Practical prescribing in cancer cachexia

Patients with cancer cachexia have shorter survival, decreased response to therapy, functional decline, and poorer quality of life. Optimal nutritional care consists of a multimodal approach, including screening, dietary counselling, nutritional supplementation, exercise advice, and consideration of prescribable medications. The aim of this article is to review the recent evidence supporting prescribing options in cancer malnutrition and cachexia.

The use of olanzapine is supported by high-quality studies and meta-analyses and appears to lead to appetite stimulation, weight gain, and reduced grade 3 chemotherapy-related toxicities. The effect may be greater in those with nausea as a contributing factor to anorexia; and whilst the safety profile of olanzapine appears acceptable, some concerns about tolerability, leukopenia, and functional decline are noted.The evidence for steroids and progestogens is outdated, and more recent studies have highlighted that these medications may worsen cachexia.Low-level evidence exists for mirtazapine and N-3 fatty acids containing DHA.

The role of pharmacotherapy in the management of cancer cachexia is limited, but when indicated, olanzapine has the strongest evidence to support its use and should displace steroids and progestogens as the first-line medication used in supportive oncology and palliative care.