Assessment of indomethacin oral spray for the treatment of oropharyngeal mucositis-induced pain during anticancer therapy

Factors Associated With Pain Catastrophizing in Patients With Chronic Neuropathic Pain: A Cross-Sectional Study

BACKGROUND

Pain catastrophizing is a significant factor in the recovery of patients with chronic pain. This topic has not received the warranted attention in clinical practice, while the outcomes of pain interventions have been suboptimal. This study explores the current situation of pain catastrophizing in patients with chronic neuropathic pain, its influencing factors, and further analyzes the complex relationship between these factors.

METHODS

A cross-sectional study design was used to select preoperative patients hospitalized in the pain and spine surgery departments of two tertiary hospitals in Shandong Province, China, between February and August 2022. The Pain Catastrophizing Scale, Toronto Alexithymia Scale, Connor-Davidson Resilience Scale-Short, Somatization Sub-Scale of Symptom Checklist 90, and a sociodemographic questionnaire were used to evaluate participants' pain catastrophizing, alexithymia, psychological resilience, somatization, and relevant sociodemographic variables, respectively. Descriptive statistics, correlation, univariate, and multivariate analyses were employed throughout this process.

RESULTS

Pain catastrophizing in patients with chronic neuropathic pain was affected by pain severity, disease type, alexithymia, psychological resilience, and somatization (p < .05). The mediating effect values of psychological resilience and somatization between alexithymia and pain catastrophizing were both 0.05, with 95% confidence intervals of (0.02, 0.09) and (0.02, 0.07), respectively.

CONCLUSIONS

Pain severity, disease type, alexithymia, psychological resilience, and somatization all had a significant effect on pain catastrophizing. Healthcare workers must provide timely and accurate assessments of patients' pain levels to help prevent the onset of pain catastrophizing. Adopting measures to improve alexithymia and somatization symptoms, and focusing on enhancing patients' psychological resilience can also help reduce the level of pain catastrophizing. Cognitive behavioral therapy may be an effective treatment method for pain catastrophizing.

Effects of an Indomethacin Oral Spray on Pain Due to Oral Mucositis in Cancer Patients Treated With Radiotherapy and Chemotherapy: A Double-Blind, Randomized, Placebo-Controlled Trial (JORTC-PAL04)

CONTEXT

Oral mucositis (OM) pain due to anticancer chemo- and radiotherapy has a very negative impact on patient quality of life. However, no high-quality studies have been performed regarding the analgesic efficacy of indomethacin (IM) oral spray for OM pain.

OBJECTIVES

This randomized, placebo-controlled, double-blind trial aimed to evaluate the analgesic efficacy of IM oral spray for OM pain due to anticancer chemo- and radiotherapy.

METHODS

From July 2015 to December 2016, we enrolled adult cancer patients with OM pain that was due to anticancer chemo- or radiotherapy and was rated 4 or higher on Brief Pain Inventory (BPI) Item 5. Patients were randomly assigned in a 1:1 ratio to receive either IM oral spray or placebo. The primary endpoint was the change in the BPI Item 6 ("current pain") score from before to 30 minutes after treatment. Secondary endpoints were the areas under the curves of BPI Item 6 at 15, 60, 120, 180, and 240 minutes after treatment; five items related to meals and conversation from the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire, Head and Neck Module 35; the Clinical Global Impressions-Improvement (CGI-I) scale; and adverse events.

RESULTS

A total of 60 patients were assigned to receive IM oral spray (n = 33) or placebo spray (n = 27). The average change in the BPI item 6 score from before to 30 minutes after treatment was -1.85 (95% confidence interval: -2.37 to -1.32) in the IM spray group and -0.59 (-1.02 to -0.16) in the placebo group, indicating a significant difference (-1.26, -1.94 to -0.57, P < 0.01). The pain improvement persisted for 180 minutes. The intergroup differences in ability to drink liquids, ease in conversing, and CGI-I were all significant (P = 0.03, P = 0.02, and P < 0.01, respectively). No serious adverse events were reported.

