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Lopez-Delgado JC, Patel JJ, Stoppe C, McClave SA. Considerations for medical nutrition therapy management of the critically ill patient with hematological malignancies: A narrative review. Nutr Clin Pract 2024; 39:800-814. [PMID: 38666811 DOI: 10.1002/ncp.11152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/26/2024] [Accepted: 03/21/2024] [Indexed: 07/04/2024] Open
Abstract
Patients with hematological malignancies (HMs) are more frequently admitted now than in the past to the intensive care unit (ICU) due to more aggressive approaches in primary therapy of HMs and the need for critical care support. Pathophysiological alterations derived from HMs and the different hematological therapies, such as chemotherapy, negatively affect gastrointestinal (GI) function, metabolism, and nutrition status. Further, malnutrition strongly influences outcomes and tolerance of the different hematological therapies. In consequence, these critically ill patients frequently present with malnutrition and pathophysiological alterations that create challenges for the delivery of medical nutrition therapy (MNT) in the ICU. Frequent screening, gauging tolerance, and monitoring nutrition status are mandatory to provide individualized MNT and achieve nutrition objectives. The present review discusses how HM impact GI function and nutrition status, the importance of MNT in patients with HM, and specific considerations for guidance in providing adequate MNT to these patients when admitted to the ICU.
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Affiliation(s)
| | - Jayshil J Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Christian Stoppe
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital, Würzburg, Würzburg, Germany
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany
| | - Stephen A McClave
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
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2
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Dambrós BF, Kobus RA, da Rosa R, Pereira LJ, Hinnig PDF, Di Pietro PF, Kunradi Vieira FG. The effect of oral dietary interventions on nutritional status and treatment tolerance in patients with hematologic neoplasms receiving chemotherapy: a systematic review. Nutr Rev 2023:nuad161. [PMID: 38114131 DOI: 10.1093/nutrit/nuad161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023] Open
Abstract
CONTEXT Adverse events from chemotherapy treatment affect food intake, nutritional status, and treatment tolerance in cancer patients. However, the effect of nutritional intervention in patients with hematologic neoplasms receiving chemotherapy remains unknown. OBJECTIVE The aim of this systematic review was to evaluate the evidence on nutritional interventions on nutritional status, treatment tolerance, inflammatory markers, quality of life, and mortality in patients with hematologic neoplasms receiving chemotherapy. DATA SOURCES The MEDLINE, LILACS, CINAHL, Web of Science, Embase, ICTRP, CENTRAL, and ClinicalTrials.gov databases were searched. Additional literature and the bibliographies of identified articles were also considered. DATA EXTRACTION Randomized controlled trials in individuals with hematologic neoplasms receiving chemotherapy along with nutritional counseling and oral nutritional supplementation, and intake of supplementary food products, alone or in combination, were assessed as criteria of interest. The data were extracted independently by 2 researchers. The risk of bias was assessed through the Cochrane risk-of-bias tool (RoB 2). DATA ANALYSIS Ten studies were included up to August 15, 2022 (updated in November of 2022). With regard to the outcomes, 4 studies assessed nutritional status and 2 studies showed a positive result of the intervention on some of the markers. Seven studies assessed certain markers of treatment tolerance and only 2 studies showed improvement in the outcome after the intervention. CONCLUSION The studies that found positive results are quite different from each other in terms of intervention, study time, and design. More randomized controlled trials are needed to test different dietary interventions using placebo and blinding, when possible, and with reduced sample variability in individuals with hematologic neoplasms receiving chemotherapy. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration no. CRD42020196765.
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Affiliation(s)
- Betina Fernanda Dambrós
- Postgraduate Program in Nutrition, Department of Nutrition, Federal University of Santa Catarina, Florianopolis, Santa Catarina, Brazil
| | - Rafaela Alexia Kobus
- Postgraduate Program in Nutrition, Department of Nutrition, Federal University of Santa Catarina, Florianopolis, Santa Catarina, Brazil
| | - Raquel da Rosa
- Postgraduate Program in Nutrition, Department of Nutrition, Federal University of Santa Catarina, Florianopolis, Santa Catarina, Brazil
| | - Luciana Jeremias Pereira
- Postgraduate Program in Nutrition, Department of Nutrition, Federal University of Santa Catarina, Florianopolis, Santa Catarina, Brazil
| | - Patrícia de Fragas Hinnig
- Postgraduate Program in Nutrition, Department of Nutrition, Federal University of Santa Catarina, Florianopolis, Santa Catarina, Brazil
| | - Patricia Faria Di Pietro
- Postgraduate Program in Nutrition, Department of Nutrition, Federal University of Santa Catarina, Florianopolis, Santa Catarina, Brazil
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Amiri Khosroshahi R, Talebi S, Zeraattalab-Motlagh S, Imani H, Rashidi A, Travica N, Mohammadi H. Nutritional interventions for the prevention and treatment of cancer therapy-induced oral mucositis: an umbrella review of systematic reviews and meta-analysis. Nutr Rev 2023; 81:1200-1212. [PMID: 36763701 DOI: 10.1093/nutrit/nuac105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
CONTEXT To date, the efficacy of nutritional interventions on oral mucositis (OM) in patients with cancer, and the quality of this evidence have not been explored. OBJECTIVE The goal of this umbrella review was to provide a comprehensive evaluation of nutritional interventions for patients with cancer with OM, as well as to assess the quality of this evidence. DATA SOURCES Meta-analyses were searched for using PubMed, Scopus, and ISI Web of Science databases until December 2021, with no time restrictions. DATA EXTRACTION Meta-analyses of randomized control trials that evaluated the effects of nutritional interventions on the incidence of OM in patients with cancer had inclusion criteria for this umbrella review. Data extraction, quality assessment of meta-analyses, and primary studies were done independently by 2 authors. The Grading of Recommendations Assessment, Development, and Evaluation technique was used to grade the certainty of evidence. DATA ANALYSIS A total of 26 meta-analyses were included in this umbrella review. The results showed that honey, glutamine, and propolis can reduce the incidence of severe OM, based on moderate evidence quality. In addition, zinc supplementation significantly reduced the incidence of OM, regardless of symptom severity; however, low certainty of the evidence was observed. The effects of vitamin E, curcumin, and probiotics on OM were not statistically significant. CONCLUSION This umbrella review shows that honey, glutamine, and propolis can significantly reduce the incidence of severe OM. These findings need to be confirmed with well-designed, longitudinal randomized controlled trials. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration no. CRD42022301010.
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Affiliation(s)
- Reza Amiri Khosroshahi
- Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | - Sepide Talebi
- Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | - Sheida Zeraattalab-Motlagh
- Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Hossein Imani
- Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirabbas Rashidi
- Hematology-Oncology and BMT Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Nikolaj Travica
- Deakin University, IMPACT-the Institute for Mental and Physical Health and Clinical Translation, Food & Mood Centre, School of Medicine, Barwon Health, Geelong, Australia
| | - Hamed Mohammadi
- Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
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4
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Peng TR, Tsai FP, Wu TW. Effects of various treatments for preventing oral mucositis in cancer patients: A network meta-analysis. PLoS One 2022; 17:e0278102. [PMID: 36480513 PMCID: PMC9731456 DOI: 10.1371/journal.pone.0278102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 11/09/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Oral mucositis (OM) is a common side effect of chemotherapy and radiotherapy in patients with cancers. The prevention or treatment of OM in cancer patients is crucial in the treatment of cancer. METHODS We searched PubMed, Embase, and Cochrane Library for the randomized control trials (RCTs) of interventions for preventing and treating OM. Network meta-analysis (NMA) was performed to estimate odds ratios (ORs) and 95% confidence intervals (CI) from both direct and indirect evidence. The prespecified primary efficacy outcome was the treatment effect of moderate to severe oral mucositis with 12 interventions. The outcome was moderate to a severe grade of OM. RESULTS This study included 55 RCTs with 3,552 participants. The results showed that honey significantly lowered the risk of chemo/radiotherapy-induced moderate to severe oral mucositis than placebo (OR: 0.01, 95%CI 0.00 to 0.45), followed by lignocaine (OR: 0.07, 95%CI 0.00 to 0.95). The surface under cumulative ranking curve (SUCRA) values for honey were 0.95, followed by lignocaine (SUCRA, 0.81) and benzydamine (SUCRA, 0.78). CONCLUSIONS The honey is effective for patients with cancer undergoing chemotherapy or radiotherapy-induced oral mucositis.
