What are the treatment options for radiation-induced mucositis?

From the Guidelines

Treatment for radiation mucositis should prioritize basic oral care, pain management with topical anesthetics or systemic analgesics, and consideration of low-level laser therapy for severe cases, as recommended by recent guidelines 1. The management of radiation mucositis involves a multi-faceted approach focusing on symptom management and prevention of complications.

Key Interventions

• Basic oral care including gentle brushing with a soft toothbrush 2-4 times daily, regular flossing, and alcohol-free mouth rinses such as 0.9% saline or sodium bicarbonate solutions (1/2 teaspoon in 8 oz water) 4-6 times daily.
• For pain management, topical anesthetics like 2% viscous lidocaine (5-15 ml swished for 1-2 minutes then spit out, every 3-4 hours) or benzydamine hydrochloride rinse can provide temporary relief.
• Systemic analgesics may be necessary, starting with acetaminophen or NSAIDs, and progressing to opioids for severe pain, with patient-controlled analgesia with morphine being recommended for patients undergoing HSCT 1.
• Mucosal coating agents are not universally recommended, with sucralfate mouthwash specifically recommended against for treating oral mucositis in patients receiving radiation therapy for head and neck cancer 1.

Additional Considerations

• Low-level laser therapy may reduce inflammation and promote healing in severe cases, with recommendations for its use in patients undergoing radiotherapy without concomitant chemotherapy for head and neck cancer 1.
• Nutritional support is crucial, focusing on soft, non-irritating foods, adequate hydration, and possibly nutritional supplements.
• Prevention strategies during radiation therapy include maintaining good oral hygiene, avoiding irritants like alcohol and tobacco, and using prescribed preventive agents like amifostine when indicated.

Guidelines and Recommendations

• The ESMO clinical practice guidelines provide recommendations for the management of oral and gastrointestinal mucosal injury, including the use of oral cryotherapy, recombinant human keratinocyte growth factor-1, and low-level laser therapy for prevention, and patient-controlled analgesia with morphine for pain management 1.
• These guidelines also suggest against the use of certain interventions, such as sucralfate mouthwash and intravenous glutamine, for the prevention or treatment of oral mucositis 1.

From the FDA Drug Label

The safety and efficacy of Kepivance in decreasing the incidence and duration of severe oral mucositis in patients with hematologic malignancies (NHL, Hodgkin's disease, acute myeloid leukemia, acute lymphoblastic leukemia, chronic myeloid leukemia, chronic lymphocytic leukemia, or multiple myeloma) receiving myelotoxic therapy requiring hematopoietic stem cell support, were established in a randomized placebo-controlled clinical trial of 212 patients (Study 1) and a randomized, schedule-ranging, placebo-controlled clinical trial of 169 patients (Study 2) In Study 1, patients received high-dose cytotoxic therapy consisting of fractionated total-body irradiation (TBI) (12 Gy total dose), high-dose etoposide (60 mg/kg), and high-dose cyclophosphamide (100 mg/kg) followed by hematopoietic stem cell support. The major efficacy outcome was the number of days during which patients experienced severe oral mucositis (Grade 3/4 on the WHO [World Health Organization] scale)

The treatment for radiation mucositis is palifermin (Kepivance), which has been shown to decrease the incidence and duration of severe oral mucositis in patients with hematologic malignancies receiving myelotoxic therapy requiring hematopoietic stem cell support, including those undergoing total body irradiation.

• Key findings:
  • Median days of WHO Grade 3/4 oral mucositis: 3 days with Kepivance vs 9 days with placebo
  • Incidence of WHO Grade 3/4 oral mucositis: 63% with Kepivance vs 98% with placebo
  • Median cumulative opioid dose: 212 mg with Kepivance vs 535 mg with placebo 2

From the Research

Treatment Options for Radiation Mucositis

• Various treatment options have been studied for radiation mucositis, including sucralfate, chlorhexidine, GM-CSF, silver nitrate, prostaglandin, anti-oxidants, and benzydamine hydrochloride 3
• Some studies have found sucralfate to be ineffective in preventing or treating radiation mucositis 4, while others have found it to be beneficial in decreasing the intensity of radiation-induced mucositis and oral discomfort 5
• Other agents that have shown promise in preventing or treating radiation mucositis include povidone-iodine, nonabsorbable antibiotic lozenges, and antifungals, as well as low-energy laser and corticosteroids 3
• Maintenance of oral hygiene is an important part of preventing radiation mucositis, and agents such as normal saline and alkali (soda bicarbonate) mouthwashes, low level laser therapy, and benzydamine have been found to be effective in preventing and treating radiation-induced oral mucositis 6

Comparison of Treatment Options

• A study comparing micronized sucralfate mouthwash to salt and soda mouthwash found no significant difference in efficacy between the two treatments 7
• Another study found that sucralfate mouth washing was beneficial in decreasing the intensity of radiation-induced mucositis and oral discomfort, but did not find a significant difference in the incidence of severe mucositis between the sucralfate and placebo groups 5
• A review of the literature found that prevention and treatment of radiation-induced oral mucositis is an active area of research, and that various agents and treatments have been found to be effective in preventing and treating the condition 6

Recommendations for Prevention and Treatment

• General prevention and global care before cancer therapy should be systematic, including oral hygiene, dental and periodontal treatment, and advice to avoid the use of tobacco and alcohol 3
• Frequent oral rinsing with a bland mouthwash, such as povidone-iodine, should be used at the start of treatment to prevent radiation mucositis 3
• Pain should be controlled, and the radiation technique should be optimized to minimize the risk of radiation mucositis 3
• Treatment of co-existing infection is also important, and both topical and systemic anti-fungals should be used judiciously 6