What is the treatment for chemotherapy-induced mucositis?

Treatment of Chemotherapy-Induced Mucositis

The treatment of chemotherapy-induced mucositis should follow a systematic approach including basic oral care protocols with saline rinses, pain management with morphine-based analgesia, and specific interventions like oral cryotherapy for patients receiving certain chemotherapy regimens. 1

Basic Oral Care (First-Line Management)

• Oral care protocols are essential for all patients receiving chemotherapy 1:
  • Frequent use of non-medicated oral rinses (saline mouth rinses 4-6 times daily)
  • Use of a soft toothbrush that is replaced regularly
  • Avoid alcohol-based mouth rinses as they can worsen irritation
  • Daily inspection of oral mucosa for abnormalities

Pain Management

• Patient-controlled analgesia with morphine is recommended as the treatment of choice for oral mucositis pain, particularly in patients undergoing HSCT 1
• Alternative pain management options include:
  • 0.2% morphine mouthwash for patients receiving chemoradiation for head and neck cancer 1
  • 0.5% doxepin mouthwash for general mucositis pain relief 1
  • Transdermal fentanyl for patients receiving conventional or high-dose chemotherapy 1
  • Topical anesthetics for short-term pain relief 1

Specific Interventions Based on Chemotherapy Type

For Patients Receiving Bolus 5-FU Chemotherapy:

• Oral cryotherapy (ice chips) for 30 minutes during administration is strongly recommended 1
  • This intervention reduces blood flow to oral mucosa during peak drug concentrations
  • Evidence level: II, A (strong recommendation)

For Patients Receiving High-Dose Melphalan:

• Oral cryotherapy (20-30 minutes) is suggested 1
  • Evidence level: III (moderate recommendation)

For Patients Undergoing HSCT with High-Dose Chemotherapy:

• Palifermin (keratinocyte growth factor-1) at 60 μg/kg/day for 3 days before conditioning treatment and for 3 days post-transplant 1, 2
  • Specifically indicated for patients with hematological malignancies receiving high-dose chemotherapy and total body irradiation with autologous stem cell transplantation
  • Evidence level: I, A (strongest recommendation)
• Low-level laser therapy (wavelength at 650 nm, power of 40 mW, tissue energy dose of 2 J/cm²) 1
  • For prevention in patients receiving HSCT conditioned with high-dose chemotherapy
  • Evidence level: II (moderate recommendation)

Nutritional Support

• Early enteral nutrition should be started in cases of swallowing problems 1
• Maintain adequate hydration to prevent dehydration 1

Interventions NOT Recommended

• Chlorhexidine mouthwash is not recommended to treat established oral mucositis 1
• Acyclovir and its analogues are not recommended to prevent mucositis caused by standard-dose chemotherapy 1
• Sucralfate mouthwash is not recommended for prevention or treatment 1
• Intravenous glutamine is not recommended for prevention in HSCT patients 1

Monitoring and Assessment

• Regular oral pain assessment using validated instruments for self-reporting is essential 1
• Monitor for signs of infection, especially during periods of neutropenia 3
• Assess pain at least once daily using an age-appropriate pain scale 3

Special Considerations

Pediatric Patients

• Similar approaches apply to pediatric patients, but with age-appropriate dosing 2
• In infants, use minimal amounts of topical anesthetics to avoid systemic absorption 3

Common Pitfalls to Avoid

1. Delaying pain management (treat pain aggressively and early)
2. Using alcohol-based mouth rinses which can worsen irritation
3. Administering palifermin within 24 hours of chemotherapy (can increase severity of mucositis) 2
4. Overlooking the risk of infection during periods of neutropenia and mucositis

By following this systematic approach to managing chemotherapy-induced mucositis, clinicians can significantly reduce patient discomfort, improve quality of life, and potentially avoid treatment interruptions due to severe symptoms.