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Affiliation(s)
- Tzu-Rong Peng
- Department of Pharmacy, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Fang-Pei Tsai
- Department of Pharmacy, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Ta-Wei Wu
- Department of Pharmacy, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
- * E-mail:
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5
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Effectiveness of glutamine in the management of oral mucositis in cancer patients: a meta-analysis of randomized controlled trials. Support Care Cancer 2021; 29:4885-4892. [DOI: 10.1007/s00520-021-06060-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 02/07/2021] [Indexed: 01/08/2023]
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Yarom N, Hovan A, Bossi P, Ariyawardana A, Jensen SB, Gobbo M, Saca-Hazboun H, Kandwal A, Majorana A, Ottaviani G, Pentenero M, Nasr NM, Rouleau T, Lucas AS, Treister NS, Zur E, Ranna V, Vaddi A, Cheng KKF, Barasch A, Lalla RV, Elad S. Systematic review of natural and miscellaneous agents for the management of oral mucositis in cancer patients and clinical practice guidelines-part 1: vitamins, minerals, and nutritional supplements. Support Care Cancer 2019; 27:3997-4010. [PMID: 31286229 DOI: 10.1007/s00520-019-04887-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Accepted: 05/22/2019] [Indexed: 12/13/2022]
Abstract
PURPOSE To update the clinical practice guidelines for the use of natural and miscellaneous agents for the prevention and/or treatment of oral mucositis (OM). METHODS A systematic review was conducted by the Mucositis Study Group of the Multinational Association of Supportive Care in Cancer / International Society of Oral Oncology (MASCC/ISOO). The body of evidence for each intervention, in each cancer treatment setting, was assigned an evidence level. The findings were added to the database used to develop the 2014 MASCC/ISOO clinical practice guidelines. Based on the evidence level, the following guidelines were determined: Recommendation, Suggestion, and No Guideline Possible. RESULTS A total of 78 papers were identified within the scope of this section, out of which 29 were included in this part, and were analyzed with 27 previously reviewed studies. A new Suggestion was made for oral glutamine for the prevention of OM in head and neck (H&N) cancer patients receiving radiotherapy with concomitant chemotherapy. The previous Recommendation against the use of parenteral glutamine for the prevention of OM in hematopoietic stem cell transplantation (HSCT) patients was re-established. A previous Suggestion for zinc to prevent OM in H&N cancer patients treated with radiotherapy or chemo-radiotherapy was reversed to No Guideline Possible. No guideline was possible for other interventions. CONCLUSIONS Of the vitamins, minerals, and nutritional supplements studied for the management of OM, the evidence supports a Recommendation against parenteral glutamine in HSCT patients and a Suggestion in favor of oral glutamine in H&N cancer patients for the management of OM.
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Affiliation(s)
- Noam Yarom
- Oral Medicine Unit, Sheba Medical Center, Tel Hashomer, Israel. .,School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Allan Hovan
- British Columbia Cancer - Vancouver Centre, Vancouver, Canada
| | - Paolo Bossi
- Medical Oncology, ASST-Spedali Civili, University of Brescia, Brescia, Italy
| | - Anura Ariyawardana
- College of Medicine and Dentistry, James Cook University, Cairns, Queensland, Australia.,Metro South Oral Health, Queensland Health, Brisbane, Australia
| | - Siri Beier Jensen
- Department of Dentistry and Oral Health, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Margherita Gobbo
- Division of Oral Medicine and Pathology, Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | | | - Abhishek Kandwal
- Cancer Research Institute, Himalayan Institute of Medical Sciences, Swami Rama Himayalan University, Dehradun, Uttarakhand, India
| | - Alessandra Majorana
- Department of Medical and Surgical Specialties, Radiological Science and Public Health, Dental School University of Brescia, Brescia, Italy
| | - Giulia Ottaviani
- Division of Oral Medicine and Pathology, Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Monica Pentenero
- Department of Oncology, Oral Medicine and Oral Oncology Unit, University of Turin, Turin, Italy
| | - Narmin Mohammed Nasr
- Special Needs Dentistry, Dental Services, Directorate General of Health Services-Muscat Governorate, Ministry of Health, Muscat, Oman
| | - Tanya Rouleau
- Dental Oncology Program, Health Sciences North, North East Cancer Center, Sudbury, ON, Canada
| | - Anna Skripnik Lucas
- Medical Oncology Service, Department of Medicine, NYU Langone Perlmutter Cancer Center, New York, NY, USA
| | - Nathaniel Simon Treister
- Division of Oral Medicine and Dentistry, Brigham and Women's Hospital, Boston, MA, USA.,Department of Oral Medicine, Infection and Immunity, Harvard School of Dental Medicine, Boston, MA, USA
| | - Eyal Zur
- Compounding Solutions, Tel-Mond, Israel
| | - Vinisha Ranna
- Department of Oral and Maxillofacial Surgery, The Mount Sinai Hospital, New York, NY, 10029, USA
| | - Anusha Vaddi
- Oral Medicine, Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, NY, USA
| | - Karis Kin Fong Cheng
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Andrei Barasch
- Division of Oncology, Weill Cornell Medical College, New York, NY, USA
| | - Rajesh V Lalla
- Section of Oral Medicine, University of Connecticut School of Dental Medicine, Farmington, CT, USA
| | - Sharon Elad
- Oral Medicine, Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, NY, USA
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Thomsen M, Vitetta L. Adjunctive Treatments for the Prevention of Chemotherapy- and Radiotherapy-Induced Mucositis. Integr Cancer Ther 2018; 17:1027-1047. [PMID: 30136590 PMCID: PMC6247548 DOI: 10.1177/1534735418794885] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background: Chemoradiotherapy-associated mucositis can manifest as
pain, inflammation, dysphagia, diarrhea, weight loss, rectal bleeding, and
infection. Mucositis is a major dose-limiting side effect of chemotherapy,
affecting nutritional intake and oral and intestinal function. Despite several
interventions being available, there is a need for safe and effective
preventative and treatment options for treatment-induced mucositis. The goals of
this review are to discuss interventions based on foods and natural products and
present the research to date. Methods: A narrative literature
review identified 60 clinical studies examining various nutritional compounds
and 20 examining probiotics. 9 studies on probiotics for the prevention of
diarrhea were also assessed on methodological quality and limitations
identified. Results: Several compounds have been posited as useful
adjuvants for cancer treatment–related mucositis. Probiotics demonstrate
efficacy for the prevention and treatment of chemoradiotherapy-induced
gastrointestinal toxicity without significant side effects. Glutamine and
activated charcoal were reported to reduce chemotherapy-induced diarrhea but not
radiation-induced intestinal mucositis. Honey has been reported to decrease
treatment interruptions, weight loss, and delays the onset of oral mucositis.
Zinc, glutamine, and topical vitamin E were demonstrated efficacy for oral
mucositis. Conclusion: There is plausible clinical evidence for the
administration of several adjunctive treatments for the prevention and treatment
of mucositis. Probiotics were reported to reduce the burden of intestinal
mucositis and treatment-induced diarrhea. Activated charcoal and glutamine are
beneficial for chemotherapy-induced diarrhea, whereas the administration of
honey, zinc, and glutamine reduce the risk of developing oral mucositis during
chemotherapy or radiotherapy.
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Affiliation(s)
| | - Luis Vitetta
- 1 University of Sydney, Sydney, New South Wales, Australia.,2 Medlab Clinical Ltd, Sydney, New South Wales, Australia
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Abstract
BACKGROUND This is an update of the original Cochrane review published in Issue 2, 2002. Bone marrow transplantation involves administration of toxic chemotherapy and infusion of marrow cells. After treatment, patients can develop poor appetite, mucositis and gastrointestinal failure, leading to malnutrition. To prevent this, parenteral nutrition (PN) support is often first choice but is associated with increased risk of infection. Enteral nutrition (EN) is an alternative, as is addition of substrates. OBJECTIVES To determine efficacy of EN or PN support for patients receiving bone marrow transplant. SEARCH METHODS Search of The Cochrane Library, MEDLINE, EMBASE and CINAHL in November 2000 and subsequently June 2006. SELECTION CRITERIA RCTs that compared one form of nutrition support with another, or control, for bone marrow transplant patients. DATA COLLECTION AND ANALYSIS Twenty nine studies were identified. Data were collected on participants' characteristics; adverse effects; neutropaenia; % change in body weight; graft versus host disease; and survival. MAIN RESULTS In two studies (82 participants) glutamine mouthwash reduced number of days patients were neutropenic (6.82 days, 95%CI (1.67 to 11.98) P = 0.009) compared with placebo. Three studies reported (103 participants) that patients receiving PN with glutamine had reduced hospital stay, 6.62 d (95%CI 3.47 to 9.77, P = 0.00004) compared with patients receiving standard PN. However, in the update a further study was added (147 participants) which altered the pooled results: duration in hospital may be increased for those who receive PN with additional glutamine - 0.22 days (95%CI (1.29 to 1.72). Two other studies reported that (73 participants) patients receiving PN plus glutamine had reduced incidence of positive blood cultures (OR 0.23, 95%CI 0.08 to 0.65, P = 0.006) compared to those receiving standard PN. However, a study from the update (113 participants in total) showed the odds of having a positive blood culture have increased but are still less likely if the patient receives PN with glutamine compared to standard PN (OR 0.46, 95%CI 0.20 to 1.04). When patients were given PN versus IV hydration, (25 participants) patients receiving PN had a higher incidence of line infections (OR 21.23, 95%CI 4.15 to 108.73, P = 0.0002) compared to those receiving standard IV fluids. The update identified one study which recognised that (55 participants) those who received IV were likely to spend less time in hospital, 3.30 days (95%CI -0.38 to 6.98, P = 0.08), although this result was not significant. As reported in the original review there remains no evaluable data to properly compare PN with EN. AUTHORS' CONCLUSIONS In this update an additional study that compared PN and Glutamine versus standard PN showed that the certain benefits of parenteral nutrition with added glutamine compared to standard PN for reducing hospital stay are no longer definite. When PN with glutamine is compared with standard PN, patients may not leave hospital earlier, but do have reduced incidence of positive blood cultures, than those receiving standard PN. Where possible use of intravenous fluids and oral diet should be considered as a preference to parenteral nutrition, however, in the event of a patient suffering severe gastrointestinal failure even with a trial of enteral feeding, PN with the addition of glutamine could be considered.