CONCLUSION

IM oral spray alleviated short-term OM pain due to anticancer chemo- and radiotherapy, and may reduce the difficulty in eating meals.

Proton beam therapy with concurrent chemotherapy is feasible in children with newly diagnosed rhabdomyosarcoma

Background

The optimal treatment for rhabdomyosarcoma (RMS) requires multidisciplinary treatment with chemotherapy, surgery, and radiotherapy. Surgery and radiotherapy are integral to the local control (LC) of RMS. However, postsurgical and radiotherapy-related complications could develop according to the local therapy and tumor location. In this study, we conducted a single-center analysis of the outcomes and toxicity of multidisciplinary treatment using proton beam therapy (PBT) for pediatric RMS.

Materials and methods

RMS patients aged younger than 20 years whose RMS was newly diagnosed and who underwent PBT at University of Tsukuba Hospital (UTH) during the period from 2009 to 2019 were enrolled in this study. The patients' clinical information was collected by retrospective medical record review.

Results

Forty-eight patients were included. The 3-year progression-free survival (PFS) and overall survival (OS) rates of all the patients were 68.8% and 94.2%, respectively. The 3-year PFS rates achieved with radical resection, conservative resection, and biopsy only were 65.3%, 83.3%, and 67.6%, respectively (p = 0.721). The 3-year LC rates achieved with radical resection, conservative resection, and biopsy only were 90.9%, 83.3%, and 72.9%, respectively (p = 0.548). Grade 3 or higher mucositis/dermatitis occurred in 14 patients. Although the days of opioid use due to mucositis/dermatitis during the chemotherapy with PBT were longer than those during the chemotherapy without PBT [6.1 and 1.6 (mean), respectively, p = 0.001], the frequencies of fever and elevation of C-reactive protein were equivalent.

Conclusions

Multidisciplinary therapy containing PBT was feasible and provided a relatively fair 3-year PFS, even in children with newly diagnosed RMS without severe toxicity.

Narrative review of the management of oral mucositis during chemoradiation for head and neck cancer

Oral mucositis (OM) can be a significant problem for patients undergoing radiation or chemoradiation for head and neck cancer. In modern clinical trials, grade 3-4 OM can be seen in over 40% of patients and can cause a significant impact on their quality of life (QOL). Despite this fact, strategies for the prevention and treatment of OM vary widely, with options including both lifestyle modifications and pharmaceuticals. Here we evaluate and summarize the current clinical interventions for the management of radiation-induced OM. The majority of the current evidence focuses on reducing OM related pain. These agents are detailed over multiple clinical trials including treatment modalities such as: GC4419, doxepin mouthwash, diphenhydramine-lidocaine-antacid (DLA) mouthwash, gabapentin, and methadone. While several strategies have been employed to prevent radiation-induced OM, there is currently no strong evidence for the routine use of these agents in the clinic. After summarization of these treatments, we offer practical guidance for the treatment of OM in the clinic. We recommend a multiagent approach of pharmacological and non-pharmacological treatments including oral rinses, home humidification, escalating doses of gabapentin, doxepin or DLA mouthwash, over the counter analgesics, and lastly methadone. These interventions are tailored to address the expected increase of severity of symptoms during the course of head and neck radiotherapy.

New tricks of old drugs: Repurposing non-chemo drugs and dietary phytochemicals as adjuvants in anti-tumor therapies

Combination therapy has long been applied to enhance therapeutic effect and deal with the occurrence of multi-drug resistance in cancer treatment. However, the overlapping toxicity of multiple anticancer drugs to healthy tissues and increasing financial burden on patients emerged as major concerns. As promising alternatives to chemo agents, repurposed non-chemo drugs and dietary phytochemicals have been investigated as adjuvants to conventional anti-tumor therapeutics, offering a safe and economic strategy for combination therapy. In this review, we aim to highlight the advances in research about combination therapy using conventional therapeutics and repurposed drugs or phytochemicals for an enhanced anti-tumor efficacy, along with the mechanisms involved in the synergism. Beyond these, we outlined the potential challenges and solutions for clinical translation of the proposed combination therapy, providing a safe and affordable strategy to improve the reach of cancer therapy to low income regions with such new tricks of old drugs.

