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Put evidence into practice to prevent and manage anorexia.


Anorexia is a common side effect in patients with cancer, affecting as many as 50% at diagnosis and upwards of 60%-65% with advanced disease. The malnutrition caused by anorexia can significantly affect the course of cancer, increasing treatment toxicity, muscle wasting, and morbidity and mortality.

Because anorexia is so common in patients with cancer, oncology nurses may encounter patients who have this side effect. The ONS Putting Evidence Into Practice [R] (PEP [R]) Anorexia Project Team reviewed, critiqued, and summarized the research evidence for nursing interventions for patients experiencing anorexia. Their work was reported in the February 2009 issue of the Clinical Journal of Oncology Nursing (Adams et al., 2009). See Figure 1 for a summary of the PEP team's recommendations.

Recommended for practice

Sufficient evidence was found to recommend only two treatments for practice: corticosteroids and progestins. The ONS PEP team systematically reviewed six randomized, placebo-controlled trials evaluating the use of different corticosteroids (i.e., oral dexamethasone, oral methylprednisolone and prednisolone, and IV methylprednisolone and dexamethasone). The results suggested that although none of the studies demonstrated weight gain in patients with cancer, the drugs had a significant but short-lived benefit on anorexia. Therefore, the PEP team recommended the use of corticosteroids in patients with limited life expectancy or those who need only short-term results.

Progestins have been used to treat hormone-dependent cancers, and their effect on appetite and weight has been noted in the past. The ONS PEP team evaluated the research surrounding the use of two types of progestins, megestrol acetate and medroxyprogesterone, and found strong evidence supporting their use. Side effects of these drugs include thrombotic events, breakthrough vaginal bleeding, peripheral edema, hyperglycemia, hypertension, Cushing syndrome, alopecia, and adrenal suppression or inefficiency.

Likely to Be Effective

In addition to the treatments recommended for practice, the ONS PEP team found one intervention that is likely to be effective: dietary intervention counseling. Studies have show that dietary counseling helped improve nutritional intake and body weight, which reduced anorexia and improved patients' quality of life.

Effectiveness Not Established

The effectiveness of several interventions could not be established, either because of study limitations, major or minor design flaws, or methodologic concerns.

Cyproheptadine: In early clinical trials, this drug was shown to cause weight gain; however, larger studies were unable to replicate this result. Cyproheptadine is also a sedative and can have negative results on quality of life.

Eicosapentaenoic acid: This omega-3 fatty acid has been found to lower levels of proinflammatory cytokines, which was hypothesized to affect appetite and weight gain in patients with cancer. Clinical trials have been unable to prove this theory.

Erythropoietin: When combined with cyclooxygenase-2 inhibitors, this glycoprotein is believed to slow the progression of weight loss. No evidence exists to support this theory.

Ghrelin: This amino acid, which stimulates the appetite, is naturally produced by cells in the lining of the stomach. Insufficient evidence exists to support the use of IV ghrelin as an appetite stimulant.

Metoclopramide: Treating patients' nausea with metoclopramide has been thought to improve anorexia. A systematic review of two studies found that although the drug is useful in treating early satiety, delayed gastric emptying, and delayed nausea and vomiting, insufficient evidence exists to support its use in cancer-related anorexia.

Oral branched-chain amino acids: Supplementing with these is thought to decrease the levels of tryptophan in the brain, thereby increasing appetite. Only one small trial tested that hypothesis; although the results were positive, the short duration, small sample size, and lack of description of the assessment tool limited the reliability of the evidence.

Pentoxifylline: Studies evaluating the usefulness of this drug in cancer-related anorexia found that the treatment was not effective.

Thalidomide: This drug decreases tumor necrosis factor activity and has demonstrated weight gain in patients with HIV or tuberculosis. The PEP team cannot recommend this drug for patients with cancer-induced anorexia because no prospective, randomized, controlled studies have been conducted in that population.

For complete information about treatment for cancer-induced anorexia, including details about the treatments whose effectiveness was unlikely, refer to the full article by Adams et al. (2009).

The ONS PEP card on anorexia is available in volume 4 of the ONS PEP cards, which also contains cards on anxiety, diarrhea, and lymphedema. To order the pocket cards, visit or e-mail

Adams, L.A., Shepard, N., Caruso, R.A., Norling, M.J., Belansky, H., & Cunningham, R. (2009). Putting Evidence Into Practice [R]: Evidence-based interventions to prevent and manage anorexia. Clinical Journal of Oncology Nursing, 13(1), 95-102.

[By elisa Becze, BA, ONS Staff Writer]

Key Definitions

Anorexia: a loss of desire to eat that is almost invariably accompanied by a decrease in oral intake

Cachexia: a loss of muscle tissue and fat that often accompanies anorexia; for the purposes of the ONS Putting Evidence Into Practice [R] resources, anorexia was studied independent of cachexia.

Orexigenic: used to describe that which stimulates the appetite

Five-Minute In-Service is a monthly feature that offers readers a concise recap of full-length articles published in the Clinical Journal of Oncology Nursing (CJON) or Oncology Nursing Forum. This edition summarizes "Putting Evidence Into Practice(r): Evidence-Based Interventions to Prevent and Manage Anorexia" by Lynn A. Adams, RN, MS, ANP, AOCN [R], Nancy Shepard, RN, MS, AOCN [R], Rose Ann Caruso, RN, OCN [R], Martha J. Norling, RN, OCN [R], Heather Belansky, RN, MSN, and Regina Cunningham, PhD, RN, AOCN [R], which was featured in the February 2009 issue of CJON. Questions regarding the information presented in this Five-Minute In-Service should be directed to the CJON editor at Photocopying of this article for educational purposes and group discussion is permitted.
Figure 1. Interventions
for Anorexia

Recommended for Practice
* Corticosteroids
* Progestins
--Megestrol acetate
Likely to Be Effective
* Dietary counseling
Effectiveness Not Established
* Cyproheptadine
* Eicosapentaenoic acid
* Erythropoietin
* Ghrelin
* Metoclopramide
* Oral branched-chain amino acids
* Pentoxifylline
* Thalidomide
Effectiveness Unlikely
* Cannabinoids
* Hydrazine sulfate
* Melatonin
Note. Based on information from Adams et
al., 2009.
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Author:Becze, Elisa
Publication:ONS Connect
Geographic Code:1USA
Date:Mar 1, 2009
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