Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Acute decline behind presumed cachexia
New profound weakness, delirium, dysphagia, haemodynamic change, fever, bleeding, hypoglycaemia, adrenal crisis or severe electrolyte disturbance may be reversible and must not be labelled expected wasting.
Action: Use ABCDE assessment, check glucose, hydration and focused neurological and swallowing safety and obtain urgent tests or treatment within goals. Stop unsafe oral intake when aspiration is likely and treat sepsis, bleeding, obstruction, hypercalcaemia, adrenal insufficiency or another identified emergency while relieving distress.
Synopsis
Distinguish reduced appetite, inflammatory cachexia and fatigue, identify reversible contributors, support food and activity without coercion, and use nutrition, transfusion, corticosteroid or other interventions only when their time to benefit matches the person's goals.
Anorexia is reduced desire to eat; cachexia is a multifactorial loss of muscle with or without fat that nutrition alone does not fully reverse; fatigue is subjective exhaustion.
First-line assessment asks what prevents eating or activity, examines mouth and swallow, reviews weight trajectory and fluid, and checks symptoms, medicines, mood and social access.
Treat contributors that can improve a valued outcome: pain, nausea, constipation, thrush, dysphagia, infection, anaemia, endocrine disturbance, sleep and depression.
Key red flags
New focal weakness, dysarthria, choking or wet voice suggests neurological or swallowing emergency and requires aspiration-safe assessment.
Refeeding risk
Very low BMI, major recent weight loss, little intake, alcohol use or low phosphate, potassium or magnesium requires controlled nutrition initiation.
Investigation priorities
01
First-line intake and barrier assessmentFirst stepFirst line
Separate appetite, taste, chewing, swallowing, nausea, early satiety, bowel, access, preparation and family pressure.
Management branches
Initial assessmentFind barriers and define the nutrition goal
The person reports poor appetite, weight loss or fatigue or family raises concern about intake.
Clarify appetite versus ability, examine mouth, swallow, abdomen, fluid and muscle and review symptoms, medicines, mood, access and disease trajectory.
Treat reversible contributors and agree whether the priority is enjoyment, strength, treatment tolerance, recovery or survival, including the person's information preference.
Key medicines
Dexamethasone short appetite trialUse 2 to 4 mg orally once each morning for a short palliative trial, reviewing within 5 to 7 days and stopping for no meaningful benefit; taper according to duration, dose and adrenal-risk guidance.
Megestrol acetate under specialist reviewWhen selected after informed risk discussion, use a protocol dose commonly beginning at 160 mg orally daily and review within weeks; higher dosing should follow oncology or palliative specialist guidance and product information.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
NICE CG32 nutrition supportNutrition assessment, enteral and parenteral treatment, consent and refeeding prevention.