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Hundeshagen G, Blears E, Mertin V, Day AG, Palackic A, Tapking C, Haug V, Kneser U, Bliesener B, Panayi AC, Aballay A, Depret F, Stoppe C, Heyland DK. Administration and effects of beta blockers and oxandrolone in severely burned adults: a post hoc analysis of the RE-ENERGIZE trial. BURNS & TRAUMA 2024; 12:tkad063. [PMID: 38650969 PMCID: PMC11033841 DOI: 10.1093/burnst/tkad063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 10/15/2023] [Accepted: 12/13/2023] [Indexed: 04/25/2024]
Abstract
Background Prospective randomized trials in severely burned children have shown the positive effects of oxandrolone (OX), beta blockers (BB) and a combination of the two (BBOX) on hypermetabolism, catabolism and hyperinflammation short- and long-term post-burn. Although data on severely burned adults are lacking in comparison, BB, OX and BBOX appear to be commonly employed in this patient population. In this study, we perform a secondary analysis of an international prospective randomized trial dataset to provide descriptive evidence regarding the current utilization patterns and potential treatment effects of OX, BB and BBOX. Methods The RE-ENERGIZE (RandomizEd Trial of ENtERal Glutamine to minimIZE Thermal Injury, NCT00985205) trial included 1200 adult patients with severe burns. We stratified patients according to their receipt of OX, BB, BBOX or none of these drugs (None) during acute hospitalization. Descriptive statistics describe the details of drug therapy and unadjusted analyses identify predisposing factors for drug use per group. Association between OX, BB and BBOX and clinical outcomes such as time to discharge alive and 6-month mortality were modeled using adjusted multivariable Cox regressions. Results More than half of all patients in the trial received either OX (n = 138), BB (n = 293) or BBOX (n = 282), as opposed to None (n = 487, 40.6%). Per study site and geographical region, use of OX, BB and BBOX was highly variable. Predisposing factors for the use of OX, BB and BBOX included larger total body surface area (TBSA) burned, higher acute physiology and chronic health evaluation (APACHE) II scores on admission and younger patient age. After adjustment for multiple covariates, the use of OX was associated with a longer time to discharge alive [hazard ratio (HR) 0.62, confidence interval (CI) (0.47-0.82) per 100% increase, p = 0.001]. A higher proportion of days on BB was associated with lower in-hospital-mortality (HR: 0.5, CI 0.28-0.87, p = 0.015) and 6-month mortality (HR: 0.44, CI 0.24-0.82, p = 0.01). Conclusions The use of OX, BB and BBOX is common within the adult burn patient population, with its use varying considerably across sites worldwide. Our findings found mixed associations between outcomes and the use of BB and OX in adult burn patients, with lower acute and 6-month-mortality with BB and longer times to discharge with OX. Further research into these pharmacological modulators of the pathophysiological response to severe burn injury is indicated.
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Affiliation(s)
- Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Elisabeth Blears
- Department of Plastic Surgery, Bayview Medical Center, Johns Hopkins University, 4940 Eastern Ave, Baltimore 21224, MD, USA
| | - Viktoria Mertin
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Andrew G Day
- Kingston General Health Research Institute, Kingston Health Sciences Centre, 76 Stuart Street, Kingston, Ontario, K7L 2V7, Canada
| | - Alen Palackic
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Christian Tapking
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Valentin Haug
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Björn Bliesener
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Adriana C Panayi
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Ariel Aballay
- Department of Plastic Surgery, Bayview Medical Center, Johns Hopkins University, 4940 Eastern Ave, Baltimore 21224, MD, USA
| | - Francois Depret
- Department of Anaesthesiology, Intensive Care Medicine and Burn center, Saint-Louis Hospital, 1 avenue Claude-Vellefaux, 75010, Asistance Publique Hôpitaux de Paris, Paris Cité University, France
| | - Christian Stoppe
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Schwanenweg 21, 24105 Kiel, Germany
- University Hospital, Würzburg, Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, Oberdürrbacher Str. 6, 97080 Würzburg, Germany
- Departments of Cardiac Anesthesiology & Intensive Care Medicine, Charité Berlin, Augustenburger Platz 1 | 13353, Berlin, Germany
| | - Daren K Heyland
- Department of Critical Care Medicine, Queen’s University, 76 Stuart Street, Kingston, K7L 2V7 Ontario, Canada
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Abstract
Cachexia is a complex wasting syndrome, accompanying a variety of end-stage chronic diseases, such as cancer, heart failure and human immunodeficiency virus (HIV) infection/acquired immunodeficiency syndrome (AIDS). It significantly affects patients' quality of life and survival. Multiple therapeutic approaches have been studied over time. However, despite promising results, no drug has been approved to date. In this review, we examine and discuss the available data on the therapeutic effects of androgens and selective androgen receptor modulators (SARMs) for cachexia.
