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Sio TT, Le-Rademacher JG, Leenstra JL, Loprinzi CL, Rine G, Curtis A, Singh AK, Martenson JA, Novotny PJ, Tan AD, Qin R, Ko SJ, Reiter PL, Miller RC. Effect of Doxepin Mouthwash or Diphenhydramine-Lidocaine-Antacid Mouthwash vs Placebo on Radiotherapy-Related Oral Mucositis Pain: The Alliance A221304 Randomized Clinical Trial. JAMA 2019; 321:1481-1490. [PMID: 30990550 PMCID: PMC6484809 DOI: 10.1001/jama.2019.3504] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
IMPORTANCE Oral mucositis causes substantial morbidity during head and neck radiotherapy. In a randomized study, doxepin mouthwash was shown to reduce oral mucositis-related pain. A common mouthwash comprising diphenhydramine-lidocaine-antacid is also widely used. OBJECTIVE To evaluate the effect of doxepin mouthwash or diphenhydramine-lidocaine-antacid mouthwash for the treatment of oral mucositis-related pain. DESIGN, SETTING, AND PARTICIPANTS A phase 3 randomized trial was conducted from November 1, 2014, to May 16, 2016, at 30 US institutions and included 275 patients who underwent definitive head and neck radiotherapy, had an oral mucositis pain score of 4 points or greater (scale, 0-10), and were followed up for a maximum of 28 days. INTERVENTIONS Ninety-two patients were randomized to doxepin mouthwash (25 mg/5 mL water); 91 patients to diphenhydramine-lidocaine-antacid; and 92 patients to placebo. MAIN OUTCOME AND MEASURES The primary end point was total oral mucositis pain reduction (defined by the area under the curve and adjusted for baseline pain score) during the 4 hours after a single dose of doxepin mouthwash or diphenhydramine-lidocaine-antacid mouthwash compared with a single dose of placebo. The minimal clinically important difference was a 3.5-point change. The secondary end points included drowsiness, unpleasant taste, and stinging or burning. All scales ranged from 0 (best) to 10 (worst). RESULTS Among the 275 patients randomized (median age, 61 years; 58 [21%] women), 227 (83%) completed treatment per protocol. Mucositis pain during the first 4 hours decreased by 11.6 points in the doxepin mouthwash group, by 11.7 points in the diphenhydramine-lidocaine-antacid mouthwash group, and by 8.7 points in the placebo group. The between-group difference was 2.9 points (95% CI, 0.2-6.0; P = .02) for doxepin mouthwash vs placebo and 3.0 points (95% CI, 0.1-5.9; P = .004) for diphenhydramine-lidocaine-antacid mouthwash vs placebo. More drowsiness was reported with doxepin mouthwash vs placebo (by 1.5 points [95% CI, 0-4.0]; P = .03), unpleasant taste (by 1.5 points [95% CI, 0-3.0]; P = .002), and stinging or burning (by 4.0 points [95% CI, 2.5-5.0]; P < .001). Maximum grade 3 adverse events for the doxepin mouthwash occurred in 3 patients (4%); diphenhydramine-lidocaine-antacid mouthwash, 3 (4%); and placebo, 2 (2%). Fatigue was reported by 5 patients (6%) in the doxepin mouthwash group and no patients in the diphenhydramine-lidocaine-antacid mouthwash group. CONCLUSIONS AND RELEVANCE Among patients undergoing head and neck radiotherapy, the use of doxepin mouthwash or diphenhydramine-lidocaine-antacid mouthwash vs placebo significantly reduced oral mucositis pain during the first 4 hours after administration; however, the effect size was less than the minimal clinically important difference. Further research is needed to assess longer-term efficacy and safety for both mouthwashes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02229539.
