1
|
Colella G, Boschetti CE, Vitagliano R, Colella C, Jiao L, King-Smith N, Li C, Nuoh Lau Y, Lai Z, Mohammed AI, Cirillo N. Interventions for the Prevention of Oral Mucositis in Patients Receiving Cancer Treatment: Evidence from Randomised Controlled Trials. Curr Oncol 2023; 30:967-980. [PMID: 36661723 PMCID: PMC9858113 DOI: 10.3390/curroncol30010074] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/04/2023] [Accepted: 01/06/2023] [Indexed: 01/13/2023] Open
Abstract
Oral mucositis is a common and most debilitating complication associated with cancer therapy. Despite the significant clinical and economic impact of this condition, there is little to offer to patients with oral mucositis, and the medications used in its management are generally only palliative. Given that mucositis is ultimately a predictable and, therefore, potentially preventable condition, in this study we appraised the scientific literature to evaluate effective methods of prevention that have been tested in randomised controlled trials (RCTs). Published high-level evidence shows that multiple preventative methods are potentially effective in the prevention of oral mucositis induced by radiotherapy, chemotherapy, or both. Anti-inflammatory medications (including benzydamine), growth factors and cytokines (including palifermin), cryotherapy, laser-and-light therapy, herbal medicines and supplements, and mucoprotective agents (including oral pilocarpine) showed some degree of efficacy in preventing/reducing the severity of mucositis with most anticancer treatments. Allopurinol was potentially effective in the prevention of radiotherapy-induced oral mucositis; antimicrobial mouthwash and erythropoietin mouthwash were associated with a lower risk of development of severe oral mucositis induced by chemotherapy. The results of our review may assist in highlighting the efficacy and testing the effectiveness of low-cost, safe preventative measures for oral mucositis in cancer patients.
Collapse
Affiliation(s)
- Giuseppe Colella
- Multidisciplinary Department of Medical-Surgical and Dental Specialties, Oral and Maxillofacial Surgery Unit, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| | - Ciro Emiliano Boschetti
- Multidisciplinary Department of Medical-Surgical and Dental Specialties, Oral and Maxillofacial Surgery Unit, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| | - Rita Vitagliano
- Multidisciplinary Department of Medical-Surgical and Dental Specialties, Oral and Maxillofacial Surgery Unit, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| | - Chiara Colella
- Multidisciplinary Department of Medical-Surgical and Dental Specialties, Oral and Maxillofacial Surgery Unit, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| | - Lebei Jiao
- Melbourne Dental School, The University of Melbourne, Carlton, Melbourne, VIC 3053, Australia
| | - Natalie King-Smith
- Melbourne Dental School, The University of Melbourne, Carlton, Melbourne, VIC 3053, Australia
| | - Chong Li
- Melbourne Dental School, The University of Melbourne, Carlton, Melbourne, VIC 3053, Australia
| | - Yii Nuoh Lau
- Melbourne Dental School, The University of Melbourne, Carlton, Melbourne, VIC 3053, Australia
| | - Zacchaeus Lai
- Melbourne Dental School, The University of Melbourne, Carlton, Melbourne, VIC 3053, Australia
| | - Ali Ibrahim Mohammed
- Melbourne Dental School, The University of Melbourne, Carlton, Melbourne, VIC 3053, Australia
| | - Nicola Cirillo
- Melbourne Dental School, The University of Melbourne, Carlton, Melbourne, VIC 3053, Australia
| |
Collapse
|
2
|
Hamstra DA, Lee KC, Eisbruch A, Sunkara P, Borgonha S, Phillip B, Campbell KCM, Ross BD, Rehemtulla A. Double-blind placebo-controlled multicenter phase II trial to evaluate D-methionine in preventing/reducing oral mucositis induced by radiation and chemotherapy for head and neck cancer. Head Neck 2018; 40:1375-1388. [PMID: 29473247 DOI: 10.1002/hed.25115] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 10/30/2017] [Accepted: 01/23/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The purpose of this study was to test if oral D-methionine (D-met) reduced mucositis during chemoradiotherapy. METHODS We conducted a placebo-controlled double-blind randomized phase II trial of D-met (100 mg/kg p.o. b.i.d.) testing the rate of severe (grades 3-4) mucositis. RESULTS Sixty patients were randomized. Grade 2 + oral pain was higher with placebo (79% vs 45%; P = .0165), whereas grade 2 + body odor was greater with D-met (3% vs 41%; P = .0015). Mucositis was decreased with D-met by the physician (World Health Organization [WHO], P = .007; Radiation Therapy Oncology Group [RTOG], P = .009) and patient functional scales (RTOG, P = .0023). The primary end point of grades 3 to 4 mucositis on the composite scale demonstrated a decrease with D-met (48% vs 24%; P = .058), which was borderline in significance. A planned secondary analysis of a semiquantitative scoring system noted decreased oral ulceration (2.2 vs 1.5; P = .023) and erythema (1.6 vs 1.1; P = .048) with D-met. CONCLUSION Although not meeting the primary end point, results of multiple assessments suggest that D-met decreased mucositis.