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Affiliation(s)
- Luca Giovanelli
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20100, Milan, Italy; Department of Endocrine and Metabolic Medicine, IRCCS Istituto Auxologico Italiano, 20100, Milan, Italy; Department of Endocrinology, Diabetes & Metabolism, Newcastle-upon-Tyne Hospitals, NE1 4LP, UK.
| | - Richard Quinton
- Department of Endocrinology, Diabetes & Metabolism, Newcastle-upon-Tyne Hospitals, NE1 4LP, UK; Translational & Clinical Research Institute, University of Newcastle-upon-Tyne, NE1 3BZ, UK.
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Sun X, Feng X, Wu X, Lu Y, Chen K, Ye Y. Fat Wasting Is Damaging: Role of Adipose Tissue in Cancer-Associated Cachexia. Front Cell Dev Biol 2020; 8:33. [PMID: 32117967 PMCID: PMC7028686 DOI: 10.3389/fcell.2020.00033] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 01/15/2020] [Indexed: 12/11/2022] Open
Abstract
Loss of body weight, especially loss of adipose tissue and skeletal muscle weight, characterizes cancer-associated cachexia (CAC). Clinically, therapeutic options for CAC are limited due to the complicated signaling between cancer and other organs. Recent research advances show that adipose tissues play a critical role during thermogenesis, glucose homeostasis, insulin sensitivity, and lipid metabolism. Understanding the adipocyte lipolysis, the formation of beige adipocytes, and the activation of brown adipocytes is vital for novel therapies for metabolic syndromes like CAC. The system-level crosstalk between adipose tissue and other organs involves adipocyte lipolysis, white adipose tissue browning, and secreted factors and metabolites. Novel CAC animal models and accumulating molecular signaling knowledge have provided mechanisms that may ultimately be translated into future therapeutic possibilities that benefit CAC patients. This mini review discusses the role of adipose tissue in CAC development, mechanism, and therapy.
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Affiliation(s)
- Xiaoting Sun
- Department of Medical Oncology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xiaogang Feng
- Institute of Physiology, University of Zurich, Zurich, Switzerland
| | - Xiaojing Wu
- Department of Cardiology, Shenzhen University General Hospital, Shenzhen, China
| | - Yongtian Lu
- Department of ENT, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Kaihong Chen
- Department of Cardiology, The Affiliated Longyan First Hospital of Fujian Medical University, Longyan, China
| | - Ying Ye
- Department of Oral Implantology, School and Hospital of Stomatology, Tongji University, Shanghai Engineering Research Center of Tooth Restoration and Regeneration, Shanghai, China
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Osmolak AM, Klatt-Cromwell CN, Price AM, Sanclement JA, Krempl GA. Does perioperative oxandrolone improve nutritional status in patients with cachexia related to head and neck carcinoma? Laryngoscope Investig Otolaryngol 2019; 4:314-318. [PMID: 31236465 PMCID: PMC6580053 DOI: 10.1002/lio2.268] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 02/28/2019] [Accepted: 03/30/2019] [Indexed: 01/06/2023] Open
Abstract
Background Cancer cachexia affects up to over 50% of advanced head and neck cancer (HNC) patients. To date, the potential utility of anabolic steroids in perioperative cachectic HNC patients has not been determined. Methods Retrospective review of pre- and post-oxandrolone administration prealbumin levels in 18 perioperative HNC patients between October 2007 and October 2014 at a tertiary academic medical center. Results The median pretreatment prealbumin was 88.5 mg/L. The median post-treatment prealbumin was 227 mg/L. The median interval improvement of the prealbumin level was 131.5 mg/L. The median differences between the pretreatment and post-treatment prealbumin levels were found to be statistically significant (P < .001). Subjective improvement in wound healing was also observed. Conclusions Perioperative administration of oxandrolone resulted in objective improvements in prealbumin levels and subjective improvements in surgical wounds. Oxandrolone administered 10 mg twice daily (BID) for 10 days may be a useful adjunct in the perioperative care of nutritionally deficient HNC patients who are at risk for or have demonstrated impaired wound healing. Level of Evidence 3.