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Affiliation(s)
- Terence T. Sio
- Department of Radiation Oncology, Mayo Clinic Hospital, Phoenix, Arizona
| | | | | | | | - Grant Rine
- Wichita National Cancer Institute Community Oncology Research Program, Wichita, Kansas
| | - Amarinthia Curtis
- Southeast Clinical Oncology Research Consortium National Cancer Institute Community Oncology Research Program, Spartanburg, South Carolina
| | | | | | - Paul J. Novotny
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, Minnesota
| | - Angelina D. Tan
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, Minnesota
| | - Rui Qin
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, Minnesota
| | - Stephen J. Ko
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | | | - Robert C. Miller
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
- Now with the University of Maryland School of Medicine, Baltimore
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Leenstra JL, Miller RC, Qin R, Martenson JA, Dornfeld KJ, Bearden JD, Puri DR, Stella PJ, Mazurczak MA, Klish MD, Novotny PJ, Foote RL, Loprinzi CL. Doxepin rinse versus placebo in the treatment of acute oral mucositis pain in patients receiving head and neck radiotherapy with or without chemotherapy: a phase III, randomized, double-blind trial (NCCTG-N09C6 [Alliance]). J Clin Oncol 2014; 32:1571-7. [PMID: 24733799 DOI: 10.1200/jco.2013.53.2630] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
PURPOSE Painful oral mucositis (OM) is a significant toxicity during radiotherapy for head and neck cancers. The aim of this randomized, double-blind, placebo-controlled trial was to test the efficacy of doxepin hydrochloride in the reduction of radiotherapy-induced OM pain. PATIENTS AND METHODS In all, 155 patients were randomly allocated to a doxepin oral rinse or a placebo for the treatment of radiotherapy-related OM pain. Patients received a single dose of doxepin or placebo on day 1 and then crossed over to receive the opposite agent on a subsequent day. Pain questionnaires were administered at baseline and at 5, 15, 30, 60, 120, and 240 minutes. Patients were then given the option to continue doxepin. The primary end point was pain reduction as measured by the area under the curve (AUC) of the pain scale using data from day 1. RESULTS Primary end point analysis revealed that the AUC for mouth and throat pain reduction was greater for doxepin (-9.1) than for placebo (-4.7; P < .001). Crossover analysis of patients completing both phases confirmed that patients experienced greater mouth and throat pain reduction with doxepin (intrapatient changes of 4.1 for doxepin-placebo arm and -2.8 for placebo-doxepin arm; P < .001). Doxepin was associated with more stinging or burning, unpleasant taste, and greater drowsiness than the placebo rinse. More patients receiving doxepin expressed a desire to continue treatment than did patients with placebo after completion of each of the randomized phases of the study. CONCLUSION A doxepin rinse diminishes OM pain. Further studies are warranted to determine its role in the management of OM.
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Affiliation(s)
- James L Leenstra
- James L. Leenstra, St Vincent Regional Cancer Center, Green Bay, WI; Robert C. Miller, Rui Qin, James A. Martenson, Paul J. Novotny, Robert L. Foote, and Charles L. Loprinzi, Mayo Clinic, Rochester; Kenneth J. Dornfeld, Essentia Health Cancer Center, Duluth, MN; James D. Bearden, Palmetto Hematology Oncology, Spartanburg, SC; Dev R. Puri, Mercy Cancer Center, Des Moines, IA; Philip J. Stella, St Joseph Mercy Cancer Care Center, Ann Arbor, MI; Miroslaw A. Mazurczak, Sandford Health Cancer Center, Sioux Falls, SD; and Marie D. Klish, Hope Cancer Center, Longmont, CO
| | - Robert C Miller
- James L. Leenstra, St Vincent Regional Cancer Center, Green Bay, WI; Robert C. Miller, Rui Qin, James A. Martenson, Paul J. Novotny, Robert L. Foote, and Charles L. Loprinzi, Mayo Clinic, Rochester; Kenneth J. Dornfeld, Essentia Health Cancer Center, Duluth, MN; James D. Bearden, Palmetto Hematology Oncology, Spartanburg, SC; Dev R. Puri, Mercy Cancer Center, Des Moines, IA; Philip J. Stella, St Joseph Mercy Cancer Care Center, Ann Arbor, MI; Miroslaw A. Mazurczak, Sandford Health Cancer Center, Sioux Falls, SD; and Marie D. Klish, Hope Cancer Center, Longmont, CO.