Collapse
Affiliation(s)
- Daniel A Hamstra
- Department of Radiation Oncology, Beaumont Health, Dearborn, Michigan
| | - Kuei C Lee
- Department of Radiation Oncology, Beaumont Health, Dearborn, Michigan
| | - Avraham Eisbruch
- Department of Radiation Oncology, The University of Michigan, Ann Arbor, Michigan
| | | | | | | | - Kathleen C M Campbell
- Department of Medical Microbiology, Immunology, and Cell Biology, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Brian D Ross
- Department of Radiology, The University of Michigan, Ann Arbor, Michigan
- Department of Biological Chemistry, The University of Michigan, Ann Arbor, Michigan
- Molecular Therapeutics Inc, Ann Arbor, Michigan
| | - Alnawaz Rehemtulla
- Department of Radiation Oncology, The University of Michigan, Ann Arbor, Michigan
- Molecular Therapeutics Inc, Ann Arbor, Michigan
| |
Collapse
|
3
|
Maria OM, Eliopoulos N, Muanza T. Radiation-Induced Oral Mucositis. Front Oncol 2017; 7:89. [PMID: 28589080 PMCID: PMC5439125 DOI: 10.3389/fonc.2017.00089] [Citation(s) in RCA: 210] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 04/21/2017] [Indexed: 01/11/2023] Open
Abstract
Radiation-induced oral mucositis (RIOM) is a major dose-limiting toxicity in head and neck cancer patients. It is a normal tissue injury caused by radiation/radiotherapy (RT), which has marked adverse effects on patient quality of life and cancer therapy continuity. It is a challenge for radiation oncologists since it leads to cancer therapy interruption, poor local tumor control, and changes in dose fractionation. RIOM occurs in 100% of altered fractionation radiotherapy head and neck cancer patients. In the United Sates, its economic cost was estimated to reach 17,000.00 USD per patient with head and neck cancers. This review will discuss RIOM definition, epidemiology, impact and side effects, pathogenesis, scoring scales, diagnosis, differential diagnosis, prevention, and treatment.
Collapse
Affiliation(s)
- Osama Muhammad Maria
- Faculty of Medicine, Experimental Medicine Department, McGill University, Montreal, QC, Canada
- Radiation Oncology Department, Jewish General Hospital, McGill University, Montreal, QC, Canada
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Nicoletta Eliopoulos
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, QC, Canada
- Faculty of Medicine, Surgery Department, McGill University, Montreal, QC, Canada
| | - Thierry Muanza
- Faculty of Medicine, Experimental Medicine Department, McGill University, Montreal, QC, Canada
- Radiation Oncology Department, Jewish General Hospital, McGill University, Montreal, QC, Canada
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, QC, Canada
- Oncology Department, McGill University, Montreal, QC, Canada
| |
Collapse
|
4
|
Stokman MA, Spijkervet FKL, Boezen HM, Schouten JP, Roodenburg JLN, de Vries EGE. Preventive Intervention Possibilities in Radiotherapy- and Chemotherapy-induced Oral Mucositis: Results of Meta-analyses. J Dent Res 2016; 85:690-700. [PMID: 16861284 DOI: 10.1177/154405910608500802] [Citation(s) in RCA: 108] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The aim of these meta-analyses was to evaluate the effectiveness of interventions for the prevention of oral mucositis in cancer patients treated with head and neck radiotherapy and/or chemotherapy, with a focus on randomized clinical trials. A literature search was performed for reports of randomized controlled clinical studies, published between 1966 and 2004, the aim of which was the prevention of mucositis in cancer patients undergoing head and neck radiation, chemotherapy, or chemoradiation. The control group consisted of a placebo, no intervention, or another intervention group. Mucositis was scored by either the WHO, the National Cancer Institute-Common Toxicity Criteria (NCI-CTC) score, or the absence or presence of ulcerations, or the presence or absence of grades 3 and 4 mucositis. The meta-analyses included 45 studies fulfilling the inclusion criteria, in which 8 different interventions were evaluated: i.e., local application of chlorhexidine; iseganan; PTA (polymyxin E, tobramycine, and amphotericin B); granulocyte macrophage-colony-stimulating factor/granulocyte colony-stimulating factor (GM-CSF/G-CSF); oral cooling; sucralfate and glutamine; and systemic administration of amifostine and GM-CSF/G-CSF. Four interventions showed a significant preventive effect on the development or severity of oral mucositis: PTA with an odds ratio (OR) = 0.61 (95% confidence interval [CI], 0.39–0.96); GM-CSF, OR = 0.53 (CI: 0.33–0.87); oral cooling, OR = 0.3 (CI: 0.16–0.56); and amifostine, OR = 0.37 (CI: 0.15–0.89). To date, no single intervention completely prevents oral mucositis, so combined preventive therapy strategies seem to be required to ensure more successful outcomes.
