Sucralfate Prophylaxis of Fluorouracil-Induced Stomatitis

Systematic review of antimicrobials, mucosal coating agents, anesthetics, and analgesics for the management of oral mucositis in cancer patients and clinical practice guidelines

PURPOSE

To update the clinical practice guidelines for the use of antimicrobials, mucosal coating agents, anesthetics, and analgesics 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 9 new papers were identified within the scope of this section, adding to the 62 papers reviewed in this section previously. A new Suggestion was made for topical 0.2% morphine for the treatment of OM-associated pain in head and neck (H&N) cancer patients treated with RT-CT (modification of previous guideline). A previous Recommendation against the use of sucralfate-combined systemic and topical formulation in the prevention of OM in solid cancer treatment with CT was changed from Recommendation Against to No Guideline Possible. Suggestion for doxepin and fentanyl for the treatment of mucositis-associated pain in H&N cancer patients was changed to No Guideline Possible.

CONCLUSIONS

Of the agents studied for the management of OM in this paper, the evidence supports a Suggestion in favor of topical morphine 0.2% in H&N cancer patients treated with RT-CT for the treatment of OM-associated pain.

Systematic review of antimicrobials, mucosal coating agents, anesthetics, and analgesics for the management of oral mucositis in cancer patients

PURPOSE

The aim of this project was to develop clinical practice guidelines on the use of antimicrobials, mucosal coating agents, anesthetics, and analgesics for the prevention and management of oral mucositis (OM) in cancer patients.

METHODS

A systematic review of the available literature was conducted. The body of evidence for the use of each agent, in each setting, was assigned a level of evidence. Based on the evidence level, one of the following three guideline determinations was possible: recommendation, suggestion, or no guideline possible.

RESULTS

A recommendation was developed in favor of patient-controlled analgesia with morphine in hematopoietic stem cell transplant (HSCT) patients. Suggestions were developed in favor of transdermal fentanyl in standard dose chemotherapy and HSCT patients and morphine mouth rinse and doxepin rinse in head and neck radiation therapy (H&N RT) patients. Recommendations were developed against the use of topical antimicrobial agents for the prevention of mucositis. These included recommendations against the use of iseganan for mucositis prevention in HSCT and H&N RT and against the use of antimicrobial lozenges (polymyxin-tobramycin-amphotericin B lozenges/paste and bacitracin-clotrimazole-gentamicin lozenges) for mucositis prevention in H&N RT. Recommendations were developed against the use of the mucosal coating agent sucralfate for the prevention or treatment of chemotherapy-induced or radiation-induced OM. No guidelines were possible for any other agent due to insufficient and/or conflicting evidence.

CONCLUSION

Additional well-designed research is needed on prevention and management approaches for OM.

Managing pain in mucositis

OBJECTIVE

To discuss pharmacologic and nonpharmacologic approaches available to manage pain.

DATA SOURCE

Published journal articles, book chapters, clinical experience.

CONCLUSION

Pain management requires treatment directed at the various factors involved in the pain experience.

IMPLICATIONS FOR NURSING PRACTICE

Nurses need to assess pain daily and follow patients closely until mucositis resolves. Management targeted to specific dimensions of pain can improve the effectiveness of pain control.

Prevention and treatment of chemotherapy- and radiotherapy-induced oral mucositis: a review

Oral mucositis is a distressing toxic effect of systemic chemotherapy with many commonly utilized drugs and of head and neck irradiation in patients with cancer. The agents and methods that have been used and studied in chemotherapy- and radiotherapy-induced oral mucositis, their mechanisms of action, and the current knowledge of their efficiency to reduce the incidence, severity or shorten the duration of oral mucositis are reviewed in this article. Oral cooling is a cheap and available method to lower the severity of bolus 5-fluorouracil-induced oral mucositis. However, more effective methods are needed. Results of studies with granulocyte-macrophage colony-stimulating factor or granulocyte colony-stimulating factor are promising. Lasers are partly beneficial, but equipment-demanding. Modification of the chemotherapy regimen resulting in shortening of the exposition time to chemotherapy agents or chronomodulation of chemotherapy has been shown to lower mucosal toxicity of some regimens. Results of animal studies with locally applied transforming growth factor beta 3 and interleukin-11 are also promising. Based on the findings of the role of the inflammatory cascade in the response of normal tissues to chemotherapy and radiotherapy, anti-inflammatory drugs might be beneficial. At the present time, no agent has been shown to be uniformly efficacious and can be accepted as standard therapy of chemotherapy- and radiotherapy-induced oral mucositis. Further intensive research is needed.