What is the treatment for radiation mucositis?

Treatment of Radiation Mucositis

The treatment of radiation mucositis should include frequent non-medicated saline oral rinses (4-6 times/day), pain management with topical anesthetics, and benzydamine oral rinse for prevention in patients receiving moderate-dose radiation therapy. 1

Basic Oral Care

• Implement multidisciplinary oral care protocols that include frequent use of non-medicated saline mouth rinses (4-6 times/day) to reduce severity of oral mucositis 1
• Use a soft toothbrush that is replaced regularly as part of systematic oral care protocols 1
• Avoid alcohol-based mouth rinses as they can irritate damaged mucosa 1
• Regular oral pain assessment using validated instruments for self-reporting is essential for proper management 1

Pain Management

• Patient-controlled analgesia with morphine is recommended as the treatment of choice for severe oral mucositis pain, particularly in patients undergoing hematopoietic stem cell transplantation (HSCT) 1
• Topical anesthetics can provide short-term pain relief for oral mucositis on an empiric basis 1
• Follow the modified WHO analgesia ladder for symptomatic treatment 1

Preventive Measures for Radiation-Induced Mucositis

• Use midline radiation blocks and three-dimensional radiation treatment techniques to reduce mucosal injury 1
• Benzydamine oral rinse is recommended for prevention of radiation-induced mucositis in patients with head and neck cancer receiving moderate-dose radiation therapy 1
• Low-level laser therapy (LLLT) is suggested to reduce incidence of oral mucositis and associated pain in patients receiving high-dose chemotherapy or chemoradiotherapy 1, 2

Treatments NOT Recommended

• Chlorhexidine is not recommended for prevention or treatment of oral mucositis in patients with solid tumors of the head and neck who are undergoing radiotherapy 1
• Antimicrobial lozenges are not recommended for prevention of radiation-induced oral mucositis 1
• Sucralfate is not recommended for prevention of radiation-induced oral mucositis 1

Nutritional Support

• Screen all patients for nutritional risk due to high risk of malnutrition following chemoradiotherapy 1
• Initiate early enteral nutrition in case of swallowing problems 1
• Consider referral to a nutrition team for patients at risk of malnutrition 1

Special Considerations for Chemotherapy-Induced Mucositis

• Oral cryotherapy (30 minutes) is recommended for prevention of oral mucositis in patients receiving bolus 5-FU chemotherapy 1
• Palifermin (keratinocyte growth factor-1) is recommended at a dose of 60 μg/kg/day for 3 days before conditioning treatment and for 3 days post-transplant for prevention of oral mucositis in patients with hematological malignancies receiving high-dose chemotherapy and total body irradiation with autologous stem cell transplant 1, 3
• Cryotherapy is suggested to prevent oral mucositis in patients receiving high-dose melphalan 1

Management of Severe Cases

• Exclude HSV, CMV, and extensive candidiasis in patients with persistent painful mucositis 1
• For patients with radiation-induced proctitis who have rectal bleeding, sucralfate enemas are suggested 1
• Consider the use of growth factors like palifermin in specific clinical scenarios, particularly for patients undergoing HSCT 3

Common Pitfalls and Caveats

• Do not administer palifermin within 24 hours of chemotherapy, as this can increase sensitivity of rapidly dividing epithelial cells and potentially worsen mucositis 3
• Avoid chlorhexidine for treatment of established oral mucositis as it has been shown to be ineffective 1
• Be aware that palifermin may not be effective in all treatment regimens - it showed lack of efficacy in patients receiving high-dose melphalan and in allogeneic transplantation 3
• Monitor for potential cataract development in patients receiving palifermin treatment 3