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Affiliation(s)
| | - Sima Pindoria
- Institute of Child HealthCentre for Paediatric Epidemiology and Biostatistics30 Guilford StLondonUKWC1N 1EH
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9
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Arends J, Bachmann P, Baracos V, Barthelemy N, Bertz H, Bozzetti F, Fearon K, Hütterer E, Isenring E, Kaasa S, Krznaric Z, Laird B, Larsson M, Laviano A, Mühlebach S, Muscaritoli M, Oldervoll L, Ravasco P, Solheim T, Strasser F, de van der Schueren M, Preiser JC. ESPEN guidelines on nutrition in cancer patients. Clin Nutr 2017. [DOI: 10.1016/j.clnu.2016.07.015 10.1016/j.clnu.2016.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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10
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Nutritional risk in allogeneic stem cell transplantation: rationale for a tailored nutritional pathway. Ann Hematol 2017; 96:617-625. [DOI: 10.1007/s00277-016-2910-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 12/23/2016] [Indexed: 12/26/2022]
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Richardson M, Martel L, Martensson L. Outpatient Transfusion Practice and Factors Leading to Inpatient Transfusion in a Pediatric Hematology/Oncology Program. J Pediatr Oncol Nurs 2016; 24:46-51. [PMID: 17185402 DOI: 10.1177/1043454206296022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Oral mucositis continues to be a common and debilitating side effect of the conditioning regimens that use high-dose chemotherapy with or without radiation for pediatric bone marrow transplantation. Limited interventions have demonstrated success in preventing or treating it. Administration of glutamine, which is a nitrogen-rich amino acid found in the body, has emerged as a possible method of preventing oral mucositis in patients undergoing bone marrow transplantation. Numerous studies have looked at the effects of oral glutamine supplementation during bone marrow transplant. The purpose of this article is to describe glutamine and how it functions, review the literature regarding the use of oral glutamine in the prevention of oral mucositis in bone marrow transplantion, discuss the administration concerns related to the pediatric setting, and stress the importance of the nurse's role at the bedside. Nurses working in pediatric bone marrow transplant play a key role in the assessment of oral mucositis, administration of oral glutamine, and education of the patient and family.
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Affiliation(s)
- Matthew Richardson
- Section of Pediatric Hematology/Oncology, Baystate Regional Cancer Center, Springfield, MA 01107, USA.
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12
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Kota H, Chamberlain RS. Immunonutrition Is Associated With a Decreased Incidence of Graft-Versus-Host Disease in Bone Marrow Transplant Recipients: A Meta-Analysis. JPEN J Parenter Enteral Nutr 2016; 41:1286-1292. [DOI: 10.1177/0148607116663278] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Harshitha Kota
- Saint George’s University School of Medicine, Grenada, West Indies
| | - Ronald S. Chamberlain
- Saint George’s University School of Medicine, Grenada, West Indies
- New Jersey Medical School, Rutgers University, Newark, New Jersey, USA
- Department of Surgery, Saint Barnabas Medical Center, Livingston, New Jersey, USA
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13
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Abstract
Cancers are among the leading causes of morbidity and mortality worldwide, and the number of new cases is expected to rise significantly over the next decades. At the same time, all types of cancer treatment, such as surgery, radiation therapy, and pharmacological therapies are improving in sophistication, precision and in the power to target specific characteristics of individual cancers. Thus, while many cancers may still not be cured they may be converted to chronic diseases. All of these treatments, however, are impeded or precluded by the frequent development of malnutrition and metabolic derangements in cancer patients, induced by the tumor or by its treatment. These evidence-based guidelines were developed to translate current best evidence and expert opinion into recommendations for multi-disciplinary teams responsible for identification, prevention, and treatment of reversible elements of malnutrition in adult cancer patients. The guidelines were commissioned and financially supported by ESPEN and by the European Partnership for Action Against Cancer (EPAAC), an EU level initiative. Members of the guideline group were selected by ESPEN to include a range of professions and fields of expertise. We searched for meta-analyses, systematic reviews and comparative studies based on clinical questions according to the PICO format. The evidence was evaluated and merged to develop clinical recommendations using the GRADE method. Due to the deficits in the available evidence, relevant still open questions were listed and should be addressed by future studies. Malnutrition and a loss of muscle mass are frequent in cancer patients and have a negative effect on clinical outcome. They may be driven by inadequate food intake, decreased physical activity and catabolic metabolic derangements. To screen for, prevent, assess in detail, monitor and treat malnutrition standard operating procedures, responsibilities and a quality control process should be established at each institution involved in treating cancer patients. All cancer patients should be screened regularly for the risk or the presence of malnutrition. In all patients - with the exception of end of life care - energy and substrate requirements should be met by offering in a step-wise manner nutritional interventions from counseling to parenteral nutrition. However, benefits and risks of nutritional interventions have to be balanced with special consideration in patients with advanced disease. Nutritional care should always be accompanied by exercise training. To counter malnutrition in patients with advanced cancer there are few pharmacological agents and pharmaconutrients with only limited effects. Cancer survivors should engage in regular physical activity and adopt a prudent diet.
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Sayles C, Hickerson SC, Bhat RR, Hall J, Garey KW, Trivedi MV. Oral Glutamine in Preventing Treatment-Related Mucositis in Adult Patients With Cancer. Nutr Clin Pract 2015; 31:171-9. [DOI: 10.1177/0884533615611857] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- Caitlin Sayles
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas
| | - Stephen C. Hickerson
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas
| | - Raksha R. Bhat
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas
| | - Jacob Hall
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kevin W. Garey
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas
| | - Meghana V. Trivedi
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas
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15
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Muscaritoli M, Capria S, Iori AP, Fanelli FR. Nutritional and Metabolic Support in Haematological Malignancies and Haematopoietic Stem-Cell Transplantation. Clin Nutr 2015. [DOI: 10.1002/9781119211945.ch15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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16
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Fuji S, Einsele H, Savani BN, Kapp M. Systematic Nutritional Support in Allogeneic Hematopoietic Stem Cell Transplant Recipients. Biol Blood Marrow Transplant 2015; 21:1707-13. [PMID: 26172477 DOI: 10.1016/j.bbmt.2015.07.003] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 07/06/2015] [Indexed: 12/15/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) has become an established treatment modality for various hematological diseases. However, in allogeneic HSCT, patients often suffer from severe gastrointestinal complications caused by the conditioning regimen and acute/chronic graft-versus-host disease, which requires support by multidisciplinary nutritional support teams (NST). In addition, pretransplantation nutritional status can affect the clinical outcome after allogeneic HSCT. Therefore, it is important to refer the patient to a NST when becoming aware of nutritional problems before allogeneic HSCT. It is also important to follow nutritional status over the long term, as patients often suffer from various nutritional problems, such as malnutrition and metabolic syndrome, even late after allogeneic HSCT. In summary, NST can contribute to the improvement of nutritional status and possibly prognosis at every stage before and after allogeneic HSCT. Here, we aim to give a comprehensive overview of current understanding about nutritional support in allogeneic HSCT and try to provoke a constructive discussion to stimulate further investigation.
