The efficacy of sodium azulene sulfonate L-glutamine for managing chemotherapy-induced oral mucositis in cancer patients: a prospective comparative study

Clinical and biochemical assessment of the effect of glutamine in management of radiation induced oral mucositis in patients with head and neck cancer: Randomized controlled clinical trial

BACKGROUND

This study aimed to evaluate the effect of oral glutamine suspension on salivary levels of transforming growth factor beta 1 (TGF-β1), a cytokine involved in inflammation and Tumor progression, and the severity of radiation-induced oral mucositis (RIOM) in head and neck cancer patients. This is the first study to investigate the impact of glutamine on TGF-β1 levels in head and neck cancer patients with radiation induced oral mucositis (RIOM).

METHODS

In this randomized controlled clinical trial, 50 HNC patients were enrolled and received either glutamine oral suspension or maltodextrin as a placebo from the baseline of RIOM to the end of radiotherapy. Salivary TGF-β1 levels were measured at baseline and after treatment. Also, RIOM was assessed using the World Health Organization (WHO) Oral Toxicity Scale, the Oral Mucositis Assessment Scale (OMAS), the Pain Visual Analog Scale (Pain-VAS), the incidence of opioid use, and body mass index (BMI).

RESULTS

Glutamine significantly reduced salivary TGF-β1 levels and improved RIOM symptoms, such as pain, opioid use, and weight loss. The reduction of TGF-β1 levels was associated with the improvement of RIOM severity.

CONCLUSION

Glutamine may modulate the inflammatory response and enhance wound healing in RIOM by decreasing salivary TGF-β1 levels. These findings support the use of glutamine as a potential intervention for RIOM and nutritional support for improving radiation sensitivity.

TRIAL REGISTRATION

This study was registered on clinicalTrials.gov with identifier no. NCT05856188.

Effect of Photobiomodulation on Salivary Cytokines in Head and Neck Cancer Patients with Oral Mucositis: A Systematic Review

Background: Oral mucositis is a common and distressing side effect of head and neck oncology treatment. Photobiomodulation therapy can be utilized to prevent and treat oral mucositis. Its impact on salivary cytokines has yet to be thoroughly investigated. This is the first systematic review aiming to evaluate the effect of photobiomodulation on salivary cytokines in patients undergoing anticancer treatment. Methods: Numerous data resources, from the Web of Science, Embase, ScienceDirect, PubMed, Cochrane Library, and Scopus were sought. Articles published up until February 2024 were included if they met the following inclusion criteria: clinical trials reporting the effect on salivary cytokines in patients undergoing anticancer therapy. The methodological quality was assessed using several appraisal tools. Results: Four studies were deemed eligible for inclusion. All the studies were conducted in Brazil and used an InGaAlP diode laser with a wavelength of 660 nm. The included studies had a relatively low risk of bias. The head and neck cancer patients' salivary cytokines that were assessed by the studies, along with photobiomodulation therapy, included IL-12p70, TNF-α, IL-6, IL-8, IL-10, CXCL8, and IL-1β. The results varied among the studies. Conclusions: Our results show that photobiomodulation demonstrated positive results for reducing the severity of OM in all the included studies. Among the examined salivary cytokines, IL-6 is the most relevant cytokine for oral mucositis development and severity. A variation in the cytokine levels between the studies was noted due to differences in the type of anticancer treatment and saliva sampling.

Nutritional interventions for the prevention and treatment of cancer therapy-induced oral mucositis: an umbrella review of systematic reviews and meta-analysis

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.

Correlations between the severity of radiation-induced oral mucositis and salivary epidermal growth factor as well as inflammatory cytokines in patients with head and neck cancer

BACKGROUND

This study aimed to investigate correlations of the severity of radiation-induced oral mucositis (RIOM) with epidermal growth factor (EGF) and inflammatory cytokines in patients with head and neck cancer (HNC).

METHODS

Levels of inflammatory cytokines and EGF in saliva of HNC patients were measured. Correlations of inflammatory cytokines and EGF levels with RIOM severity and pain degree, and their diagnostic values on RIOM severity were determined.

RESULTS

Elevated IFN-γ, TNF-α, IL-2, and IL-6 levels, and reduced IL-4, IL-10, and EGF levels were found in patients with severe RIOM. IFN-γ, TNF-α, IL-2, and IL-6 were positively correlated with RIOM severity, while IL-10, IL-4, and EGF were negatively correlated with it. All factors were effective in predicting the severity of RIOM.

CONCLUSION

IFN-γ, TNF-α, IL-2, and IL-6 in saliva of patients with HNC are positively correlated with the severity of RIOM, and IL-4, IL-10, and EGF were negatively correlated with it.

Effects of various treatments for preventing oral mucositis in cancer patients: A network meta-analysis

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.

Integrative Medicine for Pain Management in Oncology: Society for Integrative Oncology-ASCO Guideline

PURPOSE

The aim of this joint guideline is to provide evidence-based recommendations to practicing physicians and other health care providers on integrative approaches to managing pain in patients with cancer.

