulation and weight gain with megestrol
acetate.
Aisner J1, Parnes H, Tait N, Hickman M, Forrest A, Greco
FA, Tchekmedyian NS.

Expert Opin Pharmacother. 2007 Jun;8(8):1085-90.

Pharmacological options for advanced cancer patients with
loss of appetite and weight.
Behl D1, Jatoi A.
Cochrane Database Syst Rev. 2013 Mar 28;3:CD004310. doi:
10.1002/14651858.CD004310.pub3.
Megestrol acetate for treatment of anorexia-cachexia
syndrome.
Ruiz Garcia V1, Lpez-Briz E, Carbonell Sanchis R, Gonzalvez
Perales JL, Bort-Marti S.

Drugs. 1992 Apr;43(4):499-506.

Cancer-associated anorexia and cachexia. Implications
for drug therapy.
Loprinzi CL1, Goldberg RM, Burnham NL.

Standards, Options and Recommendations for the use of

appetite stimulants in oncology (2000)
J C Desport,1 G Gory-Delabaere,2 M P Blanc-Vincent,2 P Bachmann,3 J Bal,4 R Benamouzig,5 V Colomb,6 D Kere,7 J C
Melchior,8 G Nitenberg,9 B Raynard,10 S Schneider,11 and P Senesse7
Author information Article notes Copyright and License information

Management

Relieving side effectsalso called symptom

management, palliative care, or supportive,
treatment for conditions (may help improve
appetite) such as

mouth sores,
dry mouth,
pain
depression

Treatments for appetite loss and associated

weight loss may include

medications that increase appetite

medications that help move food through the
intestine

Increase appetite,
Megestrol acetate or medroxyprogesterone are
forms of the progesterone hormone that can improve appetite and weight gain.

Steroid medications can increase appetite, improve a person's sense of well-being, and help

Metoclopramide (Reglan) can prevent feeling full before eating enough

Dronabinol (Marinol), a cannabinoid made in the laboratory, may stimulate

Other medications are being studied to help people

with cancer improve their appetite and gain weight.

with nausea, weakness, or pain. Because of serious side effects, steroids should only be used for a
short time.
food.

appetite.

Medications that help food move through the intestine

nutritional supplement drinks

tube feeding, which is the use of a tube that passes through the nose into the
stomach, can also be helpful

Standards, Options and Recommendations for the use

of appetite stimulants in oncology (2000)
J C Desport,1 G Gory-Delabaere,2 M P Blanc-Vincent,2 P Bachmann,3 J Bal,4 R Benamouzig,5 V Colomb,6 D Kere,7 J C Melchior,8 G
Nitenberg,9 B Raynard,10 S Schneider,11 and P Senesse7
Author information Article notes Copyright and License information

Corticosteroids

Corticosteroids are appetite stimulants (level of evidence: B1). There is insufficient information
available to define the optimal dose and scheduling for their use in this indication
(recommendation).

Synthetic progestogens
Megesterol acetate

Megesterol acetate is an appetite stimulant (level of evidence: B1). It results in a significant

increase in appetite and there is a beneficial effect on body weight in patients with cancer
(standard, level of evidence: B1). The minimum efficacious dose is 160mgday1 (level of
evidence: B1). If there is no response, 480mgday1, which seems to be the optimal dose, can be
used (recommendation, level of evidence: C). There is no evidence that doses greater than
480mgday1 have a higher efficacy (level of evidence: B1).

Medroxyprogesterone acetate (MPA)

Medroxyprogesterone acetate is an appetite stimulant (level of evidence: B1). It results in a

significant increase in appetite (level of evidence: B1). The effect on weight gain has not been
confirmed (level of evidence: C). Randomised clinical trials should be undertaken to investigate
the optimal dose and duration of administration of this drug, although the minimum dose, shown
to have a positive effect on appetite in published trials was 200mgday1 (recommendation,
expert agreement).

Other drugs

Cyproheptadine may be an appetite stimulant, but adverse effects have been reported (level
of evidence: C). Dronabinol, metoclopramide, nandrolone and pentoxifylline have not been
shown to have any appetite-stimulating effects (level of evidence: C). These drugs should not be
used outside the setting of a randomised clinical trial (recommendation, expert agreement).

The French Regional Comprehensive Cancer Centres, the French Employment and
Solidarity Ministry The French association: Ligue Nationale Contre le Cancer and
the French Hospital Federation for their financial support.

