Olanzapine Improves Cachexia in a Breast Cancer Patient under Home Hospice Care

Dear Editor:

People aged ≥65 years in Japan constitute >25% of its population. Hospice care at home improves quality of life in terminal cancer patients. Yet, >80% of geriatric patients die in hospital. In other words, there is a gap between best quality and current medical practice. It is an important public health issue to shift the place of death from hospital to home hospice care at the end of life to improve medical cost burden and address insufficient hospital bed availability.

The Ministry of Health, Labour and Welfare is working to promote implementation of a community-based comprehensive care system by 2025. ¹ Practical medical care of such patients is not well reported in the medical literature despite many patients who are currently cared for in a home hospice institution. We describe a patient with appetite loss and nausea based on cachexia ² and with terminal breast cancer at a hospice-based care institution.

An 87-year-old woman with stage IV breast cancer rejected advanced treatments and opted for our home hospice service to receive comfort care. Her cancer metastasized to the axillary lymph nodes, and pain caused by damage to her left breast was controlled using transdermal fentanyl (50 mcg/h, 1.2 mg/day). For three months, she was stable, physically and mentally. Later, however, her appetite decreased, and was associated with nausea and vomiting. Oral and injectable metoclopramide and domperidone suppository initially controlled her nausea. Environmental and meal modifications were also implemented.

Other medications were amlodipine, azilsartan, furosemide, spironolactone, lansoprazole, and zolpidem. Her blood pressure, edema, and sleep were controlled. When nausea and vomiting recurred, 500 mL of lactated Ringer's solution was intravenously administered with no improvement. We then began 5 mg of olanzapine ³ orally to improve her gastric symptoms based on psychiatric symptoms (Fig. 1). A dramatic improvement was seen within one week, with no adverse events. Before its initiation, she was unable to take oral medications. After starting olanzapine, she could take them and eat a complete meal. Her symptoms remained well controlled for 10 months before she died.

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FIG. 1.

Clinical course of the present case.

Corticosteroids are recommended for treatment of cachexia when life expectancy is approximately one month, considering the side effects they could cause. ⁴ Effective treatment for cachexia had not been established in 2019 in Japan (anamorelin ⁵ was marketed for cachexia in April 2021). Cachexia is frequently associated with appetite loss and is sometimes accompanied by nausea and vomiting. Anamorelin improves cachexia through ghrelin-like effects.

Olanzapine has been reported to promote appetite by enhancing the ghrelin-mediated growth hormone secretagogue receptor signaling. ⁶ Research has shown that in advanced cancer patients with chronic nausea and vomiting, olanzapine drastically improves the symptoms in a randomized placebo-controlled study ⁷ because of its ability to affect dopamine, serotonin, and histamine receptors. Our case suggests that olanzapine may additionally improve cachexia through ghrelin enhancement even in hospice care settings when the life expectancy is over a month.