June 2024 Chemotherapy Induced Stomatitis Prevention and Treatment

Hi everyone, my name is Trish and I am an after-hours triage nurse at the clinical call center.

1. What was the knowledge gained from the article?

I work as an after-hours clinical call center triage nurse. I receive many calls from patients from all oncology specialties of the James that complain that mouth sores are very painful causing some of these patients to struggle with hydration and eating. I have even had some patients state that they have had some weight loss and ultimately a delay in treatment from severe mouth sores. I didn’t realize that 40 % of chemotherapy/immunotherapy patients develop OM, 90% in head and neck cancer patients receiving chemotherapy and radiation, and 80% of BMT patients. OM is not only caused by chemotherapy and radiation, but also associated with the newer targeted therapies and immunotherapy as well. I did not realize that these mouth sores can also lead to sepsis, especially in neutropenic patients resulting in hospitalization, delay in treatment and ultimately a poorer prognosis as a result. I knew that this is a painful side effect but did not realize the serious clinical issues with mouth sores.

2. Will the research/information in this article change or influence your practice? If so, how?

I am very aware of MMW combinations with Diphenhydramine, liquid Maalox and lidocaine, sometimes mixed with nystatin instead. I was not aware that a low dose of Morphine can be added, especially for the head and neck patients. I also wasn’t aware that there are lab tests that can predict or indicate which patients are at higher risk for OM. This lab test may be especially helpful for patients that are receiving chemotherapy agents that are known to cause OM especially when in combination with head and neck radiation therapy. The way our on-call program works at the James, a patient that calls in after hours or the weekend, cannot get a new prescription of MMW to treat mucositis without coming in to be seen in ICC, some of the pharmacies don’t have MMW on hand and have to order the components. this can take a few days in some of the outlying areas of Columbus. It would be nice to have this pre-ordered for high-risk patients, so they don’t have to wait days to start treatment for mouth sores.

3. What other questions does the article raise about current practice?

I am not aware of lab testing for prevention of OM and I have not yet seen a prescription for OM that contained morphine suspension in the MMW oral rinses as suggested in the first article. I do know that the chemotherapy infusion nurses have patients use oral cryotherapy (patient putting ice chips in their mouth to vasoconstrict oral mucosal blood vessels which causes reduces perfusion and absorption of chemotherapy agents)

4. Do you agree/disagree with the conclusions of the author, why?

I agree that there is great research in cancer treatments, but not so much in the prevention and treatment of oral mucositis. Since it can be such a devasting side effect and seems to be caused by so many of the cancer treatments that we use, I think it should have more emphasis on preventing and treating this, if not for the reasons already stated, but for the patient’s quality of life.

Thanks for finding the articles and hosting Patricia! My name is Jeff and I am one of the outpatient float pool nurses.

1) What was the knowledge gained from the articles?
These articles were interesting. We ask about mucositis and other sores in our patients mouths but I didn’t know the severity of them. Seeing that 40+% of patient develop mucositis is crazy (Yes, I know that tumor type influences the likelihood and severity) but I feel majority of our patients don’t report OM unless it is head and neck/ radiation patients. I found it interesting that other developed countries in Europe have Benzydamine as an OTC but it is not available at all in the US.

2) Will the research/information in this article change or influence your practice? If so, how?
These articles both will and will not influence my practice. I will be able to talk to providers about how a patient might need magic mouthwash and the current practice about needing to be seen vs them having a prescription available at home/ the struggles of smaller communities outside of Columbus may not the resources to fill these scripts. Outside of these things, my practice will not really be influenced by these articles. I already talk to providers if I look back and see patients have lost weight or aren’t eating or complain about mouth sores. Knowing our resources is a great

3) What other questions does the article raise about current practice?
The 2nd article raises multiple questions for me.
Why don’t we have benzydamine available in the US? Is it an issue where the drug company patent is preventing it/ or is there something in this drug that our FDA doesn’t approve vs FDA equivalent in Europe?
Why aren’t we using keratinocyte growth factor-1 injection or other options mentioned as treatment options?
I know magic mouthwash is difficult to come by in smaller communities or the components are- if using morphine or another analgesic would that make it even more difficult to obtain?
With infection being one of the biggest concerns for patient with OM could there be a cleansing agent/ oral disinfectant associated with magic mouthwash that also wouldn’t burn the patients to use?

4) Do you agree/ disagree with conclusions of author? Why?
I agree with the knowledge presented. I know them doing retroactive studies to review the exact criteria makes obtaining data more difficult. I feel more needs to be done here to help our patients with OM. There are times when the mouth sores are so severe it impacts the course of their treatment regimen and could lead to hospitalizations or other delays in treatment. I would like to see more treatments or therapies available to offer our patients.

1. What was the knowledge gained from the article?

I was very glad to see new research into cryotherapy for mucositis. I know it’s something we have done for years but, last I heard, the evidence was inconclusive. Therefore, I was surprised to find that the evidence supports cryotherapy. That being said, only 14 studies with 1577 patients were included so I don’t know how much of a conclusion we want to draw from this. I remember BMT having a Snow Cone machine in the old building for this very purpose.

