Medical Cannabis as a treatment option
What is Cachexia?
Cachexia is a condition that causes significant weight loss and muscle wasting in people with advanced, life-threatening illnesses such as cancer. People with cachexia usually lose their appetite (anorexia) and become physically weak.
Unlike other conditions that cause weight loss, cachexia does not completely reverse when a person increases their food intake. This is because eating too little is not the only reason why people with cachexia lose weight. Changes in levels of certain substances in the body also make people with cachexia lose muscle mass, with or without fat loss.
Cachexia is usually a symptom of a serious underlying illness such as:
- Acquired immunodeficiency syndrome (AIDS)
- Alzheimer’s disease
- Chronic infection
- Chronic obstructive pulmonary disease (COPD)
- Crohn’s disease
- Cystic fibrosis
- Heart failure
- Rheumatoid arthritis
Experts believe that changes in metabolism and inflammation are responsible for most of the weight loss and wasting in cachexia. Substances in the body called cytokines, along with certain hormones, may be responsible for these changes.
Aspects of the underlying illness and its treatment can also contribute to anorexia and weight loss. Certain medications such as chemotherapy and opioids have side effects that make it hard for people to eat enough, for example, nausea, vomiting, mouth sores, dry mouth and changes in sense of taste.
Pain from surgery or the underlying illness, as well as low mood and depression, can cause appetite loss. Digestive problems such as slowed digestion, constipation or an abdominal tumor can make a person feel full sooner than usual. Some people have difficulty swallowing because of their illness, which makes it hard to eat solid food.
Many people with serious illnesses have chronic fatigue and may not be able to prepare food for themselves.
The most recognisable symptom of cachexia is significant, unintentional weight loss. Not everyone with cachexia is underweight - if a person was overweight before their illness, they may be of average size after significant weight loss.
Cachexia can make people lose their appetite and feel exhausted because they are not getting enough energy from the food they eat. People with cachexia also feel physically weak due to reduced muscle mass.
People with cachexia often have abnormal levels of certain substances in their blood. When a doctor takes a blood test, they may find increased glucose, triglycerides, amino acids and substances associated with inflammation, while iron and albumin levels may decrease.
Humans need a certain amount of fat and muscle to survive. Extreme loss of fat and muscle from cachexia can make the underlying disease worse. Cachexia in people who have advanced illness is associated with poor prognosis and increased risk of hospitalization.
As exhaustion and physical weakness worsen, people with cachexia find it difficult to carry out day-to-day activities. Preparing and eating food has important social and emotional meaning for many people. When a person with cachexia loses interest in food, family and carers often feel like they are not doing enough to help.
Both the physical symptoms of cachexia and the associated reduction in quality of life can cause emotional distress, anxiety and depression.
Treatment should focus on the underlying illness. Increasing appetite and food intake is usually not enough to completely reverse the effects of cachexia, however doctors sometimes use medicines to relieve symptoms and improve quality of life.
Medicines for Cachexia
In some cases, doctors use medicines that stimulate appetite to help people with cachexia gain weight. If depression is contributing to appetite loss, doctors might consider using an antidepressant such as mirtazapine. Weight gain and increased appetite are side effects of mirtazapine which can be useful in cachexia.
Corticosteroids such as dexamethasone can improve appetite and feelings of wellbeing in people with advanced cancer. Megestrol acetate is another type of medicine which stimulates appetite.
If slow digestion is making it difficult for a person to eat enough, prokinetic drugs such as metoclopramide or domperidone may be helpful.
Ask your doctor for more information about treating cachexia.
Medical Cannabis and Treatment of Cachexia
The cannabis plant contains many compounds which affect the human body in different ways. Cannabinoids THC (Δ9-tetrahydrocannabinol) and CBD (cannabidiol) are the most abundant active compounds. THC is responsible for most of the mind-altering effects of cannabis.
It is thought that cannabinoids can stimulate appetite by activating the CB1 receptor which causes release of hormones that increase hunger. Dronabinol, a man-made, purified version of THC is licensed in the USA for treatment of anorexia in people with HIV/AIDS.
Currently published studies have conflicting results and are limited by small sample size and short duration. Long term effects of cannabis usage and interactions with other medicines are not yet fully understood. Further large scale trials of longer duration are needed before any conclusions can be drawn on the use of cannabis-based medicines in cachexia.
- Comparison of Orally Administered Cannabis Extract and Delta-9-Tetrahydrocannabinol in Treating Patients With Cancer-Related Anorexia-Cachexia Syndrome: A Multicenter, Phase III, Randomized, Double-Blind, Placebo-Controlled Clinical Trial From the Cannabis-In-Cachexia-Study-Group
This study compared the effect of THC with a cannabis extract containing CBD and THC and a placebo for treating cachexia. This was a double-blind trial which means that neither patients nor staff knew which treatment was given.
243 people with cachexia and anorexia from cancer were divided into three groups and given either THC, the cannabis extract or a placebo for six weeks. Participants recorded their appetite, mood and nausea level daily.
Results found no significant difference between the three groups for appetite, quality of life or toxicity at the dose tested.
- Dronabinol versus megestrol acetate versus combination therapy for cancer-associated anorexia: a North Central Cancer Treatment Group study
This study compared dronabinol with conventional appetite stimulant megestrol acetate and a combination of the two for treatment of anorexia.
469 people with anorexia from cancer were divided into three groups and given either dronabinol and a placebo, megestrol acetate and a placebo or both of the active drugs for a median of 57 to 80 days. Patients recorded weight and appetite during this period.
Results found that megestrol acetate produced greater appetite increase and weight gain compared to dronabinol at the dose tested. The addition of dronabinol to megestrol acetate did not produce any additional benefit. Toxicity was comparable in the three groups.
- Dronabinol as a treatment for anorexia associated with weight loss in patients with AIDS
This study compared dronabinol with a placebo for treating anorexia in people with AIDS.
139 people with anorexia and at least 2.3kg weight loss from AIDS were divided into two groups and given either dronabinol or a placebo for six weeks. Patients recorded change in appetite, mood, nausea and weight during this period.
Results found that the dronabinol group had a significant improvement in appetite, mood and nausea compared to the placebo group. Weight was stable in the dronabinol group, while the placebo group had a mean loss of 0.4 kg. Side effects from dronabinol were mostly mild to moderate and included euphoria, dizziness and thinking abnormalities.
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Cancer-Related Anorexia-Cachexia Syndrome
Dronabinol Versus Megestrol Acetate Versus Combination Therapy for Cancer-Associated Anorexia: A North Central Cancer Treatment Group Study
Journal of Clinical Oncology,
Multi-institutional, double-blind, randomized trial. N = 469
2.5mg CapsuleLink to publication
Cancer-related anorexia-cachexia syndrome (CACS)
Comparison of orally administered cannabis extract and delta-9-tetrahydrocannabinol in treating patients with cancer-related anorexia-cachexia syndrome
JOURNAL OF CLINICAL ONCOLOGY,
Multicenter, phase III, randomized, double-blind, placebo (PL)-controlled, three-arm, parallel study. N = 243
Whole plant extract
2.5 mg THC : 1 mg CBD capsules and 2.5 mg THC capsulesLink to publication
Patterns of use of medical cannabis among Israeli cancer patients: a single institution experience
Journal of Pain and Symptom Management,
Observational one year study n = 279
Various - uncontrolledLink to publication
The Efficacy and Tolerability of Long-Term Use of Dronabinol in Cancer-Related Anorexia: A Case Series
Journal of Pain and Symptom Management,
Uncontrolled. Case Series
Various UncontrolledLink to publication
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