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Affiliation(s)
- Angela M Osmolak
- Department of Otorhinolaryngology-Head and Neck Surgery University of Oklahoma Oklahoma City Oklahoma U.S.A
| | - Cristine N Klatt-Cromwell
- Department of Otorhinolaryngology-Head and Neck Surgery University of Oklahoma Oklahoma City Oklahoma U.S.A.,Department of Otolaryngology Head and Neck Surgery Washington University in St. Louis St. Louis Missouri U.S.A
| | - Amber M Price
- Department of Otorhinolaryngology-Head and Neck Surgery University of Oklahoma Oklahoma City Oklahoma U.S.A
| | - Jose A Sanclement
- Department of Otorhinolaryngology-Head and Neck Surgery University of Oklahoma Oklahoma City Oklahoma U.S.A
| | - Greg A Krempl
- Department of Otorhinolaryngology-Head and Neck Surgery University of Oklahoma Oklahoma City Oklahoma U.S.A
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Mazzuca F, Onesti CE, Roberto M, Di Girolamo M, Botticelli A, Begini P, Strigari L, Marchetti P, Muscaritoli M. Lean body mass wasting and toxicity in early breast cancer patients receiving anthracyclines. Oncotarget 2018; 9:25714-25722. [PMID: 29876019 PMCID: PMC5986630 DOI: 10.18632/oncotarget.25394] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 04/28/2018] [Indexed: 12/21/2022] Open
Abstract
Background Sarcopenia refers to the reduction of both volume and number of skeletal muscle fibers. Lean body mass loss is associated with survival, quality of life and tolerance to treatment in cancer patients. The aim of our study is to analyse the association between toxicities and sarcopenia in early breast cancer patients receiving adjuvant treatment. Materials and Methods Breast cancer patients who have received anthracycline-based adjuvant treatment were retrospectively enrolled. CT scan images performed before, during and after adjuvant chemotherapy were used to evaluate lean body mass at third lumbar vertebra level with the software Slice Omatic V 5.0. Results 21 stage I–III breast cancer patients were enrolled. According to the skeletal muscle index at third lumbar vertebra cut-off ≤38.5 cm2/m2, 8 patients (38.1%) were classified as sarcopenic before starting treatment, while 10 patients (47.6%) were sarcopenic at the end of treatment. A lower baseline L3 skeletal muscle index is associated with G3-4 vs G0-2 toxicities (33.4 cm2/m2 (31.1–39.9) vs 40.5 cm2/m2 (33.4–52.0), p = 0.028). Similarly skeletal muscle cross sectional area was significantly lower in patients with G3-4 toxicities (86.7 cm2 (82.6–104.7) vs 109.0 cm2 (83.3–143.9), p = 0.017). L3 skeletal muscle index is an independent predictor of severe toxicity (p = 0.0282) in multivariate analysis. Conclusion Lean body mass loss is associated with higher grade of toxicity in early breast cancer patients receiving adjuvant chemotherapy.