Preparation and Evaluation of Rebamipide Colloidal Nanoparticles Obtained by Cogrinding in Ternary Ground Mixtures

Aphthous stomatitis is one of the side effects of chemotherapy and radiotherapy in cancer treatment. Rebamipide (RB) mouthwash for stomatitis acts as a radical scavenger. However, RB is poorly soluble in water, which leads to aggregation and precipitation of the dispersoid. The particle size of the drug needs to be less than 100 nm for the particles to reach the mucus layer in the oral cavity. In this study, we attempted to prepare nanoparticles of RB by cogrinding with polyvinylpyrrolidone (PVP) or hydroxypropyl cellulose (HPC) and sodium dodecyl sulfate (SDS) using a mixer ball mill, and evaluated the physicochemical properties of RB nanoparticles, the stability of dispersion in water, and permeation of the mucus layer in vitro. By cogrinding, the particle size decreased to around 110 nm, and powder X-ray diffraction (PXRD) of the particles showed totally broad halo patterns, which suggested a decreased crystalline region. Furthermore, the solubility of RB nanoparticles increased by approximately fourfold compared with RB crystals, and the water dispersibility and permeation of the mucus layer were improved. The results suggest that in a ternary ground mixture of RB, PVP or HPC, and SDS, the RB nanoparticles obtained can be applied as a formulation for stomatitis.

Radiation-Induced Oral Mucositis in Head and Neck Cancer Patients. Five Years Literature Review

Backround: Radiation-induced oral mucositis consists of a series of relatively frequent side effects after head and neck cancer radiotherapy and has an adverse impact on both regular treatment process and the quality of life of patients.

OBJECTIVE

The purpose of the present review is to optimize the current management of radiation-induced oral mucositis in head and neck cancer patients.

METHODS

PubMed database research was performed on articles published since 2015 that demonstrated efficacy in the management of radiation-induced oral mucositis in head and neck cancer patients. The study selection included observational, prospective, comparative, randomized, double- blind, placebo-controlled or uncontrolled, and retrospective studies, as well as systematic reviews and metanalyses.

RESULTS

From the 931 citations obtained from the search, only 94 articles met the inclusion criteria, including mucosal protectants, anti-inflammatory agents, growth factors, and various miscellaneous and natural agents. Several methods, including both pharmacological and natural agents, have been proposed for the management of oral mucositis. In addition to the already known interventions with strong evidence, according to the Multinational Association of Supportive Care in Cancer and he International Society of Oral Oncology guidelines, further agents have been used. However, a great number of them lack clear evidence, which surely requires the design of more controlled clinical trials for a better assessment of the ideal methods.

CONCLUSION

The management of oral mucositis constitutes an active area of research. In light of these results, it is aimed to illustrate those treatment strategies that are most effective regarding the treatment approach of oral mucositis.

Formulation Development of Mucoadhesive Microparticle-Laden Gels for Oral Mucositis: An In Vitro and In Vivo Study

In order to relieve pain due to oral mucositis, we attempted to develop mucoadhesive microparticles containing indomethacin (IM) and gel preparations with IM microparticles that can be applied to the oral cavity. The mucoadhesive microparticles were prepared with a simple composition consisting of IM and polyvinyl alcohol (PVA). Two kinds of PVA with different block properties were used, and microparticles were prepared by heating-filtration and mixing-drying. From the X-ray powder diffraction patterns, differential scanning calorimetry thermograms, and morphological features of the IM microparticles, IM should exist as polymorphic forms in the microparticles. Rapid drug release properties were observed in the IM microparticles. Increased drug retention was observed in IM microparticles containing PVA, and the IM-NK(50) gel, using a common block character PVA and heating-filtration, showed good long-term drug retention properties. In vivo experiments showing significantly higher drug concentrations in the oral mucosa were observed with IM microparticles prepared by heating-filtration, and the IM-NK(50) gel maintained significantly higher drug concentrations in the oral mucosa. From these results, the IM-NK(50) gel may be useful as a preparation for relieving oral mucositis pain.

