What is the treatment for radiation-induced mucositis?

From the Guidelines

Dry radiation mucositis is best managed with a combination of preventive measures and symptomatic treatments, prioritizing interventions that reduce morbidity, mortality, and improve quality of life, as recommended by the most recent and highest quality study available 1.

Key Recommendations

• Regular oral rinses with a solution of 1/4 teaspoon salt and 1/4 teaspoon baking soda in 1 cup of warm water every 1-2 hours to soothe and clean the mucosa.
• For pain relief, use topical anesthetics like 2% viscous lidocaine (rinse with 1 teaspoon for 1 minute before meals) or benzydamine hydrochloride mouthwash if available, as suggested by previous guidelines 1.
• Maintain meticulous oral hygiene by brushing with a soft toothbrush and fluoride toothpaste at least twice daily.
• Stay well-hydrated and use alcohol-free moisturizing mouth sprays or gels containing hyaluronic acid or aloe vera to maintain mucosal moisture.
• Avoid irritants such as spicy foods, alcohol, tobacco, and acidic beverages.
• For severe cases, consider low-level laser therapy, which has been shown to be beneficial in preventing oral mucositis in patients undergoing radiotherapy, without concomitant chemotherapy, for head and neck cancer 1.
• Ensure adequate nutritional intake, primarily through individualized nutritional counseling and/or the use of oral nutritional supplements (ONS), to avoid nutritional deterioration and maintain intake, as recommended by the most recent guideline 1.

Rationale

The management of dry radiation mucositis focuses on preventing further irritation, promoting healing, and managing symptoms to improve quality of life. The use of oral care protocols, as suggested by 1, is crucial in preventing oral mucositis. Additionally, maintaining adequate nutrition is vital, as radiotherapy can lead to significant weight loss and malnutrition if not properly managed 1. The choice of interventions should be guided by the most recent and highest quality evidence available, with a focus on reducing morbidity, mortality, and improving quality of life.

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 drug palifermin (Kepivance) is used 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 (TBI).

• The study results show that palifermin reduces the incidence and duration of severe oral mucositis, as well as the use of opioid analgesia, in patients receiving TBI as part of their conditioning regimen 2.
• Key findings include:
  • Median days of WHO Grade 3/4 oral mucositis: 3 days with palifermin vs 9 days with placebo
  • Incidence of WHO Grade 3/4 oral mucositis: 63% with palifermin vs 98% with placebo
  • Median cumulative opioid dose: 212 mg with palifermin vs 535 mg with placebo

From the Research

Definition and Prevalence of Dry Radiation Mucositis

• Dry radiation mucositis is a major limiting acute side effect of radiotherapy for head and neck cancer, characterized by oral pain, odynophagia, reduced oral intake, and secondary infections 3.
• The incidence of mucositis is increased with the addition of concurrent chemotherapy as well as altered fractionation schedules, leading to treatment interruption and suboptimal disease control 3.

Prevention and Management of Dry Radiation Mucositis

• Maintenance of oral hygiene is an important part in the prevention of dry radiation mucositis, with agents such as normal saline and alkali (soda bicarbonate) mouthwashes, low-level laser therapy, and benzydamine (non-steroidal analgesic and anti-inflammatory) showing effectiveness in prevention and treatment 3, 4.
• Chlorhexidine mouth gargles are not recommended for radiotherapy-associated mucositis, but may be effective in preventing chemotherapy-induced oral mucositis 3, 4.
• Treatment of co-existing infection is also important, with both topical (povidone iodine) and systemic antifungals used judiciously 3.

Treatment Strategies for Dry Radiation Mucositis

• A Dexamethasone-Lidocaine-Vitamin B12 Mouth rinse (DLVBM) has been shown to reduce oral mucosal pain, reduce weight loss, and complete radiotherapy according to the course of treatment in patients with nasopharyngeal carcinoma 5.
• Herbal-based products and tissue regenerating agents have revealed comparatively better effectiveness with lesser side effects in the prevention and treatment of dry radiation mucositis, although more studies are needed to support this claim 4.
• Various methods, including pharmacological and natural agents, have been proposed for the management of dry radiation mucositis, with the Multinational Association of Supportive Care in Cancer and the International Society of Oral Oncology guidelines providing recommendations for treatment approaches 6.

Current Research and Future Directions

• The management of dry radiation mucositis constitutes an active area of research, with a need for more controlled clinical trials to assess the ideal methods for prevention and treatment 6, 4.
• Further studies are required to investigate the effectiveness of different mouth rinses and treatment strategies in preventing and treating dry radiation mucositis, as well as to identify the most effective approaches for improving patient outcomes 3, 7.