Approach to Unintentional Weight Loss Thursday Morning Teaching March 20, 2015 Dave Davidson.

Approach to Unintentional Weight Loss

Thursday Morning Teaching March 20, 2015

Dave Davidson

Case 1

Karen – 43 yr old drug company consultant

PHE • 87 kg, smoker, wants to lose weight• presented 6 mo later with 1 mo hx of nausea,

vomiting, constipation & vague abdo pain• weight 73 kg

What would you do next?

Approach to Weight Loss NYD

Case 1

Karen• LUQ mass on examination

What next?

• abdo U/S- liver is inhomogeneous throughout in keeping with multiple

small ill defined liver metastases- nodules in spleen- large lobulated irregular LUQ cystic mass- multiple enlarged lymph nodes

Next?

Karen

- liver biopsy

- peripheral T-cell lymphoma

Case 1

Cancer (16%-36%)• weight loss and tumor size not related• mediated by incr. cytokines incl. TNF-alpha & IL-6• decreased calorie intake from anorexia and symptoms

caused directly by the cancer

• GI cancer most common • lung• lymphoma• renal • prostate

Unintentional Weight Loss

Case 2

Silvia – age 77, retired opera singer

• weight fell from 56 kg to 47 kg in 9 months

• “Says she is losing weight because she isn't eating and isn't eating because she has lost her sense of taste and food is unappealing.”

What would you do next?


Case 2

Silvia

• hx & px not contributory except for loss of taste

Next?

• Lab• CBC, lytes, ferritin, glucose, albumin, LFTs all

WNL; ESR 16

• weight has stabilized & pt remains clinically well

No Identifiable Cause (10%-36%)• Clinical def’n - loss of 5kg or more than 5% of

baseline weight in 6 – 12 months is clinically important and associated with incr. morbidity and mortality

• Loss of as little as 1kg or 3% may be significant in the frail elderly

• consider socioeconomic causes• consider combinations of causes especially in the

elderly• no weight loss (up to 50%)


“anorexia of aging” often multi-factorial• changes in smell & taste• difficulty chewing• slowed gastric emptying• neuroendocrine changes causing early satiety,

decreased appetite and enjoyment of food• primary malnutrition; usually insufficient quantity• psychological and social problems• MedicationsWhat do you think the next most common category is?

Unintentional Weight LossNo Identifiable Cause cont’d

Psychiatric (9% - 42%)

• depression• screen for e.g. PHQ-9

• mania

• delusional and paranoid ideas

• dementia (screen for e.g. MMSE/MOCA)

• GAD


Case 3

Sharon – age 26, dental hygienist, wt 45 kg• 5 kg weight loss, diarrhea & abdominal pain

Physical Examination• RLQ tenderness

LAB• Hgb 100, WBC 15,000, ESR 30, CRP 15, lytes &

extended lytes, albumin WNL

What investigations would you undertake now?


Case 3

SharonDI• abdo/pelvic U/S – right tubo-ovarian abscess• small bowel wall thickeningReferral to GI

• colonoscopy w/ intubation of ileum• ileal mucosal inflammation in cobblestone pattern• areas of normal mucosa (skip areas)

GI (6%-19%)• Loss of appetite in most GI diseases

• dysphagia, early satiety, vomiting & regurgitation, abdo pain, chronic inflammation, malabsorption, surgical & spontaneous fistulas & bypasses, superior mesenteric artery syndrome

• PUD• IBD (Sharon)• Hepatitis• Celiac disease


Case 4George – 54 year old w/ PH trigeminal neuralgia &

pre-diabetes• “concerned about weight loss; says his appetite is

normal, in fact he is eating ‘a lot’.”