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Affiliation(s)
- Shigeo Fuji
- Department of Internal Medicine II, Division of Hematology, University Hospital of Würzburg, Würzburg, Germany; Division of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan.
| | - Hermann Einsele
- Department of Internal Medicine II, Division of Hematology, University Hospital of Würzburg, Würzburg, Germany
| | - Bipin N Savani
- Hematology and Stem Cell Transplantation Section, Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center and Veterans Affairs Medical Center, Nashville, Tennessee
| | - Markus Kapp
- Department of Internal Medicine II, Division of Hematology, University Hospital of Würzburg, Würzburg, Germany
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Francis DK, Smith J, Saljuqi T, Watling RM. Oral protein calorie supplementation for children with chronic disease. Cochrane Database Syst Rev 2015; 2015:CD001914. [PMID: 26014160 PMCID: PMC4460719 DOI: 10.1002/14651858.cd001914.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Poor growth and nutritional status are common in children with chronic diseases. Oral protein calorie supplements are used to improve nutritional status in these children. These expensive products may be associated with some adverse effects, e.g. the development of inappropriate eating behaviour patterns. This is a new update of a Cochrane review last updated in 2009. OBJECTIVES To examine evidence that in children with chronic disease, oral protein calorie supplements alter daily nutrient intake, nutritional indices, survival and quality of life and are associated with adverse effects, e.g. diarrhoea, vomiting, reduced appetite, glucose intolerance, bloating and eating behaviour problems. SEARCH METHODS Trials of oral protein calorie supplements in children with chronic diseases were identified through comprehensive electronic database searches, handsearching relevant journals and abstract books of conference proceedings. Companies marketing these products were also contacted.Most recent search of the Group's Trials Register: 24 February 2015. SELECTION CRITERIA Randomised or quasi-randomised controlled trials comparing oral protein calorie supplements for at least one month to increase calorie intake with existing conventional therapy (including advice on improving nutritional intake from food or no specific intervention) in children with chronic disease. DATA COLLECTION AND ANALYSIS We independently assessed the outcomes: indices of nutrition and growth; anthropometric measures of body composition; calorie and nutrient intake (total from oral protein calorie supplements and food); eating behaviour; compliance; quality of life; specific adverse effects; disease severity scores; and mortality; we also assessed the risk of bias in the included trials. MAIN RESULTS Four studies (187 children) met the inclusion criteria. Three studies were carried out in children with cystic fibrosis and one study included children with paediatric malignant disease. Overall there was a low risk of bias for blinding and incomplete outcome data.Two studies had a high risk of bias for allocation concealment. Few statistical differences were found in the outcomes we assessed between treatment and control groups, except change in total energy intake at six and 12 months, mean difference 304.86 kcal per day (95% confidence interval 5.62 to 604.10) and mean difference 265.70 kcal per day (95% confidence interval 42.94 to 485.46), respectively. However, these were based on the analysis of just 58 children in only one study. Only two chronic diseases were included in these analyses, cystic fibrosis and paediatric malignant disease. No other studies were identified which assessed the effectiveness of oral protein calorie supplements in children with other chronic diseases. AUTHORS' CONCLUSIONS Oral protein calorie supplements are widely used to improve the nutritional status of children with a number of chronic diseases. We identified a small number of studies assessing these products in children with cystic fibrosis and paediatric malignant disease, but were unable to draw any conclusions based on the limited data extracted. We recommend a series of large, randomised controlled trials be undertaken investigating the use of these products in children with different chronic diseases. Until further data are available, we suggest these products are used with caution.
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Affiliation(s)
- Damian K Francis
- Caribbean Institute for Health Research, The University of the West Indies, MonaEpidemiology Research UnitKingstonJamaica
| | | | | | - Ruth M Watling
- Alder Hey Children's NHS Foundation TrustDepartment of Nutrition and DieteticsEaton RoadLiverpoolMerseysideUKL12 2AP
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Tsujimoto T, Yamamoto Y, Wasa M, Takenaka Y, Nakahara S, Takagi T, Tsugane M, Hayashi N, Maeda K, Inohara H, Uejima E, Ito T. L-glutamine decreases the severity of mucositis induced by chemoradiotherapy in patients with locally advanced head and neck cancer: a double-blind, randomized, placebo-controlled trial. Oncol Rep 2014; 33:33-9. [PMID: 25351453 PMCID: PMC4254677 DOI: 10.3892/or.2014.3564] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 08/06/2014] [Indexed: 11/09/2022] Open
Abstract
The incidence of severe mucositis in the oral cavity, pharynx and larynx is high among patients with head and neck cancer (HNC) receiving chemoradiotherapy (CRT), resulting in significant pain and impairment of quality of life. The present study investigated whether L-glutamine (glutamine) decreases the severity of mucositis in the oral cavity, pharynx and larynx induced by CRT. This double-blind, randomized, placebo-controlled trial included 40 untreated patients with squamous cell carcinoma of the nasopharynx, oropharynx, hypopharynx or larynx. Patients received 66 or 70 Gy of total radiation at the rate of 2 Gy/fraction daily and 5 fractions/week. Cisplatin (20 mg/m2) and docetaxel (10 mg/m2) were intravenously co-administered once a week for 6 weeks. Patients were randomized to orally receive either glutamine (group G) or placebo (group P) at a dose of 10 g 3 times a day throughout the CRT course. Mucositis was assessed using the National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0. The primary end point was mucositis severity. Mucositis developed in all patients. A maximal mucositis grade of G4 was observed in 0 and 25% group G and P patients, respectively, while that of G2 was observed in 10 and 0% group G and P patients, respectively (p=0.023). Glutamine significantly decreased the maximal mucositis grade (group G, 2.9±0.3; group P, 3.3±0.4; p=0.005) and pain score at weeks 4, 5 and 6. Glutamine significantly decreased mucositis severity in the oral cavity, pharynx and larynx induced by CRT in patients with HNC.
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Affiliation(s)
- Takae Tsujimoto
- Department of Complementary and Alternative Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yoshifumi Yamamoto
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Masafumi Wasa
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yukinori Takenaka
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Susumu Nakahara
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Tastuya Takagi
- Department of Pharmainformatics and Pharmacometrics, Osaka University Graduate School of Pharmaceutical Sciences, Suita, Osaka, Japan
| | - Mamiko Tsugane
- Department of Clinical Pharmacy Research and Education, Osaka University Graduate School of Pharmaceutical Sciences, Suita, Osaka, Japan
| | - Noriyuki Hayashi
- Department of Complementary and Alternative Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Kazuhisa Maeda
- Department of Complementary and Alternative Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hidenori Inohara
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Etsuko Uejima
- Department of Clinical Pharmacy Research and Education, Osaka University Graduate School of Pharmaceutical Sciences, Suita, Osaka, Japan
| | - Toshinori Ito
- Department of Complementary and Alternative Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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Ben-Arye E, Polliack A, Schiff E, Tadmor T, Samuels N. Advising patients on the use of non-herbal nutritional supplements during cancer therapy: a need for doctor-patient communication. J Pain Symptom Manage 2013; 46:887-96. [PMID: 23707384 DOI: 10.1016/j.jpainsymman.2013.02.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2012] [Revised: 02/01/2013] [Accepted: 02/18/2013] [Indexed: 12/23/2022]
Abstract
CONTEXT Many cancer patients are using non-herbal nutritional supplements (NHNS), often without informing their oncologists. OBJECTIVES To review the literature and summarize the beneficial effects and safety of NHNS in the prevention and reduction of treatment-related symptoms. METHODS Databases were searched for randomized, controlled clinical trials (Jadad score ≥ 2) using AltHealthWatch, Cochrane Database of Systematic Reviews, Embase, MEDLINE, Memorial Sloan-Kettering Integrative Medicine Service Database, Natural Standard Database, and PubMed. The key words searched were the following: alternative and/or complementary medicine, nutritional and/or dietary supplements, quality of life, symptoms and/or side effects, specific toxicities (e.g., neuropathy, mucositis), and specific supplements (e.g., vitamin E, glutamine, etc.). RESULTS A number of NHNS products were found to be effective. The incidence and severity of peripheral sensory neuropathy associated with taxane-agents such as paclitaxel can be reduced with vitamin E, glutamine, and acetyl-L-carnitine. Vitamin E and glutamine also have been shown to reduce oral mucositis resulting from radiation and chemotherapy, and glutamine and probiotics can reduce chemotherapy-induced diarrhea. CONCLUSION There is a need to develop an open and nonjudgmental dialogue between oncologists and cancer patients, addressing the needs of the patient while dealing with issues related to the efficacy and safety of these products. Referral of patients to an integrative medicine consultant may help achieve these goals, providing both parties with the option of reaching an informed and respectful decision about treatment.