METHODS

The Society for Integrative Oncology and ASCO convened an expert panel of integrative oncology, medical oncology, radiation oncology, surgical oncology, palliative oncology, social sciences, mind-body medicine, nursing, and patient advocacy representatives. The literature search included systematic reviews, meta-analyses, and randomized controlled trials published from 1990 through 2021. Outcomes of interest included pain intensity, symptom relief, and adverse events. Expert panel members used this evidence and informal consensus to develop evidence-based guideline recommendations.

RESULTS

The literature search identified 227 relevant studies to inform the evidence base for this guideline.

RECOMMENDATIONS

Among adult patients, acupuncture should be recommended for aromatase inhibitor-related joint pain. Acupuncture or reflexology or acupressure may be recommended for general cancer pain or musculoskeletal pain. Hypnosis may be recommended to patients who experience procedural pain. Massage may be recommended to patients experiencing pain during palliative or hospice care. These recommendations are based on an intermediate level of evidence, benefit outweighing risk, and with moderate strength of recommendation. The quality of evidence for other mind-body interventions or natural products for pain is either low or inconclusive. There is insufficient or inconclusive evidence to make recommendations for pediatric patients. More research is needed to better characterize the role of integrative medicine interventions in the care of patients with cancer.Additional information is available at https://integrativeonc.org/practice-guidelines/guidelines and www.asco.org/survivorship-guidelines.

A Narrative Review about Nutritional Management and Prevention of Oral Mucositis in Haematology and Oncology Cancer Patients Undergoing Antineoplastic Treatments

Cancer is a prevalent disease worldwide, and treatments such as radiotherapy and chemotherapy sometimes lead to adverse events. Oral mucositis is one of the most disabling adverse events, and clinical guidelines do not take into account nutritional interventions. The primary endpoint was to gather the evidence about the efficacy of nutritional interventions in the prevention and/or treatment of antineoplastic-induced oral mucositis in oncological patients. A bibliographic review was carried out in the PubMed data base by combining MeSH terms with Boolean operators. Articles were selected based on inclusion and exclusion criteria; 50 final articles were found. Although further evidence is needed, glutamine, honey, and vitamins appear to be good therapeutic options. The rest of the compounds presented controversial or insufficient results, making it difficult to draw conclusions over their utilization as prevention or treatment options. Little evidence is reported about oral mucositis nutritional interventions in spite of them being attainable and affordable compounds. Scarce evidence is shown in paediatric patients compared with adults. Developing higher quality studies and combinations with the compounds researched is necessary for creating a stronger body of evidence.

Spondias pinnata bark extract- an ameliorator of inflammatory derangement in etoposide induced mucositis: An experimental approach

Background and Aim:

Mucositis, one of the vulnerabilities of chemotherapy, affects the physiological activities and therapeutic strategies of patients because it can affect the normal cell population. Etoposide is a commonly used chemotherapeutic agent for cancers such as oral, lung, and gastrointestinal. In addition to the abnormal metabolic processes in the body caused by tumorigenesis, new metabolic alterations can occur, such as oxidative stress, antioxidant imbalance, and inflammatory reactions, all of which can contribute to existing patient vulnerability. Therapeutic adjuvants can help overcome these toxic effects. Spondias pinnata is a tropical tree omnipresent in the coastal and Western Ghat section of India that is used for culinary purposes and as a local analgesic. Therefore, we aimed to study the anti-inflammatory effects of S. pinnata in an etoposide-induced mucositis rat model.

Materials and Methods:

Small intestinal tissue homogenates from albino Wistar rats were used to estimate the levels of glutathione (GSH) and nitric oxide (NO), and activities of total antioxidant (TAO), myeloperoxidase (MPO) and Na⁺-K⁺ ATPase. The animals were grouped into: (1) normal control, (2) etoposide-induced mucositis (65 mg/kg bodyweight, single IP dose), (3) S. pinnata control group, and (4) etoposide followed by S. pinnata bark extract (200 mg/kg bodyweight, once in a day). Animals were sacrificed after 24, 48, 72, and 96 h and compared with that of the normal control group (n=6). Statistical analysis was performed using EZR software.

Results:

We observed a significant decrease in the TAO and GSH levels with a marked increase in NO, MPO, and Na⁺-K⁺ ATPase activity in the mucositis group. A tendency to recover from the decreased TAO and GSH levels existed in the treated group, showing the protective effects of S. pinnata bark extract against mucositis. In addition, this extract also showed anti-inflammatory effects as reflected by the recovery in MPO levels at the end of 96 h. Maintenance of Na⁺-K⁺ ATPase activity in the treated group demonstrates the protective effects of the extract against the increased levels observed in the etoposide-induced mucositis group.

Conclusion:

This study revealed the protective effects of S. pinnata bark extract against the oxidative and inflammatory changes that occurred during the development ofmucositis. This would decrease the pathological burden during chemotherapy and prevent any hurdles in therapeutic modalities.

