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At the conclusion of the symposium, faculty members fielded questions from nurses in attendance. Excerpts from the session are highlighted here. In terms of the first patient case study (C. L.), when
be effective for appetite stimulation, because data the patient had increased nausea and vomiting
shows that dronabinol can have a 24-hour effect for early on, instead of increasing the dose of prochlor-
appetite stimulation. Increased doses can be made by perazine, would it have been appropriate to use
either giving dronabinol twice daily (2.5 mg bid) or dronabinol?
once daily (5 mg at bedtime). Because many of our Ms McIntyre: Yes, I think it would have been
elderly patients are taking many other medications, we appropriate to add dronabinol at that time. However, try to minimize the frequency of dosing to once daily the patient presented to us at the beginning of treat- ment on ondansetron and prochlorperazine. We optedto increase the dose of prochlorperazine rather than For how long are corticosteroids generally given,
and what about the side effects of muscle loss and
swelling after long-term use?

In discussing newer agents to treat cancer cachexia,
Ms Rogers: Corticosteroids have a short-term ben-
the potential for some agents to decrease IL-6
efit for appetite stimulation. Therefore, long-term use [interleukin-6] was mentioned. Can you please
of corticosteroids only enhances the side effects, with provide further information?
decreased benefit. Therefore, steroids work best in Ms Finley: One of the main causes of cancer
individuals in whom pulses can be given, such as cachexia is stimulation of cytokines, and IL-6 is one of those cytokines. Therefore, if we can suppress the [cyclophosphamide, doxorubicin, vincristine, and release of cytokines (such as IL-6) we may be able to prednisone]. If patients are getting a benefit from the significantly help the cachectic problem.
prednisone part of this regimen (5-day course) we mayinclude a taper of the steroids to allow for additional What dose of dronabinol would you recommend
benefit. Thereafter, the steroids are discontinued and for the treatment of anorexia that would be well
restarted when the patient is due for the next cycle of tolerated in an elderly patient?
Ms Rogers: The dronabinol package insert recom-
mends a starting dose of 2.5 mg twice daily before Are there any clinical trial data comparing the effi-
lunch and supper, with dose reduction to 2.5 mg daily cacy of the different pharmacologic agents for
as a single dose in the evening or at bedtime if the 5- increased appetite and increased weight gain (for
gm daily dose is not well tolerated. Through my expe- example, megestrol acetate and dronabinol)?
rience in clinical practice, dronabinol is commonly Ms Finley: Jatoi et al reported results of a random-
started at 2.5 mg at bedtime. This way, if the patients ized, double-blind study that compared megestrol have side effects, they usually sleep through them. This acetate 800 mg daily with dronabinol 2.5 mg twice can be especially helpful in the elderly, in whom we daily.1 More megestrol acetate–treated patients report- may have increased concerns regarding the potential ed increased appetite and weight gain compared with side effects of dronabinol. This once-daily dosing can dronabinol-treated patients. Toxicity was comparable between the 2 agents, with more episodes of impo- Ms Rogers: I agree with Lynda. The data show that
tence with megestrol acetate. Although not an end- weight gain, not specifically lean body mass, is associ- point of the study, nausea and vomiting episodes were ated with a positive impact for the patient. not different between treatment groups. It is impor-tant to note that the dose of dronabinol studied was at CONCLUSIONS
the low range of the dose-ranging scale (recommended Awareness and early detection of cancer cachexia dose up to 20 mg daily), yet dronabinol was still able are critical in achieving beneficial patient outcomes. A to demonstrate efficacy in this patient population. vicious cycle can develop, with weight loss being asso-ciated with a poor response to treatment, which can What about the use of mirtazapine for anorexia/
result in further declines in weight. Nurses are key cachexia?
patient advocates and should be part of the entire Ms Rogers: Mirtazapine is indicated for episodes of
healthcare team managing these patients, including major depression.2 One of the side effects reported with dietitian support. Patient management plans should be this agent is increased appetite or weight gain. However, well documented, including specific roles for each I have not seen much data on its use in cancer therapy– member of the healthcare team involved in the care of related weight loss. Rather than selecting an antidepres- a specific patient. Nurses need to be aware of the eme- sant for these patients, I try to use a drug that has been togenic potential of various chemotherapeutic regi- used in this population of cancer patients with anorexia mens. Patient education should minimize the risk of or cachexia and causes mood elevation as a side effect.
delayed chemotherapy-induced nausea and vomiting However, if the patient is diagnosed with depression (CINV). Nurses can play a key role in the preven- and has problems with weight loss, then the selection of tion of CINV. A multimember team approach is an antidepressant with the potential side effect of weight important in managing the nutritional status of Is total weight (ie, muscle and fat) more important,
or is increased lean muscle mass more important in
setting nutritional goals for cancer patients?

Ms McIntyre: We are really more concerned about
total weight as far as the patient and their well-being 1. Jatoi A, Windschit, Loprinzi CL, et al. Dronabinol versus goes. What we find with these cachectic patients is that megestrol acetate versus combination therapy for cancer-associated anorexia: a North Central Cancer Treatment an increase in weight is associated with an increased Group study. J Clin Oncol. 2002;20:567-573.
sense of well-being. Our goal in these patients is not 2. Remeron® [package insert]. N.V. Organon, The necessarily an increase in survival time.

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