Collapse
Affiliation(s)
- M A Stokman
- Departments of Oral and Maxillofacial Surgery, University of Groningen and University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands.
| | | | | | | | | | | |
Collapse
|
5
|
Jensen SB, Jarvis V, Zadik Y, Barasch A, Ariyawardana A, Hovan A, Yarom N, Lalla RV, Bowen J, Elad S. Systematic review of miscellaneous agents for the management of oral mucositis in cancer patients. Support Care Cancer 2013; 21:3223-32. [PMID: 23900593 DOI: 10.1007/s00520-013-1884-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 06/19/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE The aim of this systematic review was to analyze the available literature and define clinical practice guidelines for the use of the following agents for the prevention and treatment of oral mucositis (OM): allopurinol, midline mucosa-sparing radiation blocks, payayor, pentoxifylline, timing of radiation therapy (RT) (morning versus late afternoon), pilocarpine, bethanechol, chewing gum, propantheline, and tetrachlorodecaoxide. METHODS A systematic review was conducted by the Mucositis Study Group of the Multinational Association of Supportive Care in Cancer/International Society for Oral Oncology (MASCC/ISOO). The body of evidence for each intervention, in each cancer treatment setting, was assigned an evidence level. Based on the evidence level, one of the following three guideline determinations was possible: recommendation, suggestion, no guideline possible. RESULTS A total of 32 papers across 10 interventions were examined. New suggestions were developed against the use of systemic pilocarpine administered orally for prevention of OM during RT in head and neck cancer patients and in patients receiving high-dose chemotherapy, with or without total body irradiation, prior to hematopoietic stem cell transplantation. A suggestion was also made against the use of systemic pentoxifylline administered orally for the prevention of OM in patients undergoing bone marrow transplantation. No guideline was possible for any other agent reviewed due to inadequate and/or conflicting evidence. CONCLUSIONS None of the agents reviewed was determined to be effective for the prevention or treatment of OM. Two agents, pilocarpine and pentoxifylline, were determined to be ineffective, in the populations listed above. Additional well-designed research is needed on other interventions.
Collapse
Affiliation(s)
- Siri Beier Jensen
- Section of Oral Medicine, Clinical Oral Physiology, Oral Pathology and Anatomy, Department of Odontology, Faculty of Health and Medical Sciences, University of Copenhagen, Nørre Allé 20, 2200 N, Copenhagen, Denmark,
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
6
|
Rodríguez-Caballero A, Torres-Lagares D, Robles-García M, Pachón-Ibáñez J, González-Padilla D, Gutiérrez-Pérez JL. Cancer treatment-induced oral mucositis: a critical review. Int J Oral Maxillofac Surg 2011; 41:225-38. [PMID: 22071451 DOI: 10.1016/j.ijom.2011.10.011] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Revised: 10/01/2011] [Accepted: 10/10/2011] [Indexed: 01/09/2023]
Abstract
Head and neck cancer represents one of the main oncological problems. Its treatment, radiotherapy and chemotherapy leads to mucositis, and other side effects. The authors reviewed high-quality evidence published over the last 25 years on the treatment of cancer treatment-induced oral mucositis. A Medline search for double blind randomized controlled clinical trials between 1985 and 2010 was carried out. The keywords were oral mucositis, radiotherapy, chemotherapy, and head and neck. The different therapeutic approaches found for cancer treatment-induced oral mucositis included: intensive oral hygiene care; use of topical antiseptics and antimicrobial agents; use of anti-inflammatory agents; cytokines and growth factors; locally applied non-pharmacological methods; antioxidants; immune modulators; and homoeopathic agents. To date, no intervention has been able to prevent and treat oral mucositis on its own. It is necessary to combine interventions that act on the different phases of mucositis. It is still unclear which strategies reduce oral mucositis, as there is not enough evidence that describes a treatment with a proven efficiency and is superior to the other treatments for this condition.
Collapse
|
7
|
Worthington HV, Clarkson JE, Bryan G, Furness S, Glenny AM, Littlewood A, McCabe MG, Meyer S, Khalid T. Interventions for preventing oral mucositis for patients with cancer receiving treatment. Cochrane Database Syst Rev 2011; 2011:CD000978. [PMID: 21491378 PMCID: PMC7032547 DOI: 10.1002/14651858.cd000978.pub5] [Citation(s) in RCA: 125] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Treatment of cancer is increasingly more effective but is associated with short and long term side effects. Oral side effects remain a major source of illness despite the use of a variety of agents to prevent them. One of these side effects is oral mucositis (mouth ulcers). OBJECTIVES To evaluate the effectiveness of prophylactic agents for oral mucositis in patients with cancer receiving treatment, compared with other potentially active interventions, placebo or no treatment. SEARCH STRATEGY Electronic searches of Cochrane Oral Health Group and PaPaS Trials Registers (to 16 February 2011), CENTRAL (The Cochrane Library 2011, Issue 1), MEDLINE via OVID (1950 to 16 February 2011), EMBASE via OVID (1980 to 16 February 2011), CINAHL via EBSCO (1980 to 16 February 2011), CANCERLIT via PubMed (1950 to 16 February 2011), OpenSIGLE (1980 to 2005) and LILACS via the Virtual Health Library (1980 to 16 February 2011) were undertaken. Reference lists from relevant articles were searched and the authors of eligible trials were contacted to identify trials and obtain additional information. SELECTION CRITERIA Randomised controlled trials of interventions to prevent oral mucositis in patients receiving treatment for cancer. DATA COLLECTION AND ANALYSIS Information regarding methods, participants, interventions, outcome measures, results and risk of bias were independently extracted, in duplicate, by two review authors. Authors were contacted for further details where these were unclear. The Cochrane Collaboration statistical guidelines were followed and risk ratios calculated using random-effects models. MAIN RESULTS A total of 131 studies with 10,514 randomised participants are now included. Overall only 8% of these studies were assessed as being at low risk of bias. Ten interventions, where there was more than one trial in the meta-analysis, showed some statistically significant evidence of a benefit (albeit sometimes weak) for either preventing or reducing the severity of mucositis, compared to either a placebo or no treatment. These ten interventions were: aloe vera, amifostine, cryotherapy, granulocyte-colony stimulating factor (G-CSF), intravenous glutamine, honey, keratinocyte growth factor, laser, polymixin/tobramycin/amphotericin (PTA) antibiotic pastille/paste and sucralfate. AUTHORS' CONCLUSIONS Ten interventions were found to have some benefit with regard to preventing or reducing the severity of mucositis associated with cancer treatment. The strength of the evidence was variable and implications for practice include consideration that benefits may be specific for certain cancer types and treatment. There is a need for further well designed, and conducted trials with sufficient numbers of participants to perform subgroup analyses by type of disease and chemotherapeutic agent.
