Management of Altered Taste Sensation, Mucositis, and Anorexia During Chemotherapy
Causes
Altered Taste Sensation (Dysgeusia)
- Chemotherapy directly damages taste receptor cells and olfactory function, affecting up to 86% of cancer patients, with salty flavor distortion being the most common alteration (51.6% of cases) 1, 2.
- Direct cytotoxic effects on taste buds and mucous membranes occur during treatment, with taste changes typically appearing within 2 months of starting chemotherapy and persisting transiently 3, 2.
- Gender differences exist, with females demonstrating better taste perception than males even during chemotherapy 4.
- Taste alterations frequently co-occur with nausea, mucositis, diarrhea, and appetite changes 2.
Mucositis
- Chemotherapy causes direct mucosal injury through cytotoxic effects on rapidly dividing epithelial cells of the oral and gastrointestinal mucosa 3.
- Radiation therapy compounds this effect through direct short-term and long-term damage to mucous membranes, olfactory function, and secretory function 3.
- The severity correlates with chemotherapy regimen intensity, particularly with high-dose melphalan and 5-fluorouracil 3.
Anorexia
- Multifactorial etiology includes taste alterations, mucositis-induced pain, nausea/vomiting, metabolic derangements, and cytokine-mediated effects 3.
- Hypercatabolism occurs particularly with high-dose chemotherapy and peripheral blood stem cell support 3.
- Reduced food intake leads to malnutrition, which affects 50-70% of cancer patients 4.
Treatment Approach
For Mucositis Prevention and Treatment
Prevention Strategies (Highest Priority)
- Implement oral care protocols across all cancer treatment modalities as a foundational intervention 3.
- Use oral cryotherapy for 30 minutes during bolus 5-fluorouracil chemotherapy (Level II evidence) 3.
- Administer palifermin (recombinant human KGF-1) 60 μg/kg/day for 3 days before and 3 days after transplant in patients receiving high-dose chemotherapy with total body irradiation for hematological malignancies (Level II evidence) 3.
- Apply low-level laser therapy (wavelength 650 nm, 40 mW power, 2 J/cm² tissue energy dose) for patients undergoing HSCT with high-dose chemotherapy 3.
- Use benzydamine mouthwash for head and neck cancer patients receiving moderate-dose radiation therapy up to 50 Gy without concurrent chemotherapy (Level I evidence) 3.
Pain Management for Established Mucositis
- Initiate patient-controlled analgesia with morphine for oral mucositis pain in HSCT patients (Level II evidence) 3.
- Consider 0.2% morphine mouthwash for patients receiving chemoradiation for head and neck cancer (Level III evidence) 3.
- Trial 0.5% doxepin mouthwash as an alternative analgesic option (Level IV evidence) 3.
- Use transdermal fentanyl for pain management in patients receiving conventional or high-dose chemotherapy 3.
Interventions to AVOID
- Do NOT use sucralfate mouthwash for prevention or treatment—it has Level I evidence against its use 3.
- Do NOT use chlorhexidine mouthwash for prevention in radiation therapy patients 3.
- Do NOT use iseganan antimicrobial mouthwash (Level II evidence against) 3.
- Do NOT use intravenous glutamine for prevention in HSCT patients (Level II evidence against) 3.
For Altered Taste Sensation
Evidence-Based Interventions
- Zinc supplementation is NOT recommended—a recent RCT in 58 cancer patients showed no benefit from zinc (2 × 50 mg elemental zinc) over 3 months for taste alterations 3, 5.
- Cannabinoids (THC/dronabinol) are NOT recommended for routine use—while one small pilot RCT showed improved chemosensory perception with THC 2.5 mg twice daily, larger trials failed to demonstrate consistent benefit 3, 5.
- Focus on dietary modifications and oral care strategies rather than pharmacological interventions, as no effective pharmacological treatments exist 5.
Practical Management Strategies
- Counsel patients that taste alterations are common (affecting up to 86% of patients) but typically transient, resolving within months after chemotherapy completion 1, 2.
- Recommend dietary adjustments: avoid foods with strong metallic associations, use plastic utensils instead of metal, try cold or room-temperature foods, and experiment with flavor enhancers like lemon or herbs 1.
- Assess taste alterations using validated tools such as the Chemotherapy-induced Taste Alteration Scale (CiTAS) to monitor severity and guide supportive care 6, 2.
For Anorexia and Appetite Stimulation
First-Line Pharmacological Agent
- Prescribe megestrol acetate 400-800 mg daily as the primary appetite stimulant for cancer-related anorexia 3, 7.
- Megestrol improves appetite and body weight but not lean body mass 3.
- Important caveat: Megestrol carries risks of thromboembolic events (including higher mortality rates in some studies), edema, impotence, vaginal spotting, and adrenal suppression 3, 7.
- Approximately 1 in 4 patients will have increased appetite and 1 in 12 will gain weight 7.
Alternative Pharmacological Options
- Consider dexamethasone 2-8 mg/day for patients with shorter life expectancy, noting faster onset but significant side effects with prolonged use 7.
- For patients with concurrent depression, use mirtazapine 7.5-30 mg at bedtime, which addresses both depression and appetite simultaneously with mean weight gain of 1.9 kg at 3 months 7.
Interventions NOT Recommended
- Do NOT use cannabinoids (dronabinol) for appetite stimulation—multiple guidelines conclude insufficient evidence, and RCTs show no consistent benefit on appetite or quality of life at standard doses 3, 7.
- Do NOT use currently approved androgenic steroids to increase muscle mass—evidence is insufficient and inconsistent 3.
Non-Pharmacological Interventions (Essential Foundation)
- Implement nutritional support when patients lose >10% of usual body weight over 6 months 3.
- Provide oral nutritional supplements and fortified foods when dietary intake falls to 50-75% of usual intake 7.
- Encourage smaller, more frequent meals with energy-dense, favorite foods 7.
- Review and temporarily discontinue non-essential medications that may suppress appetite 7.
- Facilitate social eating environments when possible 7.
Critical Clinical Pitfalls to Avoid
Do not assume taste alterations are permanent—most resolve within months after chemotherapy completion, though some patients experience prolonged changes 1, 2.
Do not overlook the interconnection of symptoms—dysgeusia frequently occurs with mucositis, nausea, and anorexia, requiring comprehensive management 2.
Do not use sucralfate mouthwash despite its historical use—strong evidence (Level I) demonstrates it is ineffective for mucositis prevention and treatment 3.
Do not prescribe zinc or cannabinoids for taste alterations based on anecdotal reports—recent high-quality evidence shows no benefit 3, 5.
Monitor for rare but life-threatening capecitabine/5FU-induced enterocolitis in patients with DPD deficiency (3-5% of population), which presents with severe diarrhea, mucositis, and bone marrow suppression 3.
Recognize that megestrol acetate may attenuate benefits of resistance training and carries thromboembolic risks—weigh benefits against harms carefully 7.
Assess for treatable causes of symptoms including lactose intolerance, small intestinal bacterial overgrowth (SIBO), bile acid diarrhea, and pancreatic exocrine insufficiency, which are frequently under-recognized during chemotherapy 3.