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Affiliation(s)
- Eran Ben-Arye
- Integrative Oncology Program, The Oncology Service, Lin Medical Center, Clalit Health Services, Haifa and Western Galilee District, Haifa, Israel; Complementary and Traditional Medicine Unit, Department of Family Medicine, Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
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20
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Ottaviani G, Gobbo M, Sturnega M, Martinelli V, Mano M, Zanconati F, Bussani R, Perinetti G, Long CS, Di Lenarda R, Giacca M, Biasotto M, Zacchigna S. Effect of Class IV Laser Therapy on Chemotherapy-Induced Oral Mucositis. THE AMERICAN JOURNAL OF PATHOLOGY 2013; 183:1747-1757. [DOI: 10.1016/j.ajpath.2013.09.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Revised: 08/20/2013] [Accepted: 09/03/2013] [Indexed: 10/26/2022]
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21
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Bozzetti F. Nutritional support of the oncology patient. Crit Rev Oncol Hematol 2013; 87:172-200. [DOI: 10.1016/j.critrevonc.2013.03.006] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Revised: 01/28/2013] [Accepted: 03/06/2013] [Indexed: 01/06/2023] Open
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Parenteral glutamine supplementation has no effect on chemotherapy-induced toxicity in children with non-Hodgkin lymphoma. J Pediatr Hematol Oncol 2013; 35:371-6. [PMID: 23426005 DOI: 10.1097/mph.0b013e318282daf4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
PURPOSE Protecting patients from the acute and/or chronic toxicity of antineoplastic therapy has become a major concern of oncology centers around the world. Glutamine has been used as a multisystemic protective agent to minimize the side effects arising from the treatment of childhood cancers. In this study, the effect of intravenous glutamine supplementation was investigated in children receiving chemotherapy for non-Hodgkin lymphoma. METHODS Twelve children, of 48 to 120 months of age, and who had non-Hodgkin lymphoma were enrolled in the study. Thirty chemotherapy courses were given in combination with glutamine, and 31 chemotherapy courses were given without glutamine. Glutamine was given intravenously for 7 days, at a dose of 0.4 g/kg/d. Patients were evaluated in each course with regard to gastrointestinal, mucosal, and hematological toxicities. RESULTS There were no significant differences in the hematological parameters between the 2 groups. The requirements for red blood cells and platelets during the chemotherapy courses were similar in both groups (P=0.64 and 0.40, respectively). Patients supplemented with glutamine developed mucositis in 21 of 30 courses (70%) and patients without glutamine supplements developed mucositis in 23 of 31 courses (74%). The mean duration of mucositis and the mean mucositis score in each course were similar between the 2 groups. In addition, gastrointestinal system and hepatic toxicity did not differ between groups. The mean duration of febrile neutropenia and the length of hospitalization were also similar in both groups (P=0.09 and 0.13, respectively). CONCLUSIONS Parenteral glutamine supplementation has no effect on mucositis, fever and febrile neutropenia, length of hospitalization, red blood cell, and platelet requirements, and hematological, gastrointestinal, and hepatic toxicities in children receiving severe chemotherapy.
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Yarom N, Ariyawardana A, Hovan A, Barasch A, Jarvis V, Jensen SB, Zadik Y, Elad S, Bowen J, Lalla RV. Systematic review of natural agents for the management of oral mucositis in cancer patients. Support Care Cancer 2013; 21:3209-21. [PMID: 23764678 DOI: 10.1007/s00520-013-1869-5] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Accepted: 05/21/2013] [Indexed: 11/30/2022]
Abstract
PURPOSE The aim of this study was to review the available literature and define clinical practice guidelines for the use of natural agents for the prevention and treatment of oral mucositis. 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. 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, and no guideline possible. RESULTS A total of 49 papers across 15 interventions were examined. A new suggestion was developed in favor of systemic zinc supplements administered orally in the prevention of oral mucositis in oral cancer patients receiving radiation therapy or chemoradiation (Level III evidence). A recommendation was made against the use of intravenous glutamine for the prevention of oral mucositis in patients receiving high-dose chemotherapy prior to hematopoietic stem cell transplant (Level II evidence). No guideline was possible for any other agent, due to inadequate and/or conflicting evidence. CONCLUSIONS Of the various natural agents reviewed here, the available evidence supported a guideline only for two agents: a suggestion in favor of zinc and a recommendation against glutamine, in the treatment settings listed above. Well-designed studies of other natural agents are warranted.
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Affiliation(s)
- Noam Yarom
- Department of Oral and Maxillofacial Surgery, Sheba Medical Center, Tel-Hashomer, Israel,
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Hébuterne X, Bensadoun RJ. Nutrition chez le patient adulte atteint de cancer : place de la pharmaconutrition en cancérologie. NUTR CLIN METAB 2012. [DOI: 10.1016/j.nupar.2012.10.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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25
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Gibson RJ, Keefe DMK, Lalla RV, Bateman E, Blijlevens N, Fijlstra M, King EE, Stringer AM, van der Velden WJFM, Yazbeck R, Elad S, Bowen JM. Systematic review of agents for the management of gastrointestinal mucositis in cancer patients. Support Care Cancer 2012; 21:313-26. [PMID: 23142924 DOI: 10.1007/s00520-012-1644-z] [Citation(s) in RCA: 154] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Accepted: 10/29/2012] [Indexed: 12/17/2022]
Abstract
PURPOSE The aim of this study was to review the available literature and define clinical practice guidelines for the use of agents for the prevention and treatment of gastrointestinal mucositis. METHODS A systematic review was conducted by the Mucositis Study Group of the Multinational Association of Supportive Care in Cancer/International Society of 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, and no guideline possible. RESULTS A total of 251 clinical studies across 29 interventions were examined. Panel members were able to make one new evidence-based negative recommendation; two new evidence-based suggestions, and one evidence-based change from previous guidelines. Firstly, the panel recommends against the use of misoprostol suppositories for the prevention of acute radiation-induced proctitis. Secondly, the panel suggests probiotic treatment containing Lactobacillus spp., may be beneficial for prevention of chemotherapy and radiotherapy-induced diarrhea in patients with malignancies of the pelvic region. Thirdly, the panel suggests the use of hyperbaric oxygen as an effective means in treating radiation-induced proctitis. Finally, new evidence has emerged which is in conflict with our previous guideline surrounding the use of systemic glutamine, meaning that the panel is unable to form a guideline. No guideline was possible for any other agent, due to inadequate and/or conflicting evidence. CONCLUSIONS This updated review of the literature has allowed new recommendations and suggestions for clinical practice to be reached. This highlights the importance of regular updates.
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Affiliation(s)
- Rachel J Gibson
- School of Medical Sciences, University of Adelaide, North Terrace, Adelaide 5005, South Australia, Australia.
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Gaurav K, Goel RK, Shukla M, Pandey M. Glutamine: A novel approach to chemotherapy-induced toxicity. Indian J Med Paediatr Oncol 2012; 33:13-20. [PMID: 22754203 PMCID: PMC3385273 DOI: 10.4103/0971-5851.96962] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Treatment of cancer is associated with short- and long-term side-effects. Cancer produces a state of glutamine deficiency, which is further aggravated by toxic effects of chemotherapeutic agents leading to increased tolerance of tumor to chemotherapy as well as reduced tolerance of normal tissues to the side-effects of chemotherapy. This article reviews the possible role of glutamine supplementation in reducing the serious adverse events in patients treated with anticancer drugs. The literature related to the possible role of glutamine in humans with cancer and the supportive evidence from animal studies was reviewed. Searches were made and the literature was retrieved using PUBMED, MEDLINE, COCHRANE LIBRARY, CENAHL and EMBASE, with a greater emphasis on the recent advances and clinical trials. Glutamine supplementation was found to protect against radiation-induced mucositis, anthracycline-induced cardiotoxicity and paclitaxel-related myalgias/arthralgias. Glutamine may prevent neurotoxicity of paclitaxel, cisplatin, oxaplatin bortezomib and lenolidamide, and is beneficial in the reduction of the dose-limiting gastrointestinal toxic effects of irinotecan and 5-FU-induced mucositis and stomatitis. Dietary glutamine reduces the severity of the immunosuppressive effect induced by methotrexate and improves the immune status of rats recovering from chemotherapy. In patients with acute myeloid leukemia requiring parenteral nutrition, glycyl-glutamine supplementation could hasten neutrophil recovery after intensive myelosuppressive chemotherapy. Current data supports the usefulness of glutamine supplementation in reducing complications of chemotherapy; however, paucity of clinical trials weakens the clear interpretation of these findings.
