Managing Mucositis

Dr Barry Quinn RNMacmillan Consultant Lead Nurse Cancer & Palliative Care

EBMT MeetingIET London

5th October 2012

Oral Mucositis

• OM is defined as inflammation of the mucosa membrane. It is characterised by ulceration, which may result in pain, dysphagia and impairment of the ability to talk. Mucosal injury provides an opportunity for infection to flourish, placing the patient at risk of sepsis and septicaemia (Rubenstein et al, 2004)

Damage to Oral Mucosa

Patients with oral mucositis may suffer from • Severe pain and discomfort2,3

• Inability to eat, drink, swallow, or talk3

• Risk of systemic infections4 1Pico JL, et al. Oncologist. 1998;3:446-451;2Shea TC, et al. Bone Marrow Transplant. 2003;9:443-452;

3Bellm LA, et al. Support Care Cancer. 2000;8:33-39;4Sonis S. J Support Oncol. 2004;2:21-36.

Mucosal Bleeding Ulceration and Candida Infection1

Incidence rates of mucosal damage

1. Wardley AM et al. Br J Haematol 2000;110:292–2992. Elting LS, et al. Proceedings from the 17th MASCC/ISOO International

Symposium 2005; Abstract #15-097 and oral presentation3. Kalemkerian GP et al. Lung Cancer 1999;25:175–182

4. Sonis ST et al. Cancer 2004;100(suppl 10):1995–20255. Elting LS et al. Cancer 2003;98:1531–1539

6. Blijlevens N et al. Bone Marrow Transplant 2006;37:S24–S25

Oraland/or GI37**11**Solid tumoursMyelosuppressive

chemotherapy5

Oral87*44*Multiple myeloma, NHLHigh-dose melphalan, BEAM6

GINo data42*NSCLCChemoradiotherapy3

OralGINo data53*

39*GI malignancyRadiotherapy and5-FU and CPT-114

Oraland/or GI88–98*60–77*Head and

neck cancerRadiotherapy chemotherapy2

Oral99*67–98*Solid andhaematologicalConditioning for HSCT1

Mucosaldamage

Allgrades

Grade3–4

MalignancyTreatmentIncidence

*% of patients; **% of cycles

1. Adapted from Bellm LA et al, Support Care Cancer 2000;8:33–9

Most debilitating side effects45

Resp

ond e

n ts (

%)

40

35

30

25

20

15

10

5

0 Oral mucositis Nausea and vomiting

Weakness and lethargy

Diarrhoea

Oral mucositis: rated by some patients as the worst complication of high-dose chemotherapy for

HSCT1

Treatment & Disease

Hepatic toxicity

PainInfertility

Infections

Fatigue

New roles

Loss of privacy

Nausea and vomiting

Diarrhoea Constipation

Oral damage Weight loss

<Nutrition

Body changes

Relapse

Renal Complications Neurological complications

Pulmonary changes

Cardiac toxicity

Urological problems

Secondary malignancy

Thrombocytopenia

Anaemia

Spiritual distress

Alopecia

Leucopenia

Isolation

Lack of control

Sleep disturbance

Drug reactions

Fluid & Electrolyte imbalance

Sexual changes

GI disturbance

Bleeding disorders

Cataracts Skin toxicity

A Neglected Task

Despite its acknowledged importance, oral care is one of the first things to be set aside when workloads are excessive

(McGuire 2003)

Mucosal Damage: a Complex Biological Process

Adapted from Sonis ST. Cancer. 2004;100(suppl 10):1995-2025.

High Turnover Rate of Mucosal Cells Makes Them Susceptible to Damage from Cytotoxic Therapy

Normal mucosa provides an effective protective barrier

High epithelial turnover

Reduced turnoverReduced epithelial turnover leads to mucosal breakdown

Mucosal injury

DNA damage

NonDNA damage

Generation of ROS

Mucosa becomes susceptible to injury

Adapted from Sonis ST. Nat Rev. 2004;4:277-284.ROS = reactive oxygen species

Background

Objective to form an expert group that changes the approach to and management of OM

UKOMiC Group

• Dr Barry Quinn Nurse Consultant/Lead Cancer Nurse (Chair)• Michelle Davies Research Nurse Haematology• Jeff Horn Clinical Nurse Specialist (CNS) Haematology• Emma Riley Macmillan Dental Nurse• Dr Jenny Treleaven Consultant Haematologist• David Houghton Senior Pharmacist• Annette Beasley CNS Head and Neck• Dr Catherine McGowan Palliative Care Consultant• Maureen Thomson Consultant Radiographer• Lorraine Fulman Information and Support Radiographer, Head and Neck• and Gynaecology• Kathleen Mais Nurse Clinician, Head and Neck Oncology• Professor Petra Feyer Consultant Clinical Oncologist• Sonja Hoy CNS Head, Neck and Thyroid Cancer• Frances Campbell CNS Head and Neck Cancer

Background

• Oral problems, including oral mucositis (OM), can be a significant health burden for the individual. They also make substantial demands on health care resources.