Collapse
Affiliation(s)
- Helen V Worthington
- Cochrane Oral Health Group, School of Dentistry, The University of Manchester, Coupland III Building, Oxford Road, Manchester, UK, M13 9PL
| | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Hamstra DA, Eisbruch A, Naidu MU, Ramana GV, Sunkara P, Campbell KC, Ross BD, Rehemtulla A. Pharmacokinetic Analysis and Phase 1 Study of MRX-1024 in Patients Treated with Radiation Therapy with or without Cisplatinum for Head and Neck Cancer. Clin Cancer Res 2010; 16:2666-76. [DOI: 10.1158/1078-0432.ccr-09-3318] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
9
|
|
10
|
Vuyyuri SB, Hamstra DA, Khanna D, Hamilton CA, Markwart SM, Campbell KCM, Sunkara P, Ross BD, Rehemtulla A. Evaluation of D-methionine as a novel oral radiation protector for prevention of mucositis. Clin Cancer Res 2008; 14:2161-70. [PMID: 18381958 DOI: 10.1158/1078-0432.ccr-07-1954] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Oral mucositis is a common acute morbidity associated with radiation and/or chemotherapy treatment for cancer. D-Methionine (D-Met), the dextro-isomer of the common amino acid l-methionine, has been documented to protect normal tissues from a diverse array of oxidative insults. EXPERIMENTAL DESIGN We evaluated if D-Met could selectively prevent radiation-induced oral mucositis using in vitro cell culture models as well as an in vivo model of radiation injury to the oral mucosa in C3H mice. RESULTS Unlike free-radical scavengers, which protected both normal and transformed tumor cells in vitro from radiation-induced cell death, treatment with d-Met in culture protected nontransformed primary human cells from radiation-induced cell death (protective factor between 1.2 and 1.6; P<0.05) whereas it did not confer a similar protection on transformed tumor cells. D-Met treatment also provided significant protection to normal human fibroblasts, but not to tumor cell lines, from radiation-induced loss of clonogenicity (protection factor, 1.6+/-0.15). D-Met treatment did not alter DNA damage (as measured by histone phosphorylation) following irradiation but seemed to selectively mitigate the loss of mitochondrial membrane potential in nontransformed cells, whereas it did not provide a similar protection to tumor cells. Tumor control of implanted xenografts treated with radiation or concurrent cisplatin and radiation was not altered by D-Met treatment. Pharmacokinetics following administration of a liquid suspension of D-Met in rats showed 68% bioavailability relative to i.v. administration. Finally, in a murine model of mucositis, a dose-dependent increase in protection was observed with the protective factor increasing from 1.6 to 2.6 over a range of oral D-Met doses between 200 and 500 mg/kg (P<0.0003). CONCLUSIONS D-Met protected normal tissues, but not tumor cells, in culture from radiation-induced cell death; it also protected normal cells from radiation-induced mucosal injury in a murine model but did not alter tumor response to therapy. Further studies on the use of D-Met to protect from oral mucositis are warranted.
Collapse
Affiliation(s)
- Saleha B Vuyyuri
- Departments of Radiation Oncology, University of Michigan Medical Center, Ann Arbor, MI 48109-2200, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Quinn B, Potting CM, Stone R, Blijlevens NM, Fliedner M, Margulies A, Sharp L. Guidelines for the assessment of oral mucositis in adult chemotherapy, radiotherapy and haematopoietic stem cell transplant patients. Eur J Cancer 2008; 44:61-72. [DOI: 10.1016/j.ejca.2007.09.014] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2007] [Revised: 09/11/2007] [Accepted: 09/20/2007] [Indexed: 10/22/2022]
|
12
|
Generali J, Cada DJ. Pentoxifylline: Aphthous Stomatitis. Hosp Pharm 2007. [DOI: 10.1310/hpj4212-1117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Off-Label Drug Uses — This Hospital Pharmacy feature is extracted from Off-Label DrugFacts, a quarterly publication available from Wolters Kluwer Health. Off-Label DrugFacts is a practitioner-oriented resource for information about specific FDA-unapproved drug uses. This new guide to the literature will enable the health care professional/clinician to quickly identify published studies on off-label uses and to determine if a specific use is rational in a patient care scenario. The most relevant data are provided in tabular form, so the reader can easily identify the scope of information available. A summary of the data—including background, study design, patient population, dosage information, therapy duration, results, safety, and therapeutic considerations—precedes each table of published studies. References direct the reader to the full literature for more comprehensive information prior to patient care decisions. Direct questions or comments regarding “Off-Label Drug Uses” to hospitalpharmacy@wolterskluwer.com .