• regular tobacco & marijuana use

• stopped marijuana recently

• weight fell from 81 kg to 78 kg in 4 months

• physical exam unremarkable


Case 4

George

LAB: glucose 16.4

Endocrine & Metabolic (4% - 11%)• Diabetes Type 1 & 2

• malabsorption from intestinal autonomic neuropathy• gastroparesis

• Hyperthyroidism• Appetite may be increased or decreased (elderly)

• Hypercalcemia a, esp. if caused by cancer• Adrenal insufficiency a

• a anorexia, nausea & weight loss


Cardiac (2%-9%) & pulmonary (~6%)

• mechanisms not well understood• “cardiac cachexia” if severe CHF

• ?disuse muscle atrophy

• TNF-alpha elevation

• Pulmonary weight loss is proportional to disease severity

• ?disuse muscle atrophy

• TNF-alpha elevation


Case 5Richard – 49 year old unemployed chef w/ Type 1 DM &

chronic neck pain on opioids

• when last seen was successful at tapering & stopping opioid with help from a community pharmacist

• lost to f/u for 1 year • presented with 4 day hx of cough, fever, chills, vomiting &

obvious weight loss. Looked chronically & acutely ill. • weight not recorded.• O/E - decreased entry & crackles right base


Case 5

Richard• LAB

• WBC 14.6, glucose 32, pH 7.35, ketones neg

• CXR – RML & RLL pneumonia• managed w/ IV fluids, insulin & antibiotics in

hospital• discharged on hydromorphone (relapsed to using

high doses acquired on street)• referred to methadone clinic at his request

Substance abuse (4%-8%)

• amphetamines & cocaine• by stimulating satiety centre

• opiates

• alcoholism

• smoking

• cannabis withdrawal


Infection (2-5%)• HIV

• wt loss due mostly to decr. calorie intake in contrast w/ cancer where energy consumption increases

• rapid wt loss (>5% in 6 months) often due to 2’ary infections

• anti-retroviral therapy

• TB• chronic bacterial, fungal & parasitic diseases• lung abscess


Medications (~2%)• bupropion, fluoxetine & other SSRIs initially, lithium, L-dopa• metformin, L-thyroxine• digoxin, aspirin, diuretics, ACEI, Ca channel blockers• NSAIDS, bisphosphonates, allopurinol, colchicine• anticancer & antiretroviral drugs, opiates• iron, potassium• Rx drug withdrawal

• Neuroleptic withdrawal cachexia (typical anti-psychotics) and wt loss when stopping atypicals that have caused wt gain


Investigations• individualize based on the history, physical and your

differential diagnosis (symptom based)

Baseline diagnostic evaluation• CBC, ESR &/or CRP• lytes, creat/eGFR, glucose, calcium, LFTs, TSH, LD• HIV serology• CXR• FOBT?• further testing based on results of these tests

Approach to Weight Loss NYDSummary

Management• Identify and treat the underlying cause• Screen for depression & dementia• Exercise (physiotherapy referral)• Nutrition referral & counseling• Limited evidence & role for pharmacologic therapy

• mirtazapine (Remeron) for depression• THCs - dronabinol (Marinol), nabilone (Cesamet) for end

of life care (antinausea, analgesic, well-being)• megestrol (Megace) may be effective in LTC combined

with feeding assistance

Approach to Weight Loss NYDSummary

Unintentional Weight Loss Pearls

• Only a few diseases where weight loss is associated with increased appetite• Uncontrolled diabetes• Hyperthyroidism• Malabsorption syndromes• Marked increase in physical activity• Pheochromocytoma

• The differential for weight loss with decreased appetite is long• Cancer• No identifiable cause• Psychiatric• GI• Endocrine• Cardiopulmonary• Substance abuse• Infection• Medications


• Type 1 diabetics who reduce insulin to control their weight

• if using nutrition supplements (e.g. Ensure, Boost) give between meals

• serum prealbumin best marker for malnutrition & monitoring recovery

• In the elderly, if initial history, physical, & lab are normal 3 months of “watchful waiting” advised over further blind investigations

End


Approach to Unintentional Weight Loss Thursday Morning Teaching March 20, 2015 Dave Davidson.

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