Identification and management of sarcopenia in patients with multimorbidity: An EFIM critically appraised and adapted guideline.

BACKGROUND: Sarcopenia is highly prevalent among adults with multimorbidity and contributes substantially to frailty, disability, prolonged hospitalization, and mortality. International guidelines offer robust diagnostic and therapeutic frameworks for sarcopenia, but rarely incorporate the clinical complexity of patients with multimorbidity (MM). The European Federation of Internal Medicine (EFIM) undertook a guideline adaptation process to produce practical, evidence-based recommendations specifically tailored for internal medicine practice. METHODS: A multinational survey of European internists identified priorities and practice unsolved clinical questions (PICOs) in older people with MM. This was followed by a critical appraisal of updated existing clinical practice guidelines (CPGs) and the selection of recommendations that were most applicable to specific clinical situations. Where direct evidence in multimorbid populations was limited, Good Practice Points were formulated considering pathophysiology, feasibility, and frailty safety concerns. RESULTS: A total of eight PICO questions were prioritized, covering case-finding, screening, diagnosis, prevention, iatrogenic complications, nutritional or exercise interventions, and pharmacotherapy. The 37 adapted recommendations from 4 high quality CPG emphasize: proactive case-finding in adults ≥65 years and multimorbid adults <65 years with specific risk factors; prioritization of muscle strength (handgrip or chair-stand) as the entry point to assessment; flexible diagnostic pathways, individualized multimodal physical activity, and nutritional interventions. The guideline also addresses treatment-induced risks (e.g., corticosteroids, Glucagon-Like Peptide-1 /Gastric Inhibitory Peptide agonists) in MM contexts. Of the 37 selected recommendations (30 strong and 7 weak), 8 were based on high, 12 on moderate, and 17 on low-quality evidence, built on consensus (best practice statements). CONCLUSIONS: This EFIM-adapted clinical practice guideline provides a practical framework for the identification and management of sarcopenia in patients with MM. By integrating feasibility considerations, multimorbidity science, and functional assessment strategies, it offers a clinically relevant tool for improving outcomes in a population at high risk of frailty, disability, and mortality. Future research should prioritize MM populations to strengthen the evidence for integrated, patient-centered sarcopenia care.