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Affiliation(s)
- Kumar Gaurav
- Department of Pharmacology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
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Planas M, Fernández-Ortega JF, Abilés J. [Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): oncohematological patient]. Med Intensiva 2012; 35 Suppl 1:53-6. [PMID: 22309754 DOI: 10.1016/s0210-5691(11)70011-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Patients with cancer, irrespective of the stage of their disease, can require admission to the intensive care unit as a result of the complications of their underlying process or the surgical or pharmacological treatment provided. The cancer itself, as well as the critical status that can result from the complications of the disease, frequently lead to a high degree of hypermetabolism and inadequate energy intake, causing a high incidence of malnutrition in these patients. Moreover, cancer causes anomalous use of nutritional substrates and therefore the route of administration and proportion and intake of nutrients may differ in these patients from those in non-cancer patients.
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Affiliation(s)
- M Planas
- Escuela de Ciencias de La Salud, Universidad de Vic, Barcelona, España.
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Glutamine-Enriched Nutrition Does Not Reduce Mucosal Morbidity or Complications After Stem-Cell Transplantation for Childhood Malignancies: A Prospective Randomized Study. Transplantation 2011; 91:1321-5. [DOI: 10.1097/tp.0b013e31821ab959] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Perioperative Herbal and Supplement Use. Gynecol Oncol 2011. [DOI: 10.1002/9781118003435.ch17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Xue H, Sawyer MB, Wischmeyer PE, Baracos VE. Nutrition modulation of gastrointestinal toxicity related to cancer chemotherapy: from preclinical findings to clinical strategy. JPEN J Parenter Enteral Nutr 2011; 35:74-90. [PMID: 21224434 DOI: 10.1177/0148607110377338] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Chemotherapy-induced gut toxicity is a major dose-limiting toxicity for many anticancer drugs. Gastrointestinal (GI) complications compromise the efficacy of chemotherapy, promote overall malnutrition, aggravate cancer cachexia, and may contribute to worsened prognosis. The GI tract is an attractive target for nutrition modulation, owing to its direct exposure to the diet, participation in uptake and metabolism of nutrients, high rate of cell turnover, and plasticity to nutrition stimuli. Glutamine, ω-3 polyunsaturated fatty acids, and probiotics/prebiotics are therapeutic factors that potentially modulate GI toxicity related to cancer treatments. Preclinical and clinical evidence are reviewed to critically define plausible benefits of these factors and their potential development into adjuncts to cancer chemotherapy. Mechanisms underlying the action of these nutrients are being unraveled in the laboratory. Optimal strategies to translate these findings into clinical care still remain to be elucidated. Key questions that remain to be answered include the following: which nutrient or combination of nutrients is selected for which patient and chemotherapy regimen? What mechanisms are responsible for modulation, and how are nutrient(s) administered in a clinically optimal manner? Research exploring interactions between different nutrients in GI protection is ongoing and demands further understanding. How nutrition preparations given to chemotherapy-treated patients are formulated in terms of component selection and dose optimization should be carefully studied and justified.
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Affiliation(s)
- Hongyu Xue
- Department of Oncology, University of Alberta, Edmonton, Alberta, Canada.
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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.
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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
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Wu JC, Beale KK, Ma JD. Evaluation of current and upcoming therapies in oral mucositis prevention. Future Oncol 2011; 6:1751-70. [PMID: 21142661 DOI: 10.2217/fon.10.133] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Cancer chemotherapy has evolved from a few therapeutic agents in three drug classes to more than 50 drugs in over ten drug classes. With generally cytotoxic mechanisms of action, there is continued research interest in preventing and managing adverse events of chemotherapy. Although treatment-induced symptom management has made significant progress, most therapies lead to intolerable reactions that result in a dose reduction or discontinuation of therapy. Mucositis is a common adverse event that can occur after administration of systemic chemotherapy and/or radiation therapy leading to inflammatory lesions anywhere from the oral cavity to the GI tract. Although pathophysiologically similar, gastrointestinal mucositis and oral mucositis (OM) differ in terms of symptom presentation and offending therapies. The focus of the article will be on OM; gastrointestinal mucositis will be mentioned when therapy efficacy is relevant to OM. OM prophylaxis has been a subject of interest for at least the past 30 years, yet progress has been limited due to a lack of understanding of the condition. With the recent introduction of palifermin (Kepivance™), novel therapies continue to be developed that may significantly reduce the incidence, duration and/or severity of OM. In addition, outcomes including an improvement in patient quality of life, increasing treatment dose intensity or reducing healthcare costs may result from successful management of OM prophylaxis. This article will review currently available OM prophylactic therapies. Agents in preclinical or clinical development and natural supplements will also be discussed.
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Affiliation(s)
- Jerry C Wu
- Skaggs School of Pharmacy & Pharmaceutical Sciences University of California, San Diego 9500 Gilman Drive, MC 0714, San Diego, CA 92093, USA
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Ferreira P, Gamba MA, Saconato H, Gutiérrez MGRD. Tratamento da mucosite em pacientes submetidos a transplante de medula óssea: uma revisão sistemática. ACTA PAUL ENFERM 2011. [DOI: 10.1590/s0103-21002011000400018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Identificar as medidas terapêuticas para redução da gravidade da mucosite oral em pacientes adultos submetidos ao Transplante de Medula Óssea (TMO). MÉTODOS: Revisão sistemática nas bases de dados: LILACS, MEDLINE, CINAHL, EMBASE; CENTRAL (Cochrane Central) e DARE (Database of abstracts of reviews of effects), no período de 1972 a julho de 2010, utilizando os descritores mucositis, stomatitis e bone-marrow-transplantation. RESULTADOS: Identificaram-se 3.839 resumos, dos quais 22 foram incluídos na revisão sistemática que descreveram 14 intervenções tópicas e sistêmicas, dentre as quais oito com significância estatística para a redução dessa complicação. As terapias tópicas foram a crioterapia, clorexidine, glutamina, laser e Traumeel® e as sistêmicas, amifostine, Granulokine® e palifermin. CONCLUSÃO: A heterogeneidade dos resultados dessas intervenções e a falta de melhor elucidação para a prática assistencial indicam a necessidade de pesquisas mais precisas para identificar a efetividade de terapias tópicas para a reparação celular das mucosas.
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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. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2010. [DOI: 10.1002/14651858.cd000978.pub4] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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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 2010:CD000978. [PMID: 21154347 DOI: 10.1002/14651858.cd000978.pub3] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [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 1 June 2010), CENTRAL (The Cochrane Library 2010, Issue 2), MEDLINE via OVID (1950 to 1 June 2010), EMBASE via OVID (1980 to 1 June 2010), CINAHL via EBSCO (1980 to 1 June 2010), CANCERLIT via PubMed (1950 to 1 June 2010), OpenSIGLE (1980 to 2005) and LILACS via the Virtual Health Library (1980 to 1 June 2010) 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. Nine 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 nine interventions were: allopurinol, aloe vera, amifostine, cryotherapy, glutamine (intravenous), honey, keratinocyte growth factor, laser, and polymixin/tobramycin/amphotericin (PTA) antibiotic pastille/paste. AUTHORS' CONCLUSIONS Nine 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.
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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
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Kuhn KS, Muscaritoli M, Wischmeyer P, Stehle P. Glutamine as indispensable nutrient in oncology: experimental and clinical evidence. Eur J Nutr 2009; 49:197-210. [DOI: 10.1007/s00394-009-0082-2] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Accepted: 11/02/2009] [Indexed: 12/20/2022]
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August DA, Huhmann MB. A.S.P.E.N. clinical guidelines: nutrition support therapy during adult anticancer treatment and in hematopoietic cell transplantation. JPEN J Parenter Enteral Nutr 2009; 33:472-500. [PMID: 19713551 DOI: 10.1177/0148607109341804] [Citation(s) in RCA: 309] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- David Allen August
- Department of Surgery, Division of Surgical Oncology, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA
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Symposium 4: Hot topics in parenteral nutrition A review of the use of glutamine supplementation in the nutritional support of patients undergoing bone-marrow transplantation and traditional cancer therapy. Proc Nutr Soc 2009; 68:269-73. [DOI: 10.1017/s0029665109001384] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The relationship between glutamine and malignancy can be traced back to the 1950s and the requirement for glutamine for malignant-cell growth in culture. Later studies demonstrated an association between the rate of proliferation of the malignant cells and glutamine usage. The excessive use of glutamine by malignant cells was seen as an opportunity for the development of a treatment using glutamine analogues, but unfortunately excessive toxicity was observed during clinical studies. In animal models glutamine supplementation, initially thought to increase tumour growth, actually causes tumour regression as a result of improved immune clearance of the tumour and appears to reduce the severity of the side effects of chemo- and radiotherapy. This finding led to human studies in both traditional cancer therapy and bone-marrow transplantation, which are reviewed here. Unfortunately, the majority of the studies performed are small and have poor methodological reporting. There is clinical heterogeneity in terms of routes of administration, dosing schedules, chemotherapy regimens and diseases. Studies of glutamine in non-bone-marrow transplantation chemo- and/or radiotherapy treatment suggest a possible trend towards reductions in objective mucositis but no effect on subjective symptoms. There is no evidence for its effect on other clinical outcomes. For bone-marrow transplantation there appears to be some benefit from oral glutamine in reducing mucositis and graft v. host disease, while intravenous glutamine may reduce infections but at the expense of an increased relapse rate. Good-quality studies are required in this area.
