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or chronic problem. It’s appropriate to calories to a healthy animal, it’s going to muscle condition score over the
provide some form of nutrition as soon primarily lose fat. If we don’t provide shoulders, the hindquarters, and the
enough calories to an ill animal, it will
as possible. If a dog was hit by a car or is pullout head, but primarily over the epaxial
having surgery, it might be inappetent primarily lose muscle—what we call muscles of the back because that’s —Dr. ?
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for a relatively short period, and chances cachexia. This muscle loss associated where muscle loss starts and it’s the
are good that dog will recover without with disease has deleterious effects on easiest place to identify it.
appetite stimulation. But patients that survival, quality of life, strength, and
have chronic disease may be chronically wound healing. Dr. Larson: What else should you be
hyporexic. Then it becomes a struggle for considering in a workup of an
the rest of that pet’s life to get it to ingest There is another type of muscle loss inappetent patient?
enough food to address the disease called sarcopenia, which occurs with
process. If we had better means to aging in the absence of disease. Since Dr. Cook: Trying to get a diagnosis is
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provide nutritional support in such older animals are more likely to get really important. Sometimes the physical
cases, patients would do better. diseases, we often see cachexia and exam will give us direction—we’ll hear
sarcopenia concurrently. something abnormal in the chest or feel
Inappetence: something abnormal in the abdomen. I
Effect on Treatment Dr. Johannes: In human oncology the can’t emphasize enough that often there
are tremendously important clues to be
cachexia-anorexia syndrome is very well
Dr. Larson: Do you think established and recognized. The impact found in the very basic exam. Then I’ll
inappetence directly impacts your that it plays on the cancer patient’s quality order routine lab work—complete blood
patient’s response to treatment? of life and survival is also well recognized. count, biochemical profile, and urinalysis.
Being able to intervene is becoming a
Dr. Johannes: A primary concern is growing focus in human oncology. For example, underlying GI disease is one
that managing the disease, the pet’s Effective intervention may help with not of the most common causes of inappe-
appetite, and client expectations is just quality of life but with outcome. tence, so I tend to lean toward that as the
difficult. A lot of our clients are hesitant cause if the bloodwork doesn’t give me
about starting chemotherapy in the first Dr. Larson: Can you help us anything useful. Ultrasound and thoracic
place, so they’re probably going to stop understand what’s important in a radiographs are easy to do. Sometimes it’s
therapy if we don’t have a positive basic nutritional assessment? curable endocrine disease, but usually it’s
experience in those first 2 or 3 weeks. not. Then we’re considering an occult
Dr. Freeman: A nutritional assessment neoplastic process in the abdominal
Another issue is that inappetence may can tell you a tremendous amount, and cavity or inflammatory bowel disease.
dictate how I dose chemotherapy. If I have every patient should have one performed Sometimes those diagnoses are hard to
to delay treatment or reduce the dose at every visit. The World Small Animal make, so we look at things like cobalamin
because of inappetence, I may be hurting Veterinary Association guidelines (www. and folate levels, and then we rule out
the patient’s ability to respond to that wsava.org/nutrition-toolkit) detail how infectious diseases. All these things take
chemotherapy protocol. It puts us in a this should be done. At every patient visit, time, and sometimes days go by without
tough spot, especially if the condition is we should get the body weight, body making a diagnosis. It would be extremely
progressing and I can’t begin treatment. condition score, muscle condition score, helpful to have something to achieve
and diet history. With that information, we more effective nutrition while we’re
Or some clients say, “This isn’t for me. It’s can determine the animal’s nutritional waiting for our test results to come back.
not the quality of life I want for my pet,” status and whether the diet is contributing
and they just stop treatment. If I have the to the underlying disease or if the diet Dr. Larson: What are the most
ability to intervene to bring back the pet’s needs to be modified to help manage the common drugs used to stimulate
appetitie, that changes the dynamic. condition. We especially want to pay appetite?
attention to aging animals and those with
Dr. Freeman: To owners, appetite is so chronic disease. Dr. Johannes: That’s been the challenge.
important in terms of their animal’s Everything we’ve been using as appetite
quality of life. In chronic kidney disease Dr. Larson: Is muscle condition stimulants has 2 characteristics: it’s used
(CKD), studies have shown that renal score an important component of off-label, and it’s not designed to be an
diets can slow progression of disease the assessment of an inappetent appetite stimulant. Whether it’s mirtazap-
and improve survival, but they don’t help patient? ine, cyproheptadine, or diazepam, we’re
if the animal won’t eat them. using it because a side effect is appetite
Dr. Freeman: The body condition score stimulation. It’s no wonder that we are
Dr. Larson: What is the impact of primarily assesses fat, and the muscle frustrated, because it only works some-
the weight loss that results from condition score specifically looks at times. A high percentage of our patients
not eating very well? muscle. You can have a very obese have some level of inappetence, but we
animal with severe muscle loss, and didn’t have any drug that directly affects
Dr. Freeman: Weight loss is certainly a conversely you can have a very thin the appetite pathway. Appetite regulation
common issue, but more important is animal that has normal muscle, so you is complicated, but we do know that there
muscle. If we don’t provide enough have to do both assessments. We assess is one hormone that has a direct positive

February 2018 clinician’s forum 3