Collapse
Affiliation(s)
- Joyce Generali
- Drug Information Center, Kansas University Medical Center
| | | |
Collapse
|
13
|
Abstract
Mucositis and xerostomia are the most common oral complications of the non-surgical therapy of cancer. Mucositis, a common sequel of radio- (DXR), chemo-(CXR) and radiochemo-therapy in patients with cancer, or patients requiring haemopoietic stem cell transplants (HSCT), has a direct and significant impact on the quality of life and cost of care, and also affects survival--because of the risk of infection. Apart from dose reduction, preventive and treatment options for mucositis are scarce, although multiple agents have been tested. Evidence suggests that cryotherapy, topical benzydamine and amifostine might provide some benefit in specific situations. The recombinant human keratinocyte growth factor Palifermin (Kepivance) was recently approved as a mucositis intervention in patients receiving conditioning regimens before HSCT for the treatment of haematological malignancies. A number of mechanistically based interventions are in various stages of development. Unfortunately, many other approaches have not been rigorously tested. This paper reviews the clinical features, prevalence, diagnosis, complications, pathogenesis, prophylaxis and management of mucositis.
Collapse
Affiliation(s)
- C Scully
- Eastman Dental Institute, University College London, University of London, London, UK.
| | | | | |
Collapse
|
14
|
Lima V, Brito GAC, Cunha FQ, Rebouças CG, Falcão BAA, Augusto RF, Souza MLP, Leitão BT, Ribeiro RA. Effects of the tumour necrosis factor-alpha inhibitors pentoxifylline and thalidomide in short-term experimental oral mucositis in hamsters. Eur J Oral Sci 2005; 113:210-7. [PMID: 15953245 DOI: 10.1111/j.1600-0722.2005.00216.x] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Oral mucositis is a frequent side-effect of cancer therapy. A definitive method of prophylaxis or treatment is not yet available. As pentoxifylline (PTX) and thalidomide (TLD) have been shown to inhibit cytokine synthesis, we studied the effects of these cytokine inhibitors in an experimental oral mucositis model. Oral mucositis was induced in Golden hamsters by the administration of 5-fluorouracil (5-FU) followed by mechanical trauma of the cheek pouch. On days 4, 5, 10, 12, 14 and 16, lesions induced by 5-FU were examined macroscopically and microscopically, and the presence and intensity of hyperemia, erythema, edema, inflammatory cell infiltration, hemorrhagic areas, ulcers and abscesses were recorded. Saline (control), PTX (5, 15, 45 mg kg(-1)) or TLD (10, 30, 90 mg kg(-1)) were administered daily and animals were killed on day 10 for macroscopic and histological analysis and assay of myeloperoxidase (MPO) activity. Animals were weighed daily, and total and differential leukocyte counts were performed on peripheral blood. PTX and TLD were found to reduce the macroscopic and histological parameters of oral mucositis and MPO activity. PTX and TLD also reversed peripheral neutrophilia, but only PTX prevented weight loss. The results indicate a protective effect of PTX and TLD, suggesting an important role for tumour necrosis factor-alpha (TNF-alpha) in the pathophysiology of 5-FU induced-oral mucositis in hamsters.
Collapse
Affiliation(s)
- V Lima
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Rua Coronel Nunes de Melo 1127, Rodolfo Teófilo-CEP 60430-270, Fortaleza, Ceará, Brazil
| | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Saadeh CE. Chemotherapy- and Radiotherapy-Induced Oral Mucositis: Review of Preventive Strategies and Treatment. Pharmacotherapy 2005; 25:540-54. [PMID: 15977916 DOI: 10.1592/phco.25.4.540.61035] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Oral mucositis is a frequently encountered and potentially severe complication associated with administration of chemotherapy and radiotherapy. Although many pharmacologic interventions have been used for the prevention and treatment of oral mucositis, there is not one universally accepted strategy for its management. Most preventive and treatment strategies are based on limited, often anecdotal, clinical data. Basic oral hygiene and comprehensive patient education are important components of care for any patient with cancer at risk for development of oral mucositis. Nonpharmacologic approaches for the prevention of oral mucositis include oral cryotherapy for patients receiving chemotherapy with bolus 5-fluorouracil, and low-level laser therapy for patients undergoing hematopoietic stem cell transplantation. Chlorhexidine, amifostine, hematologic growth factors, pentoxifylline, glutamine, and several other agents have all been investigated for prevention of oral mucositis. Results have been conflicting, inconclusive, or of limited benefit. Treatment of established mucositis remains a challenge and focuses on a palliative management approach. Topical anesthetics, mixtures (also called cocktails), and mucosal coating agents have been used despite the lack of experimental evidence supporting their efficacy. Investigational agents are targeting the specific mechanisms of mucosal injury; among the most promising of these is recombinant human keratinocyte growth factor.
