Managing Mucositis
Dr Barry Quinn RN
Macmillan Consultant Lead Nurse Cancer & Palliative Care
EBMT Meeting
IET 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
Mucosal Bleeding
Ulceration and Candida Infection
1
Patients with oral mucositis may suffer from
• Severe pain and discomfort
2,3
• Inability to eat, drink, swallow, or talk
• Risk of systemic infections
4
3
Pico JL, et al. Oncologist. 1998;3:446-451;
Shea TC, et al. Bone Marrow Transplant. 2003;9:443-452;
3
Bellm LA, et al. Support Care Cancer. 2000;8:33-39;
4
Sonis S. J Support Oncol. 2004;2:21-36.
1
2
Incidence rates of mucosal damage
Treatment
Conditioning for HSCT1
Radiotherapy 
chemotherapy2
Chemoradiotherapy3
Radiotherapy and
5-FU and CPT-114
Myelosuppressive
chemotherapy5
High-dose melphalan,
BEAM6
*% of patients; **% of cycles
Malignancy
Solid and
haematological
Head and
neck cancer
NSCLC
Grade
3–4
Incidence
All
Mucosal
grades
damage
67–98*
99*
60–77*
88–98*
42*
53*
39*
No data
Solid tumours
11**
37**
Multiple myeloma, NHL
44*
87*
GI malignancy
No data
Oral
Oral
and/or GI
GI
Oral
GI
Oral
and/or GI
Oral
1.
Wardley AM et al. Br J Haematol 2000;110:292–299
2. Elting LS, et al. Proceedings from the 17th MASCC/ISOO International
Symposium 2005; Abstract #15-097 and oral presentation
3. Kalemkerian GP et al. Lung Cancer 1999;25:175–182
4. Sonis ST et al. Cancer 2004;100(suppl 10):1995–2025
5. Elting LS et al. Cancer 2003;98:1531–1539
6. Blijlevens N et al. Bone Marrow Transplant 2006;37:S24–S25
Oral mucositis: rated by some patients as
the worst complication of high-dose chemotherapy for
HSCT1
Most debilitating side effects
45
40
35
30
25
20
15
10
5
0
Oral mucositis
Nausea and
vomiting
Weakness and
lethargy
Diarrhoea
1. Adapted from Bellm LA et al, Support Care Cancer 2000;8:33–9
Cataracts
Skin toxicity
Nausea and vomiting
Lack of control Spiritual distress Body
Infertility
changes
Pain
Urological problems
Hepatic
Weight loss toxicity
Oral damage Anaemia
Loss of privacy
Drug reactions
Neurological
Renal Complications
complications
Treatment
Sexual
Bleeding disorders
& Disease
changes
Fatigue
Leucopenia
Thrombocytopenia
Cardiac toxicity
<Nutrition
Alopecia
New roles
Pulmonary changes
Secondary malignancy
GI disturbance
Infections
Isolation
Diarrhoea
Constipation
Relapse
Sleep disturbance
Fluid & Electrolyte imbalance
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
DNA damage
NonDNA damage
Generation of ROS
Reduced epithelial
turnover leads to
mucosal breakdown
Reduced turnover
Mucosa becomes
susceptible to injury
Mucosal injury
ROS = reactive oxygen species
Adapted from Sonis ST. Nat Rev. 2004;4:277-284.
Background
Objective to form an expert group that changes the
approach to and management of OM
UKOMiC Group
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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-todate 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
Mucositis Grade
Scale
0
1
WHO
None Soreness
Oral
and
Toxicity
erythema
1
Scale
2
Erythema,
ulcers,
patient can
swallow
solid diet
3
4
Ulcers,
extensive
erythema,
patient
cannot
swallow
solid diet
Mucositis to
extent that
alimentation
not possible
WHO = World Health Organization
World Health Organization.
Handbook for reporting results of cancer treatment. 1979;pp. 15-22.
1
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 highdose 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 Mucositis
Grade 1 or 2 Mucositis
•
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•
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 Mucositis
Grade 3 or 4 Mucositis
In addition to the recommendations for grade 1 and 2 OM, the following should
be 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)