Conclution

Management strategy: appetite stimulants for

use in patients with cancer

No French product licence

Corticosteroids
Megestrol acetate
MPA (French product licence) can be used in the treatment of
anorexia and weight loss in patients with cancer
(recommendation, level of evidence: B1)
Appetite stimulants can be used in combination with or after
failure of dietetic and oral nutritional management
(recommendation, expert agreement).
The use of appetite stimulants is particularly warranted in
patients with incurable disease (recommendation, level of
evidence: C).
Appetite stimulants can be administered to patients with any
type of tumour (recommendation, expert agreement). The
optimal mode of administration for these products is not
known.

Anoorexia and cachexia are serious complications

frequently found in patients with cancer (Bozetti,
1995; Donnelly and Walsh, 1995).
Multiple factors are involved in their aetiology
(Puccio and Nathanson, 1997).
The resultant malnutrition is associated with a
poorer response to anticancer treatment and an
impaired quality of life (Holmes and Dickerson,
1987; Bozetti, 1995; De Conno et al, 1998).
Many clinical trials have been undertaken to
evaluate the efficacy of drugs thought to be
appetite stimulants.
Developing New Chemotherapy Regimens With
Similar Efficacy But Less Toxicity Should Be a priority
For Future research.

Thank You

Thank You

Definiton of Standards, Options and Recommendations

Standards

Procedures or treatments that are considered to

be of benefit, inappropriate or harmful by
unanimous decision, based on the best available
evidence

Options

Procedures or treatments that are considered to

be of benefit, inappropriate or harmful by a
majority, based on the best available evidence

Recommendations

Additional information to enable the available

options to be ranked using explicit criteria (e.g.
survival, toxicity) with an indication of the level of
evidence

Br J Cancer. 2003 Aug; 89(Suppl 1): S98S100.

Definition of level of evidence

Level A
There exist a high-standard meta-analysis or several high-standard randomised clinical
trials which give consistent results
Level B
There exist good quality evidence from randomised trials (B1) or prospective or
retrospective studies (B2). The results are consistent when considered together
Level C
The methodology of the available studies is weak or their results are not consistent when
considered together
Level D
Either the scientific data do not exist or there is only a series of cases
Expert agreement
The data do not exist for the method concerned, but the experts are unanimous in their
judgement
Br J Cancer. 2003 Aug; 89(Suppl 1): S98S100.

The French Regional Comprehensive Cancer Centres, the

French Employment and Solidarity Ministry The French
association: Ligue Nationale Contre le Cancer and the
French Hospital Federation for their financial support.

The following tips for getting proper

nutrition when your appetite is poor

Eat five to six small meals a day, and snack whenever you are hungry
Determine which times of day you are hungry, make sure to eat at those times, and do not limit how much you
eat.
Eat nutritious snacks that are high in calories and protein, such as dried fruits, nuts, yogurt, cheeses, eggs,
milkshakes, ice cream, cereal, pudding, and granola bars.
Keep your favorite foods on hand for snacking.
Add calories and protein to foods by adding sauces, gravy, butter, cheese, peanut butter, cream, and nuts.
Drink fluids between meals, rather than with meals. Drinking during a meal may make you feel full too quickly.
Choose nutritious or filling drinks, such as milk or nutritional milkshakes or smoothies.
Ask family members or friends to get groceries and prepare food for you when you are too tired shop or cook,
and consider buying precooked meals.
Try to eat in pleasant surroundings, and eat meals with family or friends.
Try placing food on smaller plates rather than larger plates.
If the smell or taste of food makes your nauseous, eat food that is cold or at room temperature to decrease its
odor and reduce its taste.
However, if you are having trouble tasting food, try adding spices and condiments to foods to make them more
appealing.
If you have changes in taste, such as a metallic taste in your mouth, sucking on hard candy like mints or lemon
drops before eating a meal can be helpful.
Ask your doctor about ways to relieve gastrointestinal symptoms, such as nausea, vomiting, and constipation or if
you are having any difficulty with managing pain.
Try light exercise, such as a 20-minute walk, about an hour before meals to stimulate your appetite. Consult your
health care team before starting an exercise program. Exercise also helps maintain muscle mass.
Meet with a registered dietitian for additional advice on meal planning.

Appetite-Enhancing Drugs
Appetite-enhancing drugs to prevent
undesired weight loss in the elderly, AIDS and
cancer, which often result in wasting of the
body's muscle tissue as well as overall weight
loss. The medical term for these drugs is
orexigenic,
the orexigenic drugs in common use as of 2005
they range from antihistamines and antiemetics
(drugs given to treat or prevent nausea and
vomiting) to antidepressants and synthetic
hormones.