Efficacy and safety of transdermal fentanyl for treatment of oral mucositis pain caused by chemotherapy

Efficacy of Continuous Intravenous Fentanyl for Oral Mucosal Pain in Stevens-Johnson Syndrome: A Case Report

The management of oral mucosal pain in Stevens-Johnson syndrome (SJS), known for its severe mucocutaneous reactions, is a significant challenge due to the paucity of effective treatments reported in the literature. This case report aims to help fill this gap by describing the effective use of continuous intravenous fentanyl for the relief of severe oral mucosal pain in a patient with SJS. A patient with postoperative recurrence of cervical cancer developed SJS following chemotherapy. She had severe oral mucosal pain that was not relieved by 12.5 mcg/hour fentanyl transdermal patch, a regular medication. This pain was rated 10/10 on the Numerical Pain Rating Scale (NRS), and the patient had dysphagia and difficulty speaking. On admission, intravenous methylprednisolone (1000 mg/day), oral lip treatment with dexamethasone ointment, and oral rinses with azulene-lidocaine mixture were started. Analgesic treatment consisted of a 12.5 mcg/hour fentanyl transdermal patch of the regular medication and 1000 mg/dose of intravenous acetaminophen twice daily. Due to the inadequate efficacy of the transdermal patch, fentanyl was switched from the transdermal patch to a continuous intravenous fentanyl infusion at 20 mcg/hour on day three of admission. This adjustment significantly reduced pain intensity, which decreased to NRS 5/10 on day six of admission, and the patient was able to drink water and speak. Pain relief preceded clinical improvement of stomatitis. Grade 1 somnolence occurred after the start of intravenous fentanyl, but improved with follow-up. There were no other adverse effects such as respiratory depression. This case highlights the potential of intravenous fentanyl in the treatment of oral mucosal pain associated with SJS, although further studies are needed to confirm these findings and to develop comprehensive pain management protocols.

Glutamine for Amelioration of Radiation and Chemotherapy Associated Mucositis during Cancer Therapy

Glutamine is a major dietary amino acid that is both a fuel and nitrogen donor for healing tissues damaged by chemotherapy and radiation. Evidence supports the benefit of oral (enteral) glutamine to reduce symptoms and improve and/or maintain quality of life of cancer patients. Benefits include not only better nutrition, but also decreased mucosal damage (mucositis, stomatitis, pharyngitis, esophagitis, and enteritis). Glutamine supplementation in a high protein diet (10 grams/day) + disaccharides, such as sucrose and/or trehalose, is a combination that increases glutamine uptake by mucosal cells. This increased topical effect can reduce painful mucosal symptoms and ulceration associated with chemotherapy and radiation in the head and neck region, esophagus, stomach and small intestine. Topical and oral glutamine seem to be the preferred routes for this amino acid to promote mucosal healing during and after cancer treatment.

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.

Potential Therapeutic Effects of Gut Hormones, Ghrelin and Obestatin in Oral Mucositis

Chemotherapy and/or head and neck radiotherapy are frequently associated with oral mucositis. Oral pain, odynophagia and dysphagia, opioid use, weight loss, dehydration, systemic infection, hospitalization and introduction of a feeding tube should be mentioned as the main determinated effect of oral mucositis. Oral mucositis leads to a decreased quality of life and an increase in treatment costs. Moreover, oral mucositis is a life-threatening disease. In addition to its own direct life-threatening consequences, it can also lead to a reduced survival due to the discontinuation or dose reduction of anti-neoplasm therapy. There are numerous strategies for the prevention or treatment of oral mucositis; however, their effectiveness is limited and does not correspond to expectations. This review is focused on the ghrelin and obestatin as potentially useful candidates for the prevention and treatment of chemo- or/and radiotherapy-induced oral mucositis.

Head and Neck Cancer Pain

Pain is a significant morbidity resulting from head and neck cancer. Pain may also be the result of the treatments directed against head and neck cancer. An experienced practitioner may manage this pain by understanding the multifactorial mechanisms of pain and the various pharmacotherapies available. Pain should be managed with multiple medications in a multimodal approach, and nonpharmacologic therapies should be considered as well.

Efficacy and safety of transdermal fentanyl for the treatment of oral mucositis pain caused by chemoradiotherapy in patients with esophageal squamous cell carcinoma

PURPOSE

Oral mucositis is one of the most painful side effects found in esophageal squamous cell carcinoma (ESCC) patients treated with chemoradiotherapy. The transdermal route of administration is worthy of investigation for patients who suffer from dysphagia due to severe oral mucositis. In this phase 2 study, we investigated the efficacy and safety of transdermal fentanyl (TDF) for mucositis pain caused by chemoradiotherapy in ESCC patients.

METHODS

Forty-six ESCC patients who experienced moderate to severe oral mucosal pain during chemoradiotherapy received TDF for pain relief. The assessment of pain was made according to the Numeric Rating Scale (NRS). Efficacy and safety of TDF was collected and conducted in an open-label fashion. The analgesic effect, quality of life, and side effects were evaluated after the administration of transdermal fentanyl using the paired sample Wilcoxon signed rank test.

RESULTS

The mucositis-induced pain disappeared in 31 (67.4 %) patients during the treatment with transdermal fentanyl with the median time of onset at day 6.6 (range 3-14). The median Numeric Rating Scale (NRS) score was reduced from 6 (range 3-9) before treatment to 4.5 (range 2-9), 3 (range 2-8), 2.5 (range 1-8), 2 (range 0-6), and 0 (range 0-4) on days 3, 6, 9, 11, and 15, respectively, after treatment (P < 0.001). The patients' quality of life also improved significantly (P < 0.01). The side effects of treatment were mild and disappeared within several days.

CONCLUSION

Transdermal fentanyl is an effective, convenient, and well-tolerated treatment for mucositis pain caused by chemoradiotherapy, which can improve ESCC patients' quality of life.

Transdermal fentanyl for pain due to chemoradiotherapy-induced oral mucositis in nasopharyngeal cancer patients: evaluating efficacy, safety, and improvement in quality of life

This study evaluated the efficacy, safety, and quality of life (QoL) measure of transdermal fentanyl (TDF) for moderate-to-severe pain due to oral mucositis caused by chemoradiotherapy in patients with advanced nasopharyngeal carcinoma (NPC). Patients with NPC who experienced moderate-to-severe oral mucosal pain during chemoradiotherapy (n=78) received TDF for pain relief. Pain relief and QoL were compared before and after treatment. The mean numeric rating scale score was reduced from 7.41±0.96 before treatment to 5.54±0.86, 3.27±0.73, 2.88±0.62, and 2.82±0.68 on days 1, 4, 7, and 10, respectively, after treatment (P<0.001). Karnofsky performance status and SPAASMS (Score for pain, Physical activity levels, Additional pain medication, Additional physician/emergency room visits, Sleep, Mood, and Side effects) scores showed significant improvement after treatment, indicating an improved QoL of patients (both P<0.001). The most common adverse reactions were nausea and vomiting (10.26%). No serious life-threatening adverse events and no symptoms of drug withdrawal were observed. TDF is effective, safe, and improves QoL in treating pain due to oral mucositis caused by chemoradiotherapy in NPC patients.

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.