fatigue and weight loss

Interventions for fatigue and weight loss in adults with advanced progressive illness.

Payne C, Wiffen PJ, Martin S.

Cochrane Database Syst Rev. 2012 Jan 18;1

Source

Faculty of Life and Health Sciences, University of Ulster at Jordanstown, Belfast, UK. c.payne@ulster.ac.uk

Abstract

BACKGROUND:

Fatigue and unintentional weight loss are two of the commonest symptoms experienced by people with advanced progressive illness. Appropriate interventions may bring considerable improvements in function and quality of life to seriously ill people and their families, reducing physical, psychological and spiritual distress.

OBJECTIVES:

To conduct an overview of the evidence available on the efficacy of interventions used in the management of fatigue and/or unintentional weight loss in adults with advanced progressive illness by reviewing the evidence contained within Cochrane reviews.

METHODS:

We searched the Cochrane Database of Systematic Reviews (CDSR) for all systematic reviews evaluating any interventions for the management of fatigue and/or unintentional weight loss in adults with advanced progressive illness (The Cochrane Library 2010, Issue 8). We reviewed titles of interest by abstract. Where the relevance of a review remained unclear we reached a consensus regarding the relevance of the participant group and the outcome measures to the overview. Two overview authors extracted the data independently using a data extraction form. We used the measurement tool AMSTAR (Assessment of Multiple SysTemAtic Reviews) to assess the methodological quality of each systematic review.

MAIN RESULTS:

We included 27 systematic reviews (302 studies with 31,833 participants) in the overview. None of the included systematic reviews reported quantitative data on the efficacy of interventions to manage fatigue or weight loss specific to people with advanced progressive illness. All of the included reviews apart from one were deemed of high methodological quality. 
For the remaining review we were unable to ascertain the methodological quality of the research strategy as it was described. 

 None of the systematic reviews adequately described whether conflict of interests were present within the included studies.

Management of fatigue Amyotrophic lateral sclerosis/motor neuron disease (ALS/MND) - we identified one systematic review (two studies and 52 participants); the intervention was exercise.


Cancer - we identified five systematic reviews (116 studies with 17,342 participants); the pharmacological interventions were eicosapentaenoic acid (EPA) and any drug therapy for the management of cancer-related fatigue and the non pharmacological interventions were exercise, interventions by breast care nurses and psychosocial interventions.

Chronic obstructive pulmonary disease (COPD) - we identified three systematic reviews (59 studies and 4048 participants); the interventions were self management education programmes, nutritional support and pulmonary rehabilitation.

Cystic fibrosis - we identified one systematic review (nine studies and 833 participants); the intervention was physical training.

Human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) - we identified two systematic reviews (21 studies and 748 participants); the interventions were progressive resistive exercise and aerobic exercise.

Multiple sclerosis (MS) - we identified five systematic reviews (23 studies and 1502 participants); the pharmacological interventions were amantadine and carnitine. The non pharmacological interventions were diet, exercise and occupational therapy.Mixed conditions in advanced stages of illness - we identified one systematic review (five studies and 453 participants); the intervention was medically assisted hydration.

Management of weight loss ALS/MND - we identified one systematic review but no studies met the inclusion criteria for the systematic review; the intervention was enteral tube feeding.

Cancer - we identified three systematic reviews with a fourth systematic review also containing extractable data on cancer (66 studies and 5601 participants); the pharmacological interventions were megestrol acetate and eicosapentaenoic acid (EPA) (this systematic review is also included in the cancer fatigue section above). The non pharmacological interventions were enteral tube feeding and non invasive interventions for patients with lung cancer.COPD - we identified one systematic review (59 studies and 4048 participants); the intervention was nutritional support. This systematic review is also included in the COPD fatigue section.

Cystic fibrosis - we identified two systematic reviews (three studies and 131 participants); the interventions were enteral tube feeding and oral calorie supplements.

HIV/AIDS - we identified four systematic reviews (42 studies and 2071 participants); the pharmacological intervention was anabolic steroids. The non pharmacological interventions were nutritional interventions, progressive resistive exercise and aerobic exercise. Both of the systematic reviews on exercise interventions were also included in the HIV/AIDS fatigue section.MS - we found no systematic reviews which considered interventions to manage unintentional weight loss for people with a clinical diagnosis of multiple sclerosis at any stage of illness.
Mixed conditions in advanced stages of illness - we identified two systematic reviews (32 studies and 4826 participants); the interventions were megestrol acetate and medically assisted nutrition.

AUTHORS' CONCLUSIONS:

There is a lack of robust evidence for interventions to manage fatigue and/or unintentional weight loss in the advanced stage of progressive illnesses such as advanced cancer, heart failure, lung failure, cystic fibrosis, multiple sclerosis, motor neuron disease, Parkinson's disease, dementia and AIDS. The evidence contained within this overview provides some insight into interventions which may prove of benefit within this population such as exercise, some pharmacological treatments and support for self management.Researchers could improve the methodological quality of future studies by blinding of outcome assessors. Adopting uniform reporting mechanisms for fatigue and weight loss outcome measures would also allow the opportunity for meta-analysis of small studies.Researchers could also improve the applicability of recommendations for interventions to manage fatigue and unintentional weight loss in advanced progressive illness by including subgroup analysis of this population within systematic reviews of applicable interventions.