| | - Rui Qin
- James L. Leenstra, St Vincent Regional Cancer Center, Green Bay, WI; Robert C. Miller, Rui Qin, James A. Martenson, Paul J. Novotny, Robert L. Foote, and Charles L. Loprinzi, Mayo Clinic, Rochester; Kenneth J. Dornfeld, Essentia Health Cancer Center, Duluth, MN; James D. Bearden, Palmetto Hematology Oncology, Spartanburg, SC; Dev R. Puri, Mercy Cancer Center, Des Moines, IA; Philip J. Stella, St Joseph Mercy Cancer Care Center, Ann Arbor, MI; Miroslaw A. Mazurczak, Sandford Health Cancer Center, Sioux Falls, SD; and Marie D. Klish, Hope Cancer Center, Longmont, CO
| | - James A Martenson
- James L. Leenstra, St Vincent Regional Cancer Center, Green Bay, WI; Robert C. Miller, Rui Qin, James A. Martenson, Paul J. Novotny, Robert L. Foote, and Charles L. Loprinzi, Mayo Clinic, Rochester; Kenneth J. Dornfeld, Essentia Health Cancer Center, Duluth, MN; James D. Bearden, Palmetto Hematology Oncology, Spartanburg, SC; Dev R. Puri, Mercy Cancer Center, Des Moines, IA; Philip J. Stella, St Joseph Mercy Cancer Care Center, Ann Arbor, MI; Miroslaw A. Mazurczak, Sandford Health Cancer Center, Sioux Falls, SD; and Marie D. Klish, Hope Cancer Center, Longmont, CO
| | - Kenneth J Dornfeld
- James L. Leenstra, St Vincent Regional Cancer Center, Green Bay, WI; Robert C. Miller, Rui Qin, James A. Martenson, Paul J. Novotny, Robert L. Foote, and Charles L. Loprinzi, Mayo Clinic, Rochester; Kenneth J. Dornfeld, Essentia Health Cancer Center, Duluth, MN; James D. Bearden, Palmetto Hematology Oncology, Spartanburg, SC; Dev R. Puri, Mercy Cancer Center, Des Moines, IA; Philip J. Stella, St Joseph Mercy Cancer Care Center, Ann Arbor, MI; Miroslaw A. Mazurczak, Sandford Health Cancer Center, Sioux Falls, SD; and Marie D. Klish, Hope Cancer Center, Longmont, CO
| | - James D Bearden
- James L. Leenstra, St Vincent Regional Cancer Center, Green Bay, WI; Robert C. Miller, Rui Qin, James A. Martenson, Paul J. Novotny, Robert L. Foote, and Charles L. Loprinzi, Mayo Clinic, Rochester; Kenneth J. Dornfeld, Essentia Health Cancer Center, Duluth, MN; James D. Bearden, Palmetto Hematology Oncology, Spartanburg, SC; Dev R. Puri, Mercy Cancer Center, Des Moines, IA; Philip J. Stella, St Joseph Mercy Cancer Care Center, Ann Arbor, MI; Miroslaw A. Mazurczak, Sandford Health Cancer Center, Sioux Falls, SD; and Marie D. Klish, Hope Cancer Center, Longmont, CO
| | - Dev R Puri
- James L. Leenstra, St Vincent Regional Cancer Center, Green Bay, WI; Robert C. Miller, Rui Qin, James A. Martenson, Paul J. Novotny, Robert L. Foote, and Charles L. Loprinzi, Mayo Clinic, Rochester; Kenneth J. Dornfeld, Essentia Health Cancer Center, Duluth, MN; James D. Bearden, Palmetto Hematology Oncology, Spartanburg, SC; Dev R. Puri, Mercy Cancer Center, Des Moines, IA; Philip J. Stella, St Joseph Mercy Cancer Care Center, Ann Arbor, MI; Miroslaw A. Mazurczak, Sandford Health Cancer Center, Sioux Falls, SD; and Marie D. Klish, Hope Cancer Center, Longmont, CO
| | - Philip J Stella
- James L. Leenstra, St Vincent Regional Cancer Center, Green Bay, WI; Robert C. Miller, Rui Qin, James A. Martenson, Paul J. Novotny, Robert L. Foote, and Charles L. Loprinzi, Mayo Clinic, Rochester; Kenneth J. Dornfeld, Essentia Health Cancer Center, Duluth, MN; James D. Bearden, Palmetto Hematology Oncology, Spartanburg, SC; Dev R. Puri, Mercy Cancer Center, Des Moines, IA; Philip J. Stella, St Joseph Mercy Cancer Care Center, Ann Arbor, MI; Miroslaw A. Mazurczak, Sandford Health Cancer Center, Sioux Falls, SD; and Marie D. Klish, Hope Cancer Center, Longmont, CO