• A multi-professional group of UK oral care experts working in cancer and palliative care has drawn on their expertise and the most up-to-date evidence to develop guidance and support on the assessment, care, prevention and treatment of oral problems secondary to disease and treatments.

Guidance

• This guidance has been developed for all health care professionals involved in the care and treatment of cancer patients. It is anticipated that it can be adapted to other clinical settings, including palliative and terminal care, and other specialist areas such as gerontology.

Care of the Oral Cavity

• All patients undergoing high-dose chemotherapy or HSCT procedure, and all head and neck cancer patients, should ideally be referred for dental assessment prior to commencing treatment.

Oral Assessment

Assessment of Oral Mucositis

1World Health Organization.Handbook for reporting results of cancer treatment. 1979;pp. 15-22.

Scale

Mucositis Grade

0 1 2 3 4

WHO Oral Toxicity Scale

1

None Soreness and erythema

Erythema, ulcers, patient can swallow solid diet

Ulcers, extensive erythema, patient cannot swallow solid diet

Mucositis to extent that alimentation not possible

WHO = World Health Organization

Prevention of therapy induced OM• The choice of prevention regimens for mucositis will depend on the

perceived risk of mucositis.

• Compliance with the prevention measures and good oral hygiene will minimise the risk of subsequent issues with mucositis.

Prevention of therapy induced OM

Prevention of therapy induced OM

Anti-Infective Prophylaxis

• As well as good oral hygiene, patients receiving chemotherapy for haematological cancers may be prescribed antifungal and antiviral treatments to prevent infections. Infection prophylaxis for head and neck cancer patients is only required if the patient is known to be at risk of infection due to co-morbidity factors.

• Antifungal prophylaxis should be given to patients receiving high-dose steroids (the equivalent of at least 15 mg of prednisolone per day for at least one week), and may include 50 mg oral fluconazole once daily. High-risk patients, including those undergoing HSCT, should also receive an antifungal agent; this may include fluconazole, itraconazole or posaconazole (the choice of drug will be dependent on local guidance).

• Antiviral prophylaxis may comprise 200 mg aciclovir three times a day orally (or according to local guidance).

Treatment of Therapy-Induced MucositisGrade 1 or 2 Mucositis

• Ensure oral hygiene is adequate. Consider increasing the frequency of saline rinses. • Closely monitor nutritional status & refer to dietician.• Provide simple analgesia, which may include soluble paracetamol 1 g four times daily. It

should be remembered that paracetamol may mask fever.• Escalate to soluble co-codamol 30/500 if required. The use of NSAIDs is contraindicated

due to the risk of bleeding and renal impairment (Keefe et al., 2007).• Consider benzydamine 0.15% oral solution (Difflam®), 10 ml rinsed around the mouth and

spat out. Repeat between every 1.5 to 3 hours, as required. However, this may be poorly tolerated in patients with severe mucositis.

• Consider increasing folinic acid rescue for methotrexate-induced mucositis. • Check to see if the patient has evidence of oral infection and if so ensure an anti-infective

agent is prescribed.• Consider Caphosol® (4–10 times a day) to prevent grade 1 and 2 OM becoming more

severe.

Treatment of Therapy-Induced MucositisGrade 3 or 4 Mucositis

In addition to the recommendations for grade 1 and 2 OM, the following shouldbe considered:• Use of stronger analgesia, including Oxynorm®, Sevredol® and Oramorph®

(Oramorph® may sting mucosa due to its alcohol base). If patients continue to suffer from pain from mucositis, consider - fentanyl patches, patient controlled ‑analgesia or a syringe driver (seek advice from the acute pain team or the palliative care service). Laxative medications should be prescribed to prevent constipation and associated nausea.

• Ensure intravenous and/or enteral hydration and feeding is prescribed, as oral intake may be reduced .

• Consider Caphosol® .• Consider applying a coating protectant, e.g. Gelclair®,

MuGard®, Episil®. The product should be rinsed around the mouth to form a protective layer over the sore areas, and generally applied 1 hour before eating.

Treatment of Therapy-Induced Mucositis

Reference guides

www.ukomic.co.uk

Conclusion

“My mouth became ulcerated and I could not swallow my own saliva. Every day of chemo brought some new horrifying change to my body” (Liz)