Collapse
Affiliation(s)
- Claire E Saadeh
- Department of Pharmacy Practice, College of Pharmacy, Ferris State University, Big Rapids, Michigan, USA.
| |
Collapse
|
16
|
Generali J, Cada DJ. Pentoxifylline: Aphthous Stomatitis. Hosp Pharm 2004. [DOI: 10.1177/001857870403901006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Off-Label Drug Uses This Hospital Pharmacy feature is extracted from Off-Label DrugFacts, a quarterly publication available from Facts and Comparisons. Off-Label DrugFacts is a practitioner-oriented resource for information about specific FDA-unapproved drug uses. This new guide to the literature will enable the health care professional/clinician to quickly identify published studies on off-label uses and to determine if a specific use is rational in a patient care scenario. The most relevant data are provided in tabular form so that the reader can easily identify the scope of information available. A summary of the data—including background, study design, patient population, dosage information, therapy duration, results, safety, and therapeutic considerations—precedes each table of published studies. References direct the reader to the full literature for more comprehensive information prior to patient care decisions. Direct questions or comments on “Off-Label Drug Uses” to hospitalpharmacy@drugfacts.com .
Collapse
Affiliation(s)
- Joyce Generali
- Drug Information Center, Kansas University Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160
| | - Dennis J. Cada
- Drug Information Center, Kansas University Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160
| |
Collapse
|
17
|
Scully C, Epstein J, Sonis S. Oral mucositis: a challenging complication of radiotherapy, chemotherapy, and radiochemotherapy: part 1, pathogenesis and prophylaxis of mucositis. Head Neck 2004; 25:1057-70. [PMID: 14648865 DOI: 10.1002/hed.10318] [Citation(s) in RCA: 131] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Oral mucositis is a common sequel of radiotherapy, chemotherapy, and radiochemotherapy in patients with cancer or patients requiring hemopoietic stem cell transplants. Mucositis has a direct and significant impact on the duration of disease remission and cure rates, because it is a cancer treatment-limiting toxicity. Mucositis also affects survival because of the risk of infection and has a significant impact on the quality of life and cost of care. METHODS This article reviews publications on the etiopathogenesis and prevention of oral mucositis accessible from a MEDLINE search using as key words, mucositis, radiotherapy, chemotherapy, hemopoietic stem cell transplant, and oral. CONCLUSIONS Of the current available products, ice chips and benzydamine have the strongest scientific evidence of support for prophylaxis of mucositis.
Collapse
Affiliation(s)
- Crispian Scully
- Eastman Dental Institute for Oral Health Care Sciences, World Health Organisation Collaborating Centre for Oral Health, Disability and Cultures, University College London, University of London, London WC1X 8LD United Kingdom.
| | | | | |
Collapse
|
18
|
Abstract
Oropharyngeal mucositis is an acute and distressing toxic effect of chemotherapy and head and neck irradiation. This oral sequela significantly impairs the daily functioning and quality of life of patients. The biological basis of mucositis is quite complex, involving sequential interaction of chemotherapeutic drugs or irradiation on mitosis of proliferating epithelium, a number of cytokines, and elements of oral microbial environment. Various interventions based on biological attenuation have been tested for mucositis. Such interventions have been reviewed elsewhere; however, most reviews focus on biomedical outcomes. Little attention has been paid to mucositis outcomes with oral morbidity or psychosocial aspects. The purpose of this article is to review the current research studies on the prevention and treatment of oropharyngeal mucositis following chemotherapy, radiotherapy, and bone marrow transplantation with an emphasis on biomedical, oral symptomatic, and functional impairment outcomes. In addition, further avenues of mucositis management, including psychotherapeutic intervention and integrated and stage-based treatment approaches are discussed.
Collapse
Affiliation(s)
- Karis K F Kwong
- Faculty of Medicine, Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong.
| |
Collapse
|
19
|
Barasch A, Peterson DE. Risk factors for ulcerative oral mucositis in cancer patients: unanswered questions. Oral Oncol 2003; 39:91-100. [PMID: 12509961 DOI: 10.1016/s1368-8375(02)00033-7] [Citation(s) in RCA: 135] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A multitude of laboratory and clinical research studies of ulcerative oral mucositis induced by cytotoxic cancer therapies have been reported during the past decade. However, a comprehensive understanding of oral mucositis pathogenesis, together with a clear definition of risk factors for development and severity of the lesion, remain under investigation. The literature presents sometimes divergent data regarding these issues, which in turn restrict efforts to develop a unified approach for management of this morbid condition. The current review summarizes these controversies and highlights the need for strategies for stratification of patients enrolled in clinical trials, in relation to both pathophysiologic and associated risk factors.