More research is required to ascertain the best interventions to manage fatigue and/or weight loss in advanced illness. There is a need for standardised reporting of these symptoms and agreement amongst researchers of the minimum duration of studies and minimum percentage change in symptom experience that proves the benefits of an intervention. There are, however, challenges in providing meaningful outcome measurements against a background of deteriorating health through disease progression. Interventions to manage these symptoms must also be mindful of the impact on quality of life and should be focused on patient-orientated rather than purely disease-orientated experiences for patients. Systematic reviews and primary intervention studies should include the impact of the interventions on standardised validated quality of life measures.

Lung cancer

Supportive and palliative care for lung cancer patients.

Yates P, Schofield P, Zhao I, Currow D.

J Thorac Dis. 2013 Oct;5(Suppl 5):S623-S628.

 Source

Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia;

Abstract

Lung cancer patients face poor survival and experience co-occurring chronic physical and psychological symptoms. These symptoms can result in significant burden, impaired physical and social function and poor quality of life. This paper provides a review of evidence based interventions that support best practice supportive and palliative care for patients with lung cancer. Specifically, interventions to manage dyspnoea, one of the most common symptoms experienced by this group, are discussed to illustrate the emerging evidence base in the field. The evidence base for the pharmacological management of dyspnoea report systemic opioids have the best available evidence to support their use. In particular, the evidence strongly supports systemic morphine preferably initiated and continued as a once daily sustained release preparation. Evidence supporting the use of a range of other adjunctive non-pharmacological interventions in managing the symptom is also emerging. Interventions to improve breathing efficiency that have been reported to be effective include pursed lip breathing, diaphragmatic breathing, positioning and pacing techniques. 
Psychosocial interventions seeking to reduce anxiety and distress can also improve the management of breathlessness although further studies are needed. 
In addition, evidence reviews have concluded that case management approaches and nurse led follow-up programs are effective in reducing breathlessness and psychological distress, providing a useful model for supporting implementation of evidence based symptom management strategies. 

Optimal outcomes from supportive and palliative care interventions thus require a multi-level approach, involving interventions at the patient, health professional and health service level.

KEYWORDS:

Lung cancer, dyspnoea, palliative care

Evaluation of Prescribing Medications for Terminal Cancer Patients near Death: 

Essential or Futile.

Lee HR, Yi SY, Kim do Y.

Cancer Res Treat. 2013 Sep;45(3):220-5.

 Source

Department of Internal Medicine, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea.

Abstract

PURPOSE:

The purpose of this study is to evaluate the prescription of essential or futile medications for terminal cancer patients during their final admission.

MATERIALS AND METHODS:

We conducted a retrospective review of the medical charts of terminally ill cancer patients admitted to the Hemato-oncology Department of two teaching hospitals from March 1, 2007 to December 31, 2009. Essential medications were based on the drugs listed by the International Association for Hospice and Palliative Care, while futile medications were defined when short-term benefit to patients with respect to survival, quality of life, or symptom control was not anticipated.

RESULTS:

A total of 196 patients were included. 
Among essential medications, strong opioids were the most frequently prescribed drugs during the last admission (62.2% fentanyl, 44.3% morphine), followed by megestrol (46.0%), and metoclopramide (37.2%); 51% of gastric protectors were prescribed with potential futility. 
Anti-hypertensive and antiglycemic agents were administered to those who experienced arterial blood pressure below 90 mm Hg (47.3%) or presented with a single measurement of fasting glucose below 50 mg/dL (10.7%), respectively. 
Statins were prescribed to 6.1% (12/196) of patients, and 75% of those prescriptions were regarded as futile.

CONCLUSION:

Our data suggest that effective prescription of essential medications and withdrawal from futile medications should be actively reconciled for improvement of a patient's end-of-life care.

KEYWORDS:

Drug therapy, Medical futility, Neoplasms, Symptom

A systematic review of the influence of opioids on advanced cancer patient survival.

López-Saca JM, Guzmán JL, Centeno C.

Curr Opin Support Palliat Care. 

2013 Nov;7(4):424-30

Source

aPalliative Care Unit, Clinic University of Navarra bUniversity of Navarra, Institute for Culture and Society (ICS), ATLANTES Research Program: Human Dignity, Advance Disease and Palliative Care cBiomedical Humanities Department, Navarra University, Pamplona, Spain.

Abstract

PURPOSE OF REVIEW:

Many health professionals still believe that opioids shorten the lifespan of patients. This situation implies that the ethical doctrine of double effect is often invoked to justify their use in extreme circumstances. The objective of this study is to revise the evidence existing in the recently published literature regarding the effect on patient survival of opioid used to control disease symptoms.

