Mucositis

Question 1

How does mucositis occur?

Answer 1

Chemotherapy kills fast reproducing cells in the GIT, cause damage to the mucosa of the oral cavity

Targeted therapies and small-molecule inhibitors demonstrate potential to cause mucositis

EGFR plays a role in maintaining mucosal integrity - levels increased in inflamed mucosa

Question 2

What are the 5 stages of mucositis?

Answer 2

1. Initiation - toxicity, oxidative stress, incr vascular permeability
2. Upregulation - pro-inflammatory cytokines
3. Signaling and amplification - positive feedback
4. Ulceration - atrophy and mucosal breakdown
5. Healing - proliferation of epithelial cells

*Occurs rapidly and concurrently along alimentary tract

Question 3

Progression of mucositis with time

Answer 3

Day 0-5: asymptomatic, redness, swelling, burning
Day 0-7: Desquamation, white patches
Day 6-12: Contiguous pseudomembranes
Day 7-16: Ulceration, painful erosions

Question 4

Grading of mucositis

Answer 4

Grade 0: NIL
Grade 1: Erