What is the treatment for chemotherapy-induced mucositis?

From the Guidelines

Treatment of chemotherapy-induced mucositis should prioritize a multi-faceted approach focusing on pain management, infection prevention, and supportive care, with the use of oral care protocols, oral cryotherapy, low-level laser therapy, and palifermin (Kepivance) as recommended by recent guidelines 1. The management of chemotherapy-induced mucositis involves several key interventions to reduce morbidity, mortality, and improve quality of life.

Key Interventions

• Oral care protocols should be used to prevent oral mucositis in all age groups and across all cancer treatment modalities, as suggested by the panel 1.
• Oral cryotherapy, such as 30 minutes of ice chips, is recommended to prevent oral mucositis in patients receiving bolus 5-fluorouracil chemotherapy 1.
• Low-level laser therapy (wavelength at 650 nm, power of 40 mW, and each square centimeter treated with the required time to a tissue energy dose of 2 J/cm2) is recommended to prevent oral mucositis in patients receiving HSCT conditioned with high-dose chemotherapy, with or without total body irradiation 1.
• Palifermin (Kepivance), a keratinocyte growth factor, can be used at 60 μg/kg/day for 3 days before and after high-dose chemotherapy for hematopoietic stem cell transplant patients to prevent oral mucositis, as recommended by the guidelines 1.

Pain Management

• Topical anesthetics like 2% viscous lidocaine, benzocaine, or doxepin rinses can be used every 3-4 hours for pain relief.
• Systemic pain management may require opioids such as morphine or fentanyl for severe cases, with patient-controlled analgesia with morphine recommended for patients undergoing HSCT 1.

Supportive Care

• Maintaining good oral hygiene is crucial, with patients advised to brush with a soft toothbrush and use alcohol-free rinses like 0.9% saline or sodium bicarbonate solutions 4-6 times daily.
• Nutritional support is essential, with soft, bland, non-acidic foods recommended, and nutritional supplements if needed. These interventions work by reducing inflammation, promoting tissue healing, preventing secondary infection, and managing pain while the mucosa recovers following chemotherapy-induced damage to rapidly dividing oral epithelial cells.

From the FDA Drug Label

The results for Study 1 were supported by results observed in the subset of patients in Study 2 who received the same dose and schedule of Kepivance administered in Study 1 In a randomized, double-blind, placebo-controlled post-approval study designed to determine the efficacy of Kepivance with a high-dose melphalan preparative regimen, the incidence of treatment-emergent infections was significantly greater in patients treated with Kepivance compared to placebo Do not administer Kepivance within 24 hours before, during infusion of, or within 24 hours after administration of myelotoxic chemotherapy [see Dosage and Administration ( 2. 1) and Clinical Studies ( 14)].

Treatment of Chemotherapy-Induced Mucositis:

• Palifermin (Kepivance) may be used to treat chemotherapy-induced mucositis.
• The recommended dose is 60 mcg/kg/day, administered intravenously, for 3 consecutive days before and after chemotherapy.
• Key Considerations:
  • Do not administer within 24 hours of chemotherapy.
  • Monitor for adverse reactions, including infections and elevated serum lipase and amylase.
  • Use with caution in patients with non-hematologic malignancies, as safety and efficacy have not been established. 2 2

From the Research

Treatment Options for Chemotherapy-Induced Mucositis

• Palifermin, a recombinant human keratinocyte growth factor, has been shown to decrease oral mucosal injury induced by cytotoxic therapy 3, 4, 5.
• The use of palifermin has been associated with significant reductions in the incidence and severity of oral mucositis, as well as the duration of mucositis 3.
• Other treatment options that have been found to be effective in diminishing the severity of oral mucositis include:
  • Dentoxol mouthwashes
  • Plantago major extract
  • Thyme honey extract
  • Zinc oxide paste
  • Vitamin B complex combined with GeneTime
  • L-glutamine consumption 6
• Pain intensity has been found to be lower with the use of doxepin mouthwashes and diphenhydramine-lidocaine-antacid mouthwashes 6

Management of Mucositis

• A multidisciplinary approach is key to managing mucositis, including pain control, oral hygiene, nutritional support, and management of superimposed infection 7
• The scarcity of therapeutic options for prevention or treatment of mucositis has resulted in clinical difficulty in controlling it, which can seriously affect the patient's quality of life and cancer management 7

Potential Indications for Palifermin

• Palifermin has potential clinical applications beyond the prevention of severe oral mucositis, including:
  • Acceleration of immune reconstitution
  • Inhibition of graft-versus-host disease in patients undergoing hematopoietic stem cell transplantation
  • Mitigation of dysphagia in lung cancer patients treated with concurrent chemoradiotherapy 4