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Crowther M, Avenell A, Culligan DJ. Systematic review and meta-analyses of studies of glutamine supplementation in haematopoietic stem cell transplantation. Bone Marrow Transplant 2009; 44:413-25. [DOI: 10.1038/bmt.2009.41] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Abstract
BACKGROUND This is an update of the original Cochrane review published in Issue 2, 2002. Bone marrow transplantation involves administration of toxic chemotherapy and infusion of marrow cells. After treatment, patients can develop poor appetite, mucositis and gastrointestinal failure, leading to malnutrition. To prevent this, parenteral nutrition (PN) support is often first choice but is associated with increased risk of infection. Enteral nutrition (EN) is an alternative, as is addition of substrates. OBJECTIVES To determine efficacy of EN or PN support for patients receiving bone marrow transplant. SEARCH STRATEGY Search of The Cochrane Library, MEDLINE, EMBASE and CINAHL in November 2000 and subsequently June 2006. SELECTION CRITERIA RCTs that compared one form of nutrition support with another, or control, for bone marrow transplant patients. DATA COLLECTION AND ANALYSIS Twenty nine studies were identified. Data were collected on participants' characteristics; adverse effects; neutropaenia; % change in body weight; graft versus host disease; and survival. MAIN RESULTS In two studies (82 participants) glutamine mouthwash reduced number of days patients were neutropenic (6.82 days, 95%CI (1.67 to 11.98) P = 0.009) compared with placebo. Three studies reported (103 participants) that patients receiving PN with glutamine had reduced hospital stay, 6.62 d (95%CI 3.47 to 9.77, P = 0.00004) compared with patients receiving standard PN. However, in the update a further study was added (147 participants) which altered the pooled results: duration in hospital may be increased for those who receive PN with additional glutamine - 0.22 days (95%CI (1.29 to 1.72). Two other studies reported that (73 participants) patients receiving PN plus glutamine had reduced incidence of positive blood cultures (OR 0.23, 95%CI 0.08 to 0.65, P = 0.006) compared to those receiving standard PN. However, a study from the update (113 participants in total) showed the odds of having a positive blood culture have increased but are still less likely if the patient receives PN with glutamine compared to standard PN (OR 0.46, 95%CI 0.20 to 1.04). When patients were given PN versus IV hydration, (25 participants) patients receiving PN had a higher incidence of line infections (OR 21.23, 95%CI 4.15 to 108.73, P = 0.0002) compared to those receiving standard IV fluids. The update identified one study which recognised that (55 participants) those who received IV were likely to spend less time in hospital, 3.30 days (95%CI -0.38 to 6.98, P = 0.08), although this result was not significant. As reported in the original review there remains no evaluable data to properly compare PN with EN. AUTHORS' CONCLUSIONS In this update an additional study that compared PN and Glutamine versus standard PN showed that the certain benefits of parenteral nutrition with added glutamine compared to standard PN for reducing hospital stay are no longer definite. When PN with glutamine is compared with standard PN, patients may not leave hospital earlier, but do have reduced incidence of positive blood cultures, than those receiving standard PN. Where possible use of intravenous fluids and oral diet should be considered as a preference to parenteral nutrition, however, in the event of a patient suffering severe gastrointestinal failure even with a trial of enteral feeding, PN with the addition of glutamine could be considered.
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Affiliation(s)
- Susan M Murray
- National Collaborating Centre for Acute Care, Royal College of Surgeons of England, London, UK, WC2A 3PE.
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Abstract
BACKGROUND This is an update of the original Cochrane review published in Issue 2, 2002. Bone marrow transplantation involves administration of toxic chemotherapy and infusion of marrow cells. After treatment, patients can develop poor appetite, mucositis and gastrointestinal failure, leading to malnutrition. To prevent this, parenteral nutrition (PN) support is often first choice but is associated with increased risk of infection. Enteral nutrition (EN) is an alternative, as is addition of substrates. OBJECTIVES To determine efficacy of EN or PN support for patients receiving bone marrow transplant. SEARCH STRATEGY Search of The Cochrane Library, MEDLINE, EMBASE and CINAHL in November 2000 and subsequently June 2006. SELECTION CRITERIA RCTs that compared one form of nutrition support with another, or control, for bone marrow transplant patients. DATA COLLECTION AND ANALYSIS Twenty nine studies were identified. Data were collected on participants' characteristics; adverse effects; neutropaenia; % change in body weight; graft versus host disease; and survival. MAIN RESULTS In two studies (82 participants) glutamine mouthwash reduced number of days patients were neutropenic (6.82 days, 95%CI (1.67 to 11.98) P = 0.009) compared with placebo. Three studies reported (103 participants) that patients receiving PN with glutamine had reduced hospital stay, 6.62 d (95%CI 3.47 to 9.77, P = 0.00004) compared with patients receiving standard PN. However, in the update a further study was added (147 participants) which altered the pooled results: duration in hospital may be increased for those who receive PN with additional glutamine - 0.22 days (95%CI (1.29 to 1.72). Two other studies reported that (73 participants) patients receiving PN plus glutamine had reduced incidence of positive blood cultures (OR 0.23, 95%CI 0.08 to 0.65, P = 0.006) compared to those receiving standard PN. However, a study from the update (113 participants in total) showed the odds of having a positive blood culture have increased but are still less likely if the patient receives PN with glutamine compared to standard PN (OR 0.46, 95%CI 0.20 to 1.04). When patients were given PN versus IV hydration, (25 participants) patients receiving PN had a higher incidence of line infections (OR 21.23, 95%CI 4.15 to 108.73, P = 0.0002) compared to those receiving standard IV fluids. The update identified one study which recognised that (55 participants) those who received IV were likely to spend less time in hospital, 3.30 days (95%CI -0.38 to 6.98, P = 0.08), although this result was not significant. As reported in the original review there remains no evaluable data to properly compare PN with EN. AUTHORS' CONCLUSIONS In this update an additional study that compared PN and Glutamine versus standard PN showed that the certain benefits of parenteral nutrition with added glutamine compared to standard PN for reducing hospital stay are no longer definite. When PN with glutamine is compared with standard PN, patients may not leave hospital earlier, but do have reduced incidence of positive blood cultures, than those receiving standard PN. Where possible use of intravenous fluids and oral diet should be considered as a preference to parenteral nutrition, however, in the event of a patient suffering severe gastrointestinal failure even with a trial of enteral feeding, PN with the addition of glutamine could be considered.
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Affiliation(s)
- Susan M Murray
- National Collaborating Centre for Acute Care, Royal College of Surgeons of England, London, UK, WC2A 3PE.
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Enteral glutamine supplementation impairs intestinal blood flow in rats. Am J Surg 2008; 196:293-9. [DOI: 10.1016/j.amjsurg.2007.11.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2007] [Revised: 11/05/2007] [Accepted: 11/05/2007] [Indexed: 11/17/2022]
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Nutritional recommendations in hematopoietic stem cell transplantation. Nutrition 2008; 24:769-75. [DOI: 10.1016/j.nut.2008.02.021] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2007] [Revised: 02/23/2008] [Accepted: 02/23/2008] [Indexed: 12/16/2022]
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Kuskonmaz B, Yalcin S, Kucukbayrak O, Cetin N, Cetin M, Tezcan I, Uckan D. The effect of glutamine supplementation on hematopoietic stem cell transplant outcome in children: a case-control study. Pediatr Transplant 2008; 12:47-51. [PMID: 18186888 DOI: 10.1111/j.1399-3046.2007.00776.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
HSCT associated morbidity and mortality is usually attributed to high-dose chemotherapy/radiotherapy regimens used for conditioning. Glutamine (Gln), a conditionally essential amino acid during severe catabolic states, has been shown to have favorable effects in patients with malignancies and in those undergoing HSCT. However, controversy exists regarding its routine use. Studies in children investigating gln supplementation are very limited. In the present study, including 21 gln-supplemented and 20 control pediatric patients, gln supplementation was shown to reduce the duration of fever and decrease the incidence of SOS during the HSCT course. In addition, a decrease in drug-related toxicity and a trend toward reduced incidence of severe mucositis were observed.