RECENT FINDINGS:

A review of the scientific literature regarding the effects of opioids on symptom control and survival does not provide any evidence that there is an association between these two variables.

SUMMARY:

The studies revised have not shown that the use of opioids for symptom control in advanced disease stages or in the last days of life has any effect on patient survival. 
Similarly, survival was not influenced by either the use of higher or lower doses of opioids, or by the practice of administering a double dose at night.

Oral morphine for cancer pain.

Wiffen PJ, Wee B, Moore RA.

Cochrane Database Syst Rev. 2013 Jul 22;7

 Source

Pain Research and Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK. phil.wiffen@ndcn.ox.ac.uk.

Abstract

BACKGROUND:

This is the second updated version of a Cochrane review first published in Issue 4, 2003 of The Cochrane Library and first updated in 2007. Morphine has been used for many years to relieve pain. Oral morphine in either immediate release or modified release form remains the analgesic of choice for moderate or severe cancer pain.

OBJECTIVES:

To determine the efficacy of oral morphine in relieving cancer pain, and assess the incidence and severity of adverse effects.

SEARCH METHODS:

We searched the following databases: Cochrane Pain, Palliative and Supportive Care Group Trials Register (June 2013); Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 5, May); MEDLINE (1966 to June 2013); and EMBASE (1974 to June 2013).

SELECTION CRITERIA:

Published randomised controlled trials (RCTs) using placebo or active comparators reporting on the analgesic effect of oral morphine in adults and children with cancer pain. Trials with fewer than ten participants were excluded.

DATA COLLECTION AND ANALYSIS:

One review author extracted data, which were checked by another review author. There were insufficient comparable data for meta-analysis to be undertaken or to produce numbers needed to treat (NNTs) for the analgesic effect. We extracted any available data on the number or proportion of participants with 'no worse than mild pain' or treatment success (very satisfied, or very good or excellent on patient global impression scales).

MAIN RESULTS:

Ten new studies (638 participants) were identified for this update, bringing the total of included studies to 62, with 4241 participants. 
Thirty-six studies used a cross-over design ranging from one to 15 days, with the greatest number (11) for seven days for each arm of the trial.

Fifteen studies compared oral morphine modified release (Mm/r) preparations with morphine immediate release (MIR). 

Fourteen studies compared Mm/r in different strengths; six of these included 24-hour modified release products. 


 Fifteen studies compared Mm/r with other opioids. 


Six studies compared MIR with other opioids. 
Two studies compared oral Mm/r with rectal Mm/r. 
Three studies compared MIR with MIR by a different route of administration. 
Two studies compared Mm/r with Mm/r at different times and two compared MIR with MIR given at a different time. 
One study was found comparing each of the following: Mm/r tablet with Mm/r suspension; Mm/r with non-opioids; MIR with non-opioids; and oral morphine with epidural morphine.

In this update a standard of 'no worse than mild pain' was set equivalent to a score of 30/100 mm or less on a visual analogue pain intensity scale (VAS), or the equivalent in other pain scales. 

Eighteen studies achieved this level of pain relief on average, and no study reported that good levels of pain relief were not attained. Where results were reported for individual participants in 17 studies, 'no worse than mild pain' was achieved by 96% of participants (362/377), and an outcome equivalent to treatment success in 63% (400/638).

Morphine is an effective analgesic for cancer pain. 

Pain relief did not differ between Mm/r and MIR. Modified release versions of morphine were effective for 12- or 24-hour dosing depending on the formulation. Daily doses in studies ranged from 25 mg to 2000 mg with an average of between 100 mg and 250 mg. Dose titration was undertaken with both instant release and modified release products. A small number of participants did not achieve adequate analgesia with morphine. Adverse effects were common and approximately 6% of participants discontinued treatment because of intolerable adverse effects.

AUTHORS' CONCLUSIONS:

The effectiveness of oral morphine has stood the test of time, but the randomised trial literature for morphine is small given the importance of this medicine. Most trials recruited fewer than 100 participants and did not provide appropriate data for meta-analysis. 
Only a few reported how many people had good pain relief, but where it was reported, over 90% had no worse than mild pain within a reasonably short time period. The review demonstrates the wide dose range of morphine used in studies, and that a small percentage of participants are unable to tolerate oral morphine. The review also shows the wide range of study designs, and inconsistency in cross-over designs. Trial design was frequently based on titration of morphine or comparator to achieve adequate analgesia, then crossing participants over in cross-over design studies. It was not clear if these trials are sufficiently powered to detect any clinical differences between formulations or comparator drugs. New studies added to the review reinforce the view that it is possible to use modified release morphine to titrate to analgesic effect. There is qualitative evidence that oral morphine has much the same efficacy as other available opioids.

Update of

• Cochrane Database Syst Rev. 2007;(4):CD003868.