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Affiliation(s)
- Federica Mazzuca
- Department of Clinical and Molecular Medicine, "Sapienza" University of Rome, Rome, Italy.,Department of Medical Oncology, Sant'Andrea Hospital, Rome, Italy
| | - Concetta Elisa Onesti
- Department of Clinical and Molecular Medicine, "Sapienza" University of Rome, Rome, Italy.,Department of Medical Oncology, University Hospital (CHU) and University of Liège, Liège, Belgium
| | - Michela Roberto
- Department of Clinical and Molecular Medicine, "Sapienza" University of Rome, Rome, Italy.,Department of Medical Oncology, Sant'Andrea Hospital, Rome, Italy
| | | | - Andrea Botticelli
- Department of Clinical and Molecular Medicine, "Sapienza" University of Rome, Rome, Italy
| | - Paola Begini
- Department of Gastroenterology, Sant'Andrea Hospital, Rome, Italy
| | - Lidia Strigari
- Laboratory of Medical Physics and Expert Systems, Regina Elena National Cancer Institute, Rome, Italy
| | - Paolo Marchetti
- Department of Clinical and Molecular Medicine, "Sapienza" University of Rome, Rome, Italy.,Department of Medical Oncology, Sant'Andrea Hospital, Rome, Italy
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Abstract
Patients with cancer frequently experience unintended weight loss due to gastrointestinal (GI) dysfunction caused by the malignancy or treatment of the malignancy. However, others may present with weight loss related to other symptoms not clearly associated with identifiable GI dysfunction such as anorexia and early satiety. Cancer cachexia (CC) is a multifactorial syndrome that is generally characterized by ongoing loss of skeletal muscle mass with or without fat loss, often accompanied by anorexia, weakness, and fatigue. CC is associated with poor tolerance of antitumor treatments, reduced quality of life (QOL), and negative impact on survival. Symptoms associated with CC are thought to be caused in part by tumor-induced changes in host metabolism that result in systemic inflammation and abnormal neurohormonal responses. Unfortunately, there is no single standard treatment for CC. Nutrition consequences of oncologic treatments should be identified early with nutrition screening and assessment. Pharmacologic agents directed at improving appetite and countering metabolic abnormalities that cause inefficient nutrient utilization are currently the foundation for treating CC. Multiple agents have been investigated for their effects on weight, muscle wasting, and QOL. However, few are commercially available for use. Considerations for choosing the most appropriate treatment include effect on appetite, weight, QOL, risk of adverse effects, and cost and availability of the agent.
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Study Design and Rationale for the Phase 3 Clinical Development Program of Enobosarm, a Selective Androgen Receptor Modulator, for the Prevention and Treatment of Muscle Wasting in Cancer Patients (POWER Trials). Curr Oncol Rep 2017; 18:37. [PMID: 27138015 PMCID: PMC4853438 DOI: 10.1007/s11912-016-0522-0] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Muscle wasting in cancer is a common and often occult condition that can occur prior to overt signs of weight loss and before a clinical diagnosis of cachexia can be made. Muscle wasting in cancer is an important and independent predictor of progressive functional impairment, decreased quality of life, and increased mortality. Although several therapeutic agents are currently in development for the treatment of muscle wasting or cachexia in cancer, the majority of these agents do not directly inhibit muscle loss. Selective androgen receptor modulators (SARMs) have the potential to increase lean body mass (LBM) and hence muscle mass, without the untoward side effects seen with traditional anabolic agents. Enobosarm, a nonsteroidal SARM, is an agent in clinical development for prevention and treatment of muscle wasting in patients with cancer (POWER 1 and 2 trials). The POWER trials are two identically designed randomized, double-blind, placebo-controlled, multicenter, and multinational phase 3 trials to assess the efficacy of enobosarm for the prevention and treatment of muscle wasting in subjects initiating first-line chemotherapy for non-small-cell lung cancer (NSCLC). To assess enobosarm's effect on both prevention and treatment of muscle wasting, no minimum weight loss is required. These pivotal trials have pioneered the methodological and regulatory fields exploring a therapeutic agent for cancer-associated muscle wasting, a process hereby described. In each POWER trial, subjects will receive placebo (n = 150) or enobosarm 3 mg (n = 150) orally once daily for 147 days. Physical function, assessed as stair climb power (SCP), and LBM, assessed by dual-energy X-ray absorptiometry (DXA), are the co-primary efficacy endpoints in both trials assessed at day 84. Based on extensive feedback from the US Food and Drug Administration (FDA), the co-primary endpoints will be analyzed as a responder analysis. To be considered a physical function responder, a subject must have ≥10 % improvement in physical function compared to baseline. To meet the definition of response on LBM, a subject must have demonstrated no loss of LBM compared with baseline. Secondary endpoints include durability of response assessed at day 147 in those responding at day 84. A combined overall survival analysis for both studies is considered a key secondary safety endpoint. The POWER trials design was established with extensive clinical input and collaboration with regulatory agencies. The efficacy endpoints are a result of this feedback and discussion of the threshold for clinical benefit in patients at risk for muscle wasting. Full results from these studies will soon be published and will further guide the development of future anabolic trials. Clinical Trial ID: NCT01355484. https://clinicaltrials.gov/ct2/show/NCT01355484 , NCT01355497. https://clinicaltrials.gov/ct2/show/NCT01355497?term=g300505&rank=1 .