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Affiliation(s)
- Baris Kuskonmaz
- Department of Pediatric Hematology, Hacettepe University Faculty of Medicine Ihsan, Dogramaci Childrens Hospital, Ankara, Turkey
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Abstract
Oral mucositis continues to be a common and debilitating side effect of the conditioning regimens that use high-dose chemotherapy with or without radiation for pediatric bone marrow transplantation. Limited interventions have demonstrated success in preventing or treating it. Administration of glutamine, which is a nitrogen-rich amino acid found in the body, has emerged as a possible method of preventing oral mucositis in patients undergoing bone marrow transplantation. Numerous studies have looked at the effects of oral glutamine supplementation during bone marrow transplant. The purpose of this article is to describe glutamine and how it functions, review the literature regarding the use of oral glutamine in the prevention of oral mucositis in bone marrow transplantion, discuss the administration concerns related to the pediatric setting, and stress the importance of the nurse's role at the bedside. Nurses working in pediatric bone marrow transplant play a key role in the assessment of oral mucositis, administration of oral glutamine, and education of the patient and family.
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Affiliation(s)
- Beth Storey
- Children's Hospital of Philadelphia on Pediatric Oncology/Bone Marrow Transplant Unit, USA.
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Epstein JB, Klasser GD. Emerging approaches for prophylaxis and management of oropharyngeal mucositis in cancer therapy. Expert Opin Emerg Drugs 2006; 11:353-73. [PMID: 16634706 DOI: 10.1517/14728214.11.2.353] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Oral mucositis is a common treatment-limiting side effect of cancer therapy that may have a significant impact on quality of life and on the cost of care. Oral mucositis is the most distressing complication of cancer therapy as reported by head and neck cancer patients, in patients receiving dose-dense myelosuppressive chemotherapy and in patients receiving haematopoietic stem cell transplant. Mucositis may increase the risk of local and systemic infection, particularly in myelosuppressed patients. Severe oral mucositis can lead to the need to interrupt or discontinue cancer therapy, and thus may impact cure of the primary disease. Current care of patients with mucositis is essentially palliative, and includes appropriate oral hygiene, nonirritating diet and oral care products, topical palliative mouth rinses, topical anaesthetics and use of systemic opioid analgesics. Emerging approaches for prevention and treatment of oral mucositis are developing based on an increasing understanding of the pathobiology of mucosal damage and repair. New interventions are expected to be administered based on the mechanisms of initiation, progression and resolution of the condition. The approval by the FDA of keratinocyte growth factor (palifermin; Amgen) in 2004 represents a new step in prevention of oral mucositis in stem cell transplant patients based on the increasing understanding of the pathogenesis of mucositis. Progress in the prevention and management of mucositis will improve quality of life, reduce cost of care and facilitate completion of more intensive cancer chemotherapy and radiotherapy protocols. Improved management of mucositis may allow implementation of cancer treatment protocols that are currently excessively mucotoxic, but have potentially higher cure rates of the malignant disease.
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Affiliation(s)
- Joel B Epstein
- Department of Oral Medicine and Diagnostic Sciences, University of Illinois at Chicago, College of Dentistry, 801 South Paulina St, MC 838, Chicago, Illinois 60612, USA
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Arends J, Bodoky G, Bozzetti F, Fearon K, Muscaritoli M, Selga G, van Bokhorst-de van der Schueren MAE, von Meyenfeldt M, Zürcher G, Fietkau R, Aulbert E, Frick B, Holm M, Kneba M, Mestrom HJ, Zander A. ESPEN Guidelines on Enteral Nutrition: Non-surgical oncology. Clin Nutr 2006; 25:245-59. [PMID: 16697500 DOI: 10.1016/j.clnu.2006.01.020] [Citation(s) in RCA: 386] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2006] [Accepted: 01/20/2006] [Indexed: 02/06/2023]
Abstract
Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and tube feeding (TF) offers the possibility of increasing or ensuring nutrient intake in cases where normal food intake is inadequate. These guidelines are intended to give evidence-based recommendations for the use of ONS and TF in cancer patients. They were developed by an interdisciplinary expert group in accordance with officially accepted standards, are based on all relevant publications since 1985 and were discussed and accepted in a consensus conference. Undernutrition and cachexia occur frequently in cancer patients and are indicators of poor prognosis. EN should be started if undernutrition already exists or if food intake is markedly reduced for more than 7-10 days. Standard formulae are recommended for EN. Nutritional needs generally are comparable to non-cancer subjects. In cachectic patients metabolic modulators such as progestins, steroids and possibly eicosapentaenoic acid may help to improve nutritional status. EN is indicated preoperatively for 5-7 days in cancer patients undergoing major abdominal surgery. During radiotherapy of head/neck and gastrointestinal regions dietary counselling and ONS prevent weight loss and interruption of radiotherapy. Routine EN is not indicated during (high-dose) chemotherapy.
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Affiliation(s)
- J Arends
- Department of Medical Oncology, Tumor Biology Center, Albert-Ludwigs-Universität, Freiburg, Germany.
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Worthington HV, Clarkson JE, Eden OB. Interventions for preventing oral mucositis for patients with cancer receiving treatment. Cochrane Database Syst Rev 2006:CD000978. [PMID: 16625538 DOI: 10.1002/14651858.cd000978.pub2] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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 The Cochrane Oral Health Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE were searched. Reference lists from relevant articles were scanned and the authors of eligible studies were contacted to identify trials and obtain additional information. Date of most recent searches: April 2004. SELECTION CRITERIA Trials were selected if they met the following criteria: design - random allocation of participants; participants - anyone with cancer receiving chemotherapy or radiotherapy treatment for cancer; interventions - agents prescribed to prevent oral mucositis; outcomes - prevention of mucositis, pain, amount of analgesia, dysphagia, systemic infection, length of hospitalisation, cost and patient quality of life. DATA COLLECTION AND ANALYSIS Information regarding methods, participants, interventions and outcome measures and results were independently extracted, in duplicate, by two review authors. Authors were contacted for details of randomisation and withdrawals and a quality assessment was carried out. The Cochrane Oral Health Group statistical guidelines were followed and risk ratios (RR) calculated using random-effects models. MAIN RESULTS Two hundred and two studies were eligible. One hundred and thirty two were excluded for various reasons, usually as there was no useable information on mucositis. Of the 71 useable studies all had data for mucositis comprising 5217 randomised patients. Interventions evaluated were: acyclovir, allopurinol mouthrinse, aloe vera, amifostine, antibiotic pastille or paste, benzydamine, beta carotene, calcium phosphate, camomile, chlorhexidine, clarithromycin, folinic acid, glutamine, GM-CSF, honey, hydrolytic enzymes, ice chips, iseganan, keratinocyte GF, misonidazole, oral care, pentoxifylline, povidone, prednisone, propantheline, prostaglandin, sucralfate, traumeel and zinc sulphate. Of the 29 interventions included in trials, 10 showed some evidence of a benefit (albeit sometimes weak) for either preventing or reducing the severity of mucositis. Interventions where there was more than one trial in the meta-analysis finding a significant difference when compared with a placebo or no treatment were: amifostine which provided minimal benefit in preventing moderate and severe mucositis RR = 0.84 (95% confidence interval (CI) 0.75 to 0.95) and 0.60 (95% CI 0.37 to 0.97), antibiotic paste or pastille demonstrated a moderate benefit in preventing mucositis RR = 0.87 (95% CI 0.79 to 0.97), hydrolytic enzymes reduced moderate and severe mucositis with RRs = 0.52 (95% CI 0.36 to 0.74) and 0.17 (95% CI 0.06 to 0.52), and ice chips prevented mucositis at all levels RR = 0.63 (95% CI 0.44 to 0.91), 0.43 (95% CI 0.23 to 0.81), 0.27 (95% CI 0.11 to 0.68). Other interventions showing some benefit with only one study were: benzydamine, calcium phosphate, honey, oral care protocols, povidone and zinc sulphate. The number needed to treat (NNT) to prevent one patient experiencing moderate or severe mucositis over a baseline incidence of 60% for amifostine is 10 (95% CI 7 to 33), antibiotic paste or pastille 13 (95% CI 8 to 56), hydrolytic enzyme 4 (95% CI 3 to 6) and ice chips 5 (95% CI 3 to 19). When the baseline incidence is 40%/90% the NNTs for amifostine are 16/7, for antibiotic paste or pastille 19/7, for hydrolytic enzyme 5/3 and for ice chips 7/3. The general reporting of RCTs was poor. However, the assessments of the quality of the randomisation improved when the authors provided additional information. AUTHORS' CONCLUSIONS Several of the interventions were found to have some benefit at 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 well designed and conducted trials with sufficient numbers of participants to perform subgroup analyses by type of disease and chemotherapeutic agent.
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Affiliation(s)
- H V Worthington
- School of Dentistry, University of Manchester, MANDEC, Higher Cambridge Street, Manchester, UK, M15 6FH.
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