Ibuprofen gargle for chemo- or Chemoradiotherapy-induced Oral Mucositis: a feasibility study

Background

Oral mucositis frequently occurs in cancer patients treated with chemotherapy and chemoradiotherapy (CRT). This study examined the safety and efficacy of ibuprofen gargle in healthy volunteers and patients with chemotherapy- and concomitant CRT-induced oral mucositis.

Methods

We enrolled healthy volunteers and patients with chemotherapy- and CRT-induced oral mucositis. In cohort I, single and multiple doses of ibuprofen gargle (0.6% or 1.0%) were administered to healthy volunteers on day 1 and days 4–10. In cohort II, multiple doses of ibuprofen gargle (0.6%) were administered to patients with complicated grade 2–3 oral mucositis based on the Common Terminology Criteria for Adverse Events (CTCAE) version 4.0. The primary endpoint of cohort I was the treatment-related adverse events (TRAEs) as defined by CTCAE version 4.0. The primary endpoint of cohort II was the change in the visual analogue scale (VAS) pain score from before to 15 min after gargle use on day 3. The incidence and severity of TRAEs were assessed based on the CTCAE version 4.0 and a subjective rating scale completed by healthy volunteers and patients.

Results

In cohort I, 9 of 10 healthy volunteers were evaluable for safety. All 9 healthy volunteers reported the TRAE of oral irritation with single or multiple use of the gargle. In cohort II, 10 patients were enrolled and evaluable for safety and 7 of 10 patients were evaluable for efficacy. The mean change in the VAS pain score from before to 15 min after using the gargle on day 3 was − 1.28 (95% confidence interval: − 2.06, − 0.51), and all patients experienced some degree of pain relief (range: − 0.2 to − 2.5). All 10 patients reported the TRAE of oral irritation. No other TRAEs of ibuprofen gargle were observed in the healthy volunteers and patients.

Conclusion

Despite oral irritation, the ibuprofen gargle appeared to be safe and effective for the pain related to chemo- or CRT-induced oral mucositis. However, ibuprofen-related oral irritation warrants further formulation improvement.

Trial registration

This study was registered with the University Hospital Medical Information Network Clinical Trials Registry (UMIN000014433).

Oral health problems among palliative and terminally ill patients: an integrated systematic review

BACKGROUND

High incidence of treatable oral conditions has been reported among palliative patients. However, a large proportion of palliative patients lose their ability to communicate their sufferings. Therefore, it may lead to under-reporting of oral conditions among these patients. This review systematically synthesized the published evidence on the presence of oral conditions among palliative patients, the impact, management, and challenges in treating these conditions.

METHODS

An integrative review was undertaken with defined search strategy from five databases and manual search through key journals and reference list. Studies which focused on oral conditions of palliative patients and published between years 2000 to 2017 were included.

RESULTS

Xerostomia, oral candidiasis and dysphagia were the three most common oral conditions among palliative patients, followed by mucositis, orofacial pain, taste change and ulceration. We also found social and functional impact of having certain oral conditions among these patients. In terms of management, complementary therapies such as acupuncture has been used but not well explored. The lack of knowledge among healthcare providers also posed as a challenge in treating oral conditions among palliative patients.

CONCLUSIONS

This review is first in its kind to systematically synthesize the published evidence regarding the impact, management and challenges in managing oral conditions among palliative patients. Although there is still lack of study investigating palliative oral care among specific group of patients such as patients with dementia, geriatric or pediatric advanced cancer patients, this review has however provided baseline knowledge that may guide health care professionals in palliative settings.