2. Will the research/information in this article change or influence your practice? If so how?

We don’t typically use OC for our patients in the clinic, although SSCBC uses scalp cooling for some of their infusion patients. The article discusses using OC for 5-FU, but this isn’t something we use or educate patients about for GI cancers at MMMP infusion. I’m assuming the authors are referring to high-dose 5-FU, while we administer 5-FU at MMMP over 46 hours via a home pump. It’s completely unrealistic to ask someone to use OC for 46 hours! So, no, I likely won’t be making major changes to my practice because it’s not applicable for me.

3. What other questions does the article raise about current practice?

I know the article discussed use of cold during chemotherapy administration, and they mentioned that there is no evidence that OC would be effective for radiation, but would there be an effective method? You can’t exactly eat ice chips during radiation. Would something cold like a popsicle before and after radiation have any effect? Probably not, since the article discusses how OC is most effective with chemotherapy that has a short half-life. Radiation therapy affects cells for a much longer period of time. I appreciate the authors including other guidelines and interventions for reducing radiotherapy-induced OC in their discussion.

4. Do you agree/disagree with the conclusions of the author, why?

The authors were very thorough in their analysis of the data. I agree with their findings. The fact that they assessed OC interventions for mucositis with both solid tumors and hematological cancers and found similar results further reassures me that their findings are accurate. The authors also found that OC decreased other detrimental effects of mucositis such as hospitalizations and requirement of analgesics.

Al-Rudayni, A. H. M., Gopinath, D., Maharajan, M. K., Veettil, S. K., & Menon, R. K. (2021). Efficacy of Oral Cryotherapy in the Prevention of Oral Mucositis Associated with Cancer Chemotherapy: Systematic Review with Meta-Analysis and Trial Sequential Analysis. Current oncology (Toronto, Ont.), 28(4), 2852–2867. https://doi.org/10.3390/curroncol28040250

Jeff,

I agree that it is frustrating when we hear about treatments and/or medications available everywhere except the United States. The FDA exists to protect us but sometimes they take so long they actually cause harm because we are missing out on the latest therapy or treatment. Like you, I wondered why Benzydamine is not available in the US. A quick internet search showed that, in high doses, it has psychoactive effects similar to LSD. I’m guessing the FDA has a high concern for abuse if available OTC in the US.I wish they would at least allow it as a prescription medication.

Hi,

I agree with you that MMW is not the best solution especially for the head and neck patients, it is even further compounded when they are receiving head and neck radiation due to the very thick secretions that cause them to gag and vomit. I wish we had something better to provide for the patients to help them manage the symptoms but sometimes the MMW is effective enough to keep them hydrated and out of the hospital. Our goal in the after-hours triage call center is to help the patients as much as we can while they are at home and to use the observation unit and ICC as a way to help them resolve severe side effects of cancer treatment without lengthy hospital stays and exposures while in the ED and inpatient. I would be very excited to see new research to help these patients have better quality of life and prognosis by being able to continue their treatment. The head and neck patients have the added disadvantage of requiring liquid Pain medications that are not typically in stock at the outlying smaller pharmacies, these pharmacies also do not keep MMW components in stock either. We have been working with the inpatient PCRM’s to make sure that at least the patients that need this type of hard to stock prescriptions, have their post-op/post-discharge prescriptions filled at the James pharmacy before they go home. We have many patients that are discharged on Friday night, drive two hours home to find they can’t get the MMW filled locally for many days. Many of the outlying pharmacies in smaller towns are not open on the weekends at all. WE call the James pharmacy, and they offer to fill the MMW prescriptions, but the family has to drive back to Columbus to get them. I feel like we should be able to do better for them.

Trish-
I agree with you that it would be nice to have the preventative measures for the high risk population on hand already rather than waiting and having to call in a prescription. Treat it almost like anticipating nausea and already having zofran/compazine etc at home.

Jeff-
I agree with you and would love to know the reasoning of Benzydamine not being available in the United States.

Hello! My name is DeAnna Lybarger and I work in After Hours Triage at The James. We answer calls for all of clinics after hours and holidays so we get a variety of calls, many of which include requests for something to help with mouth soars.

1. I was already aware that head and neck cancer patients as well as our immunocompromised patients are at high risk for mouth soars. I recently completed the chemotherapy/biotherapy modules and it also mentioned several of the newer treatments include high incidence of mouth soars. I knew of cryotherapy, and I feel like we have done that with a few of our treatments, however, I found it interesting the articles fully supported cryotherapy as I don’t feel it’s conclusive. I do feel it’s something worth doing more research on as more and more oncology patients are experiencing mouth soars and because of the mouth soars have delayed treatments because of side effects such as dehydration and weight loss.

2. Regarding changing my practice, I’m not sure it will change my personal practice much with my role. I do however, feel every patient should have an order set that would include MMW or equivalent for when patients need it. We get calls with request for medication and our covering providers in ICC are not able to order medications over the phone and the patient has to come in to be seen. If we had something already in the set, the patient could request when needed or even go ahead and fill a prescription, because not all pharmacies can complete and it delays the patient getting the medication. I also think trying a form of cryotherapy might be helpful to have the patient try no matter what. Would it hurt to have the patient suck on ice chips prior to any infusion for example?

3. Why is there not more about this testing they have? The morphine suspension is also interesting, but I wonder if it would numb the area too much to where the patient would eat/drink things that would make it worse?

4.I agree in the fact that mucositis is a big and growing factor in many of our patients, especially with new treatments being development. I feel we could do better being proactive in plans for how to manage this part of treatment.