Collapse
Affiliation(s)
- Andrei Barasch
- Department of Oral Diagnosis, School of Dental Medicine, University of Connecticut Health Center, Farmington 06030-1605, USA.
| | | |
Collapse
|
20
|
Wolf R, Matz H, Orion E, Tüzün B, Tüzün Y. Miscellaneous treatments, I: sulfasalazine and pentoxifylline: unapproved uses, dosages, or indications. Clin Dermatol 2002; 20:531-46. [PMID: 12435524 DOI: 10.1016/s0738-081x(02)00270-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Ronni Wolf
- Dermatology Unit, Kaplan Medical Center, Rechovot, Israel.
| | | | | | | | | |
Collapse
|
21
|
Abstract
Oral mucositis is a frequent and potentially severe complication of chemotherapy which has a considerable impact on patient quality of life. While the management of other chemotherapy-related toxicities has improved, the incidence of mucositis is increasing. A critical review of the literature published between 1985 and 1999 reveals very few strategies or agents with proven efficacy, leaving few recommendations for the standard care in the prevention and treatment of mucositis at this time. Recommendations that can be made include: reducing patient risk factors, implementing proven preventative interventions such as utilising oral ice chips with fluorouracil chemotherapy, and optimising supportive care practices individualised to the patients' needs and symptoms. Progress in understanding the pathophysiology of mucositis at the molecular level has led to the evaluation of a number of new investigational agents, specifically those directed to the epithelial mucosa, such as mitogens and epithelial growth factors. These appear to be very promising in preclinical studies. Randomised clinical trials with these agents may finally demonstrate an impact on the clinical practice of mucositis management in the coming years.
Collapse
Affiliation(s)
- J J Knox
- Department of Medical Oncology, Princess Margaret Hospital/University Health Network, Toronto, Ontario, Canada
| | | | | |
Collapse
|
22
|
Woo PC, Ng WF, Leung HC, Tsoi HW, Yuen KY. Clarithromycin attenuates cyclophosphamide-induced mucositis in mice. Pharmacol Res 2000; 41:527-32. [PMID: 10753551 DOI: 10.1006/phrs.1999.0613] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
No universally recognized agent is available for prophylaxis or therapy of mucositis induced by chemotherapy or chemo-radiotherapy. The effect of clarithromycin on the severity of mucositis induced by cyclophosphamide was investigated using a mouse model. Four cross-sections of small intestine (levels A, B, C, and D) were taken at equivalent intervals at day 5 after cyclophosphamide (400 mg kg(-1)) administration. The sections were stained with haematoxylin and eosin, and were graded for the degree of mucositis histologically. At section level B, the number of mice with no mucositis (grade 0) in the clarithromycin group was significantly greater than that in the ceftriaxone group (P<0.05). At levels B and C, the number of mice with no mucositis (grade 0) in the clarithromycin group was significantly greater than that in the normal saline (NS) group (P<0.05). At level C, the number of mice with grade 2 mucositis in the ceftriaxone group was significantly greater than that in the NS group (P<0.05). When the number of sections at all levels were analyzed together, the number of mice with no mucositis (grade 0) in the clarithromycin group was significantly greater than that in the ceftriaxone and NS groups (P<0.05). The present observation suggests that clarithromycin and ceftriaxone attenuates and aggravates cyclophosphamide-induced mucositis. It prompts clinical trials in bone marrow transplant (BMT) recipients receiving cyclophosphamide for conditioning, and reconsideration in the use of ceftriaxone in the treatment of neutropenic fever in BMT recipients.
Collapse
Affiliation(s)
- P C Woo
- Department of Microbiology, The University of Hong Kong, University Pathology Building, Queen Mary Hospital Compound, Hong Kong, PR China
| | | | | | | | | |
Collapse
|
23
|
Bez C, Demarosi F, Sardella A, Lodi G, Bertolli VG, Annaloro C, Rimondini L, Porter SR, Carrassi A. GM-CSF mouthrinses in the treatment of severe oral mucositis: a pilot study. ORAL SURGERY, ORAL MEDICINE, ORAL PATHOLOGY, ORAL RADIOLOGY, AND ENDODONTICS 1999; 88:311-5. [PMID: 10503860 DOI: 10.1016/s1079-2104(99)70034-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of this open trial was to test the efficacy of granulocyte-macrophage colony-stimulating factor (GM-CSF) mouthrinses as a potential treatment in reducing the duration of severe oral mucositis in patients undergoing bone marrow transplantation for hematologic malignancies. STUDY DESIGN The study group was composed of 10 consecutive patients suffering from severe oral mucositis during bone marrow transplantation procedures. The control group was similar to the study group in age and gender and comprised 29 historical patients with similar clinical characteristics. Freshly prepared GM-CSF mouthwash (0.5 microg/mL) was administered to the study population for 1 minute 3 times per day after oral hygiene procedures, starting from the first day of mucositis until clinical improvement of oral lesions. The study and control populations were compared with respect to duration of severe oral mucositis (1-9 days, 10-19 days, > or =20 days). RESULTS There was no statistically (chi2 exact test) significant difference in mean mucositis score between the study group (11.9+/-6.1) and the control group (16.6+/-8.9). However, the duration of severe mucositis appeared to be reduced; 60% of the GM-CSF mouthrinse patients had severe mucositis for less than 9 days, whereas only 28% of the controls had severe mucositis for less than 9 days. In addition, 10% of the GM-CSF mouthrinse patients experienced severe mucositis lasting 20 or more days, whereas 34% of the controls experienced severe mucositis for 20 or more days. CONCLUSIONS These findings suggest that GM-CSF may reduce the duration of severe mucositis, but controlled, double-blind clinical trials are now required.