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Khamoui AV, Kim JS. Candidate mechanisms underlying effects of contractile activity on muscle morphology and energetics in cancer cachexia. Eur J Cancer Care (Engl) 2011; 21:143-57. [PMID: 21880081 DOI: 10.1111/j.1365-2354.2011.01287.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Skeletal muscle wasting is a prominent pathophysiological feature of cancer cachexia. Recent evidence suggests the manifestation of mitochondrial dysfunction along with a diminished oxidative capacity. These abnormalities have been concurrently observed with impaired muscle force production and the accelerated onset of fatigue in both tumour-bearing animals and cancer patients exhibiting wasting. To address the burden imposed by cachexia, nutritional and pharmacological interventions have been investigated extensively; in contrast, contractile activity-based countermeasures (i.e. exercise training) have been less frequently explored. Although limited, several preclinical studies that implemented contractile activity have reported favourable outcomes such as the retention of muscle mass and the restoration of energetic homeostasis. Even fewer investigations have examined the mechanisms accounting for these protective effects. An experimental approach addressing contractile activity-dependent expression of muscle mass and energy metabolism regulators may yield information that provides mechanistic support for exercise countermeasures. In this review, we present several candidate mechanisms underlying the protective effects of contractile activity as support for exercise countermeasure strategies. Given the limited quantity of data in this area, insights will be derived from studies on contractile activity-dependent modulation of common cellular and molecular events regulating muscle morphology and energetics during other muscle wasting conditions (e.g. sarcopenia).
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Affiliation(s)
- A V Khamoui
- Department of Nutrition, Food and Exercise Sciences, The Florida State University, Tallahassee, FL 32306, USA
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Dodson S, Baracos VE, Jatoi A, Evans WJ, Cella D, Dalton JT, Steiner MS. Muscle wasting in cancer cachexia: clinical implications, diagnosis, and emerging treatment strategies. Annu Rev Med 2011; 62:265-79. [PMID: 20731602 DOI: 10.1146/annurev-med-061509-131248] [Citation(s) in RCA: 230] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Cancer cachexia is a complex metabolic condition characterized by loss of skeletal muscle. Common clinical manifestations include muscle wasting, anemia, reduced caloric intake, and altered immune function, which contribute to increased disability, fatigue, diminished quality of life, and reduced survival. The prevalence of cachexia and the impact of this disorder on the patient and family underscore the need for effective management strategies. Dietary supplementation and appetite stimulation alone are inadequate to reverse the underlying metabolic abnormalities of cancer cachexia and have limited long-term impact on patient quality of life and survival. Therapies that can increase muscle mass and physical performance may be a promising option; however, there are currently no drugs approved for the prevention or treatment of cancer cachexia. Several agents are in clinical development, including anabolic agents, such as selective androgen receptor modulators and drugs targeting inflammatory cytokines that promote skeletal muscle catabolism.
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Abstract
PURPOSE OF REVIEW Cachexia affects millions of cancer patients around the world. Though its causes are poorly understood, its devastating impact on the patient and their loved ones underscore the urgency of this unmet medical need. Recent research efforts suggest multiple body systems are dysregulated in cachexia, not only increasing the challenge in effectively treating the disease but also expanding the opportunities for intervention. RECENT FINDINGS Agents as diverse as anti-inflammatory monoclonal antibodies and novel anabolic small molecules are under clinical evaluation for their ability to prevent and treat wasting. The therapies evaluated to date range in their ability to improve appetite, mitigate weight loss and reverse undesirable changes in body composition and physical function. SUMMARY An increased understanding of cancer cachexia, both mechanistically and its impact on cancer patients' struggle with their disease, has resulted in diverse therapeutic concepts. Recent clinical efforts demonstrate progress with novel therapies but fall short of effectively treating most cachectic patients and highlight a clear need for further research. Given the inherent heterogeneity of cancer patients and the significant impact of muscle wasting on morbidity and mortality, continued research efforts are critical in developing effective therapies to prevent and treat cancer cachexia.
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