The cachectic states are subdivided into:
Cachexia in states of malnutrition with dyspromidemic status (see malabsorption
syndrome)
Cardiac cachexia in patients with severe heart failure (see Pulmonary heart
Heart failure)
Hypophyseal hormone deficiency: Simonds disease or pituitary cachexia.
Cachexia in chronic debilitating infections such as in AIDS, tuberculosis
Cachexia from mental anorexia or eating disorders (caused by the almost total
loss of appetite, due to a complex psychic illness typical of adolescence).
Cachexia from autoimmune diseases
Cachexia of the patient with hyperthyroidism
Cachexia of diabetes decompensated before diagnosis, a very frequent cause of
weight loss, with polyuria and polyphagia.
Cachexia in patients with chronic obstructive pulmonary disease or in patients
with lung cancer. Cachectic patients with cancer, in fact, have a general
protein turnover much faster than that of non-cancerous patients, which seems to
be related to the production, by the tumor, of cytokines such as: Tumor Necrosis
Factor (TNFa) and interleukin 1 (IL1), which would act, in fact, stimulating
proteolysis and catabolism.
Addiction cachexia
Neoplastic cachexia: typical of patients affected by malignant tumors in the pre-terminal phase (especially if located in the digestive system, esophagus or stomach), has a complex etiology in which different mechanisms come into play (anorexia, alteration of metabolism glucidic and release of substances produced by both the tumor and the host, capable of influencing the metabolism moving it towards catabolism); it is often the most debilitating feature of this morbid process.
Neoplastic cachexia is a severely debilitating paraneoplastic syndrome, which is characterized by an early loss of weight, lack of appetite, but also and especially for a loss of muscle mass, with depletion of fat deposits and profound metabolic alterations. It negatively affects the quality of life of cancer patients. Today it is no longer considered a terminal event but is seen as the final consequence of a series of metabolic and biomolecular alterations that arise very early during the course of the study, which is substantially non-reversible with the common nutritional and metabolic treatments. The pathogenesis of muscle mass loss during neoplasia has not yet been completely clarified, since it depends on disparate factors, but it appears mainly from an imbalance between synthesis speed and protein degradation at the muscular level, where there is a role played by the proteolytic system of the ATP-dependent ubiquitin / proteasome in accelerated muscle protein degradation. For these reasons a substance has been studied, the bortezomib inhibitor of the proteasome, able to block the destruction of the lean mass.
Cachexia is a state of profound general decay, characterized by weakness, a
sense of prostration, a slowing of psychic abilities, loss of appetite and
reduction of fat and muscle mass. It often happens to the internist to have to
identify the pathologies that underlie this symptom, that is weight loss and
weight loss, with generalized asthenia. Usually they are patients who have
diabetes and do not know it, eat, drink and urinate continuously and lose weight
and lean muscle mass, or neoplastic patients, especially with lung or digestive
cancer. At best, they do not feed on benign stress or ulcer gastritis. But let's
see together what the good internist should look for when he runs into these
patients.
Cachexia is an expression of different conditions:
The doctor must subject the patient to a series of investigations, reasoning on
the symptoms (cf. approach to the patient), for example must request the
haemochromocytometric and the iron structure, the protidemia and dosage the
albumin, the stool occult blood, thyroid hormones, tumor markers; must perform a
radiological survey of the thorax, an electrocardiogram, an abdominal
ultrasound; must exclude conditions of psychological stress and conditions of
poverty, because especially the old man, at the present time is forced to
collect food from the trash (!)
Once excluded that the aforementioned pathologies do not exist, the good
internist must think about whether the caloric intake is adequate and the diet
is correct (cf. Energy requirements).
The therapy of cachexia is therefore the goal of:
calculate the energy needs of the individual (diet);
to supply proteins, glycides, lipids, vitamins, hydroelectrolytes, generally
through nutritional bags, where the quantity of glucose must be considered and
the intake of fast or ready insulin to be calculated for the diabetic subject.
Generally the rule is to add 6- 8 units of insulin every 25 g in glucose, but
the doctor must continuously monitor the blood sugar levels !!
to take into account the pathologies that have determined the cachectic state,
be they neoplastic or from malnutrition, and, in any case, also count towards
amorbidity: diabetes, gout, cirrhosis, renal failure). Depending on the
patient's condition, nutrition can be performed by OS, by naso-gastric or
naso-enteric (see enteral nutrition) or parenterally.
Many drugs have been used in the treatment of this phenomenon; some with low
efficacy, among them cytoheptadine and anabolic steroids with considerable side
effects: apatotoxicity, virilism. Corticosteroids have provided discreet results,
but of short duration and with well known secondary phenomena. Megestrol acetate
has been used for some time in the treatment of cancer cachexia: a progestin
used in the treatment of advanced breast cancer, able to increase appetite and
body weight in cancer patients. been obtained in anorexia induced by AIDS.
According to the literature on the subject, megestrol acetate seems well
tolerated and does not determine water retention. The ghrelin is a new peptide
that releases growth hormone (GH) also able to induce a positive energy balance
by reducing the use of fat and stimulating the appetite through GH-independent
mechanisms., And it seems that the ghrelin improves the cachectic status and
functional capacity in patients with COPD. Proinflammatory cytokines, especially
TNF-alpha (Tumor Necrosis Factor) play an important role in the pathogenesis of
cancer cachexia. Researchers at Queen Alexandra Hospital in Portsmouth, UK,
evaluated the safety and efficacy of Thalidomide in attenuating weight loss in
patients with cachexia, secondary to advanced pancreatic cancer. A total of 50
patients with advanced pancreatic cancer who had lost at least 10% of their body
weight were randomized to receive thalidomide 200 mg / day or placebo for 24
weeks. Many diets in cachectic patients must be supplemented by well-known
pharmacological substances such as carnitine or eicosapentaenoic acid, an
omega-3 fatty acid (EPA) enriched in proteins and calories, and according to the
doctors involved in the meeting, they can make a difference , by acting on
weight loss and combating it, thus combating a series of incapacitating effects
of the tumor and affecting the quality of life.
Gastroenterology