| | - Miroslaw A Mazurczak
- James L. Leenstra, St Vincent Regional Cancer Center, Green Bay, WI; Robert C. Miller, Rui Qin, James A. Martenson, Paul J. Novotny, Robert L. Foote, and Charles L. Loprinzi, Mayo Clinic, Rochester; Kenneth J. Dornfeld, Essentia Health Cancer Center, Duluth, MN; James D. Bearden, Palmetto Hematology Oncology, Spartanburg, SC; Dev R. Puri, Mercy Cancer Center, Des Moines, IA; Philip J. Stella, St Joseph Mercy Cancer Care Center, Ann Arbor, MI; Miroslaw A. Mazurczak, Sandford Health Cancer Center, Sioux Falls, SD; and Marie D. Klish, Hope Cancer Center, Longmont, CO
| | - Marie D Klish
- James L. Leenstra, St Vincent Regional Cancer Center, Green Bay, WI; Robert C. Miller, Rui Qin, James A. Martenson, Paul J. Novotny, Robert L. Foote, and Charles L. Loprinzi, Mayo Clinic, Rochester; Kenneth J. Dornfeld, Essentia Health Cancer Center, Duluth, MN; James D. Bearden, Palmetto Hematology Oncology, Spartanburg, SC; Dev R. Puri, Mercy Cancer Center, Des Moines, IA; Philip J. Stella, St Joseph Mercy Cancer Care Center, Ann Arbor, MI; Miroslaw A. Mazurczak, Sandford Health Cancer Center, Sioux Falls, SD; and Marie D. Klish, Hope Cancer Center, Longmont, CO
| | - Paul J Novotny
- James L. Leenstra, St Vincent Regional Cancer Center, Green Bay, WI; Robert C. Miller, Rui Qin, James A. Martenson, Paul J. Novotny, Robert L. Foote, and Charles L. Loprinzi, Mayo Clinic, Rochester; Kenneth J. Dornfeld, Essentia Health Cancer Center, Duluth, MN; James D. Bearden, Palmetto Hematology Oncology, Spartanburg, SC; Dev R. Puri, Mercy Cancer Center, Des Moines, IA; Philip J. Stella, St Joseph Mercy Cancer Care Center, Ann Arbor, MI; Miroslaw A. Mazurczak, Sandford Health Cancer Center, Sioux Falls, SD; and Marie D. Klish, Hope Cancer Center, Longmont, CO
| | - Robert L Foote
- James L. Leenstra, St Vincent Regional Cancer Center, Green Bay, WI; Robert C. Miller, Rui Qin, James A. Martenson, Paul J. Novotny, Robert L. Foote, and Charles L. Loprinzi, Mayo Clinic, Rochester; Kenneth J. Dornfeld, Essentia Health Cancer Center, Duluth, MN; James D. Bearden, Palmetto Hematology Oncology, Spartanburg, SC; Dev R. Puri, Mercy Cancer Center, Des Moines, IA; Philip J. Stella, St Joseph Mercy Cancer Care Center, Ann Arbor, MI; Miroslaw A. Mazurczak, Sandford Health Cancer Center, Sioux Falls, SD; and Marie D. Klish, Hope Cancer Center, Longmont, CO
| | - Charles L Loprinzi
- James L. Leenstra, St Vincent Regional Cancer Center, Green Bay, WI; Robert C. Miller, Rui Qin, James A. Martenson, Paul J. Novotny, Robert L. Foote, and Charles L. Loprinzi, Mayo Clinic, Rochester; Kenneth J. Dornfeld, Essentia Health Cancer Center, Duluth, MN; James D. Bearden, Palmetto Hematology Oncology, Spartanburg, SC; Dev R. Puri, Mercy Cancer Center, Des Moines, IA; Philip J. Stella, St Joseph Mercy Cancer Care Center, Ann Arbor, MI; Miroslaw A. Mazurczak, Sandford Health Cancer Center, Sioux Falls, SD; and Marie D. Klish, Hope Cancer Center, Longmont, CO
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