Collapse
Affiliation(s)
- C Bez
- Department of Oral Pathology and Medicine, School of Dentistry, University of Milan, Italy
| | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Abstract
Oral mucositis is a distressing toxic effect of systemic chemotherapy with many commonly utilized drugs and of head and neck irradiation in patients with cancer. The agents and methods that have been used and studied in chemotherapy- and radiotherapy-induced oral mucositis, their mechanisms of action, and the current knowledge of their efficiency to reduce the incidence, severity or shorten the duration of oral mucositis are reviewed in this article. Oral cooling is a cheap and available method to lower the severity of bolus 5-fluorouracil-induced oral mucositis. However, more effective methods are needed. Results of studies with granulocyte-macrophage colony-stimulating factor or granulocyte colony-stimulating factor are promising. Lasers are partly beneficial, but equipment-demanding. Modification of the chemotherapy regimen resulting in shortening of the exposition time to chemotherapy agents or chronomodulation of chemotherapy has been shown to lower mucosal toxicity of some regimens. Results of animal studies with locally applied transforming growth factor beta 3 and interleukin-11 are also promising. Based on the findings of the role of the inflammatory cascade in the response of normal tissues to chemotherapy and radiotherapy, anti-inflammatory drugs might be beneficial. At the present time, no agent has been shown to be uniformly efficacious and can be accepted as standard therapy of chemotherapy- and radiotherapy-induced oral mucositis. Further intensive research is needed.
Collapse
Affiliation(s)
- P Plevová
- Department of Radiotherapy, University Hospital of Ostrava, Ostrava-Poruba, Czeck Republic.
| |
Collapse
|
25
|
Abstract
Mucositis may be a painful, debilitating, dose-limiting side-effect of both chemotherapy and radiotherapy for which there is no widely accepted prophylaxis or effective treatment. The basis of management is pain relief, prevention of dehydration and adequate nutrition. When tested vigorously, most antiseptic mouthwashes and anti-ulcer agents are ineffective. Simple mechanical cleansing by saline is the most effective traditional measure. A variety of new agents are effective. Granulocyte macrophage colony-stimulating factor (GM-CSF) and granulocyte colony-stimulating factor (G-CSF) act outwith the haemopoeitic system and can reduce mucositis, but the best schedule, dosage and method of administration is not known or which is the best growth factor to prevent this side-effect. A placebo-controlled randomized trial of antibiotic pastilles has shown a significant reduction in mucositis and weight loss during radiotherapy for head and neck cancer. Another method to reduce radiation effects in normal tissue is to stimulate cells to divide before radiotherapy by silver nitrate or interleukin 1. These methods may be particularly effective when given along with hyperfractionated radiation treatment such as CHART.
Collapse
Affiliation(s)
- R P Symonds
- Beatson Oncology Centre, Western Infirmary, Glasgow, UK
| |
Collapse
|
26
|
Sonis ST. Mucositis as a biological process: a new hypothesis for the development of chemotherapy-induced stomatotoxicity. Oral Oncol 1998; 34:39-43. [PMID: 9659518 DOI: 10.1016/s1368-8375(97)00053-5] [Citation(s) in RCA: 339] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Mucositis induced by antineoplastic drugs is an important, dose-limiting and costly side effect of cancer therapy. The ulcerative lesions which result are frequent systemic portals of entry for microorganisms which inhabit the mouth and consequently are often sources of systemic infection in the myelosuppressed patient. A number of clinical observations and the inconsistency of responses to a broad range of treatment modalities suggests a physiological complexity to mucositis which has not previously been comprehensively considered. We now propose a hypothesis as to the mechanism by which mucositis develops and resolves, which is based on four phases: an initial inflammatory/vascular phase; an epithelial phase; an ulcerative/bacteriological phase; and a healing phase. The role of cytokines as initiators and ampliers of the process is discussed, as is the potential influence of genetic factors in establishing risk and modifying the course of stomatotoxicity.
Collapse
Affiliation(s)
- S T Sonis
- Division of Oral Medicine, Oral and Maxillofacial Surgery and Dentistry, Brigham and Women's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
27
|
Bondi E, Baroni C, Prete A, Gatti M, Carrassi A, Lodi G, Porter SR. Local antimicrobial therapy of oral mucositis in paediatric patients undergoing bone marrow transplantation. Oral Oncol 1997; 33:322-6. [PMID: 9415330 DOI: 10.1016/s1368-8375(97)00039-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The present investigation has examined the clinical benefits of tobramycin, polymyxin E and amphotericin therapy in the management of oral mucositis in children undergoing chemotherapy prior to bone marrow transplantation. Tobramycin, polymyxin E, and amphotericin reduced the degree of oral mucositis more than conventional therapy of diphenhydramine, Maalox, and local analgesic. While there was a statistically significant fall in the severity of the mucositis with tobramycin, polymyxin E and amphotericin, this was unlikely to be of practical benefit.
Collapse
Affiliation(s)
- E Bondi
- University of Bologna, School of Dentistry, Bologna, Italy
| | | | | | | | | | | | | |
Collapse
|