Role of Glutamine in the Management of Oral Mucositis in Patients with Cancer: A Meta-Analysis of Randomized Controlled Trials

As the effectiveness of glutamine supplementation for oral mucositis (OM) in patients with cancer remains controversial, a comprehensive summary and analysis of available evidence is necessary. The aim of the present meta-analysis was to evaluate the benefits of glutamine supplementation on OM and OM-related adverse reactions in patients with cancer receiving chemotherapy (CT) and/or radiotherapy (RT), using data from randomized controlled trials (RCTs). The PubMed, Embase, Cochrane Library, and Web of Science databases were searched for RCTs on the use of glutamine for treating OM, published until September 11, 2020. Risk ratios (RRs) or standardized mean differences (SMDs) and 95% confidence intervals (CI) were calculated using RevMan 5.3. Fifteen studies with 988 participants were included. Glutamine did not reduce the incidence of OM (RR 0.94), but it reduced the severity of OM (SMD -0.73) and incidence of severe OM (RR 0.41). Additionally, glutamine reduced the incidence of opioid analgesic use (RR 0.84), feeding tube use (RR 0.46), hospitalization (RR 0.39), and treatment interruption (RR 0.49) caused by OM. Glutamine effectively improved OM and reduced OM-related adverse reactions in patients with cancer receiving CT and/or RT.

In vitro and in vivo biological activities of azulene derivatives with potential applications in medicine

Azulene is an aromatic hydrocarbon that possesses a unique chemical structure and interesting biological properties. Azulene derivatives, including guaiazulene or chamazulene, occur in nature as components of many plants and mushrooms, such as Matricaria chamomilla, Artemisia absinthium, Achillea millefolium, and Lactarius indigo. Due to physicochemical properties, azulene and its derivatives have found many potential applications in technology, especially in optoelectronic devices. In medicine, the ingredients of these plants have been widely used for hundreds of years in antiallergic, antibacterial, and anti-inflammatory therapies. Herein, the applications of azulene, its derivatives and their conjugates with biologically active compounds are presented. The potential use of these compounds concerns various areas of medicine, including anti-inflammatory with peptic ulcers, antineoplastic with leukemia, antidiabetes, antiretroviral with HIV-1, antimicrobial, including antimicrobial photodynamic therapy, and antifungal.

Effect of Different Irradiation Modes of Azulene-mediated Photodynamic Therapy on Singlet Oxygen and PGE2 Formation

Azulene samples in ethanol/distilled water (1, 10 and 100 µm) were irradiated with a 638 nm red laser (0.5 watts, light-to-target distance 2 cm, energy density 4 or 40 J cm^-2 ) by either continuous, fractionation or pulse mode. Singlet oxygen in the samples was measured using 10 µm 9,10-dimethyl anthracene (positive control 10 μm erythrosine) and relative fluorescence intensities were measured at 375/436 nm excitation/emission. Peripheral blood mononuclear cells (PBMCs, 1 × 10⁵ cells/well) preincubated with 0.01 μg mL^-1 rhTNF-α for 6 h were cultured with irradiated azulene samples in RPMI-1640 under standard conditions. PGE₂ was quantified by rhPGE₂ ELISA kit using a Varioscan® microplate reader at an excitation wavelength of 420 nm. Kruskal Wallis with Dunn`s test was performed at a significance level of P < 0.05. The highest singlet oxygen amount was found in 10 µm azulene samples irradiated at 40 J cm^-2 under continuous mode (P = 0.001 when compared with 10 µm erythrosine). PGE₂ expression in rhTNF-α-induced PBMCs was reduced to 45% of control by 1 µm azulene irradiated at 40 J cm^-2 under fractionation mode. Fractionation mode with intermediate laser energy density in the presence of low concentration of azulene could increase singlet oxygen and tend to reduce PGE₂ .

Effects of Immunonutrition on Chemoradiotherapy Patients: A Systematic Review and Meta-Analysis

OBJECTIVE

We conducted a systematic review to assess the effects of immunonutrition on chemoradiotherapy patients.

METHODS

We searched the Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, CINAHL, and the Web of Science. We assessed the risk of bias using the Cochrane Risk of Bias tool. Our primary outcomes were the incidence of oral mucositis and diarrhea. The secondary outcomes were the incidence of esophagitis, grade ≥3 oral mucositis, grade ≥3 diarrhea, grade ≥3 esophagitis, and body weight loss.

RESULTS

A total of 1478 patients and 27 studies were included. There were no significant differences in the incidence of oral mucositis (relative risk [RR] = 0.91; 95% confidence interval [CI], 0.79-1.05), diarrhea (RR = 0.89; 95% CI, 0.76-1.05), or esophagitis (RR = 0.55; 95% CI, 0.11-2.86) between the immunonutrition group and standard nutrition/placebo group. Nevertheless, immunonutrition significantly reduced the incidence of grade ≥3 oral mucositis (RR = 0.45; 95% CI, 0.22-0.92), grade ≥3 diarrhea (RR = 0.56; 95% CI, 0.35-0.88), grade ≥3 esophagitis (RR = 0.15; 95% CI, 0.04-0.54), and losing >5% body weight (RR = 0.34; 95% CI, 0.18-0.64).

CONCLUSIONS

In this study, immunonutrition failed to reduce the incidence rates of oral mucositis, diarrhea, or esophagitis but was conducive to significantly improving the severity of oral mucositis and diarrhea esophagitis and reducing the rate of body weight loss.

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

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.