How is dysgeusia (distortion of the sense of taste) managed?

Management of Dysgeusia

For most cases of dysgeusia, zinc supplementation is the primary evidence-based intervention, with moderate quality evidence supporting overall taste improvement in zinc-deficient or idiopathic taste disorders. 1

Initial Diagnostic Approach

When evaluating dysgeusia, the priority is identifying reversible causes that impact morbidity and mortality:

• Assess for COVID-19 infection, especially when dysgeusia presents with concurrent anosmia, as this combination has high specificity (98.7%) for SARS-CoV-2 infection and requires immediate isolation to prevent transmission 2
• Review all current and former medications as drug-induced dysgeusia is common with keratolytic agents, chemotherapeutic drugs, antihistamines, antibiotics, and ACE inhibitors 3
• Evaluate for zinc deficiency, particularly in patients with chronic renal failure, malnutrition, or conditions causing high gastrointestinal losses 4
• Screen for neurological conditions including stroke, Parkinson's disease, and dementia that may present with taste disturbances 5
• Assess for concurrent dysphagia as this combination may indicate silent aspiration risk requiring urgent evaluation with videofluoroscopy 2, 5

Treatment Algorithm

First-Line Management

Zinc supplementation is the primary evidence-based treatment:

• Zinc supplementation improves overall taste in zinc-deficient/idiopathic taste disorders (effect size 0.44,95% CI 0.23 to 0.65; moderate quality evidence) 1
• Dosing: Zinc supplementation at 3-4 mg per day for adults covers daily needs; up to 15 mg per day may be needed to compensate for abnormally high losses 4
• Duration: Taste acuity improvement typically occurs within weeks of supplementation 1, 6
• Monitoring: Check baseline zinc levels and monitor for adverse effects including nausea, abdominal pain, diarrhea, and changes in iron or alkaline phosphatase levels 1

Context-Specific Interventions

For drug-induced dysgeusia:

• Identify and discontinue the offending medication when clinically feasible, as this is the most direct intervention 3
• Common culprits include boceprevir (dysgeusia in 37-45% of patients), telaprevir, and various chemotherapeutic agents 2
• Do not reduce doses of protease inhibitors like boceprevir to manage dysgeusia, as suboptimal dosing promotes resistant viral species 2

For immunotherapy-related dysgeusia:

• Mild cases (Grade 1): Continue immunotherapy with dietary modifications (avoid crunchy, spicy, acidic, or hot foods) 2
• Moderate to severe cases (Grade 2-3): Hold immunotherapy and initiate gabapentin, high-potency topical steroids (gel or dental paste), or viscous lidocaine 2
• Rechallenge considerations: Can be considered once symptoms become mild, but discuss risks of worsening symptoms versus benefits with patients 2

For COVID-19-related dysgeusia:

• Spontaneous recovery occurs in 73.3% of patients with median recovery time of 7.1 days 2
• Supportive care during recovery period with dietary modifications 2

For radiation-induced dysgeusia:

• Zinc supplementation may prevent and alleviate taste disorders in patients undergoing head and neck radiotherapy 6

Adjunctive Measures

Oral hygiene optimization:

• Improving oral hygiene may promote taste ability and should be implemented in all patients 6
• This is particularly important for patients with sicca syndrome to protect against dental caries 2

Dietary modifications:

• Recommended for all patients with oral dysesthesia to improve comfort and maintain nutrition 2
• Avoid crunchy, spicy, acidic, or hot foods as appropriate 2

For dry mouth (sicca syndrome) with dysgeusia:

• Mild cases: Dietary modifications, improve hydration, limit caffeine, use topical measures (water sips, saliva substitutes, moisture-preserving mouth rinses) 2
• Moderate to severe cases: Add prednisone 20-40 mg daily for 2-4 weeks then taper, systemic sialagogues (cevimeline or pilocarpine), and consider rheumatology/dental referral 2

Critical Pitfalls to Avoid

• Never assume dysgeusia is purely psychiatric or benign without appropriate workup, as it may indicate serious underlying conditions including COVID-19 infection, neurological disease, or nutritional deficiencies 2, 5
• Do not overlook silent aspiration risk in patients with concurrent dysphagia and dysgeusia, as this can lead to aspiration pneumonia and mortality 2, 5
• Avoid dose reduction of protease inhibitors to manage dysgeusia, as this promotes viral resistance 2
• Do not neglect nutritional assessment in patients with chronic dysgeusia, as taste disturbances can lead to food aversion, malnutrition, and loss of muscle mass affecting quality of life 7
• Monitor zinc supplementation for adverse effects including gastrointestinal symptoms and metabolic changes 1

When Conservative Management Fails

Consider acupuncture for idiopathic dysgeusia and hypogeusia, though evidence is limited (low quality) and insufficient to draw firm conclusions about efficacy 1

Refer to specialists (neurology, gastroenterology, or otolaryngology) when:

• Dysgeusia persists despite zinc supplementation and removal of offending agents 7, 8
• Neurological examination suggests cranial nerve involvement (VII, IX, X) 7, 8
• Concurrent symptoms suggest systemic disease requiring specialist management 5, 7