What are the management options for a patient with impaired taste, specifically a bitter taste, undergoing chemotherapy with cisplatin?

Management of Bitter Taste in Patients Receiving Cisplatin Chemotherapy

Critical Recognition: This is NOT About Nausea/Vomiting

The bitter taste complaint during cisplatin chemotherapy represents chemotherapy-induced taste dysfunction (dysgeusia), not chemotherapy-induced nausea and vomiting (CINV), and unfortunately there are no evidence-based interventions proven to prevent or treat this specific symptom. The antiemetic guidelines extensively cover nausea and vomiting prevention but do not address taste alterations 1.

Understanding the Problem

Mechanism and Prevalence

• Cisplatin directly damages taste receptor cells in the circumvallate papilla, inhibiting cell proliferation and promoting apoptosis, which impairs taste cell homeostasis and regeneration 2
• Dysgeusia occurs in 37.5% of chemotherapy-naive patients at baseline and worsens significantly after cisplatin-based treatment 3
• Up to 86% of cancer patients report taste and smell alterations during chemotherapy 4
• The gustatory threshold can become unmeasurable (severe dysfunction) as early as day 8-15 after cisplatin administration and may persist for 2+ months 5

Specific Taste Changes with Cisplatin

• Increased sensitivity to bitter taste: Detection threshold decreases (foods taste more bitter than normal) 3
• Altered umami perception: Both detection and recognition thresholds decrease, making savory foods unpleasant 3
• Sweet taste changes: Detection threshold may not decrease significantly, but this is associated with reduced protein, fat, and iron intake 3
• These changes are associated with clinical neuropathy, worse quality of life, and appetite loss 3

What Does NOT Work (Common Pitfall)

Do not confuse taste dysfunction with nausea management. The standard antiemetic regimens (5-HT3 antagonists, NK1 antagonists, dexamethasone, olanzapine) are designed to prevent vomiting and nausea, not to restore taste function 1. While these should absolutely be used for CINV prophylaxis, they will not address the bitter taste complaint.

Current Management Approach (Supportive Care Only)

Counseling and Expectation Setting

• Inform patients before starting cisplatin that taste changes are common and may persist for months after treatment completion 6, 4
• Explain that this is a direct effect on taste receptor cells, not related to nausea 2
• Set realistic expectations that taste dysfunction may continue 2+ months after chemotherapy ends 5

Practical Dietary Modifications

Since patients often try self-management strategies, provide specific guidance 6:

• Modify food seasoning: Experiment with different herbs, spices, and marinades to mask bitter tastes
• Alter food temperature: Cold or room-temperature foods may be better tolerated than hot foods
• Use plastic utensils: Metal utensils can worsen metallic/bitter taste perception
• Rinse mouth before eating: Use water or mild salt water rinses to temporarily clear taste receptors
• Focus on texture and appearance: Since taste is impaired, make foods visually appealing and vary textures

Nutritional Monitoring

• Assess for reduced intake of protein, fat, and iron specifically, as these are associated with sweet taste threshold changes 3
• Monitor for malnutrition risk, as taste dysfunction directly contributes to poor oral intake 4
• Consider nutritional supplementation if dietary intake becomes inadequate

Address Associated Symptoms

• Manage concurrent dry mouth (xerostomia), which frequently accompanies taste changes and worsens the problem 6
• Ensure optimal CINV prophylaxis is in place, as nausea compounds the taste dysfunction 6

Experimental Approach (Not Standard of Care)

Potential Protective Agent

• LY411575 (γ-secretase inhibitor) showed promise in preclinical models by reducing apoptosis and increasing proliferative cells in taste tissue exposed to cisplatin 2
• This is NOT FDA-approved for this indication and remains investigational 2
• Cannot be recommended for clinical use at this time

Key Clinical Caveats

• Oncology providers rarely discuss taste changes proactively with patients, despite their high frequency and impact on quality of life 6
• Taste dysfunction is often misreported as "appetite loss" in clinical documentation, masking its true prevalence 5
• The problem may worsen with cumulative cisplatin exposure and is associated with peripheral neuropathy development 3, 5
• Recovery is unpredictable: Some patients recover within weeks, others have persistent dysfunction for months, and some may have irreversible changes 5, 4

Bottom Line Algorithm

1. Before cisplatin: Counsel patient that bitter taste and other taste changes are expected (not preventable)
2. During treatment: Provide dietary modification strategies and monitor nutritional intake
3. If taste dysfunction occurs: Reassure this is expected, optimize nutrition support, manage dry mouth
4. After treatment: Inform patient recovery may take 2+ months; continue nutritional monitoring
5. Throughout: Maintain optimal antiemetic prophylaxis per guidelines, but recognize this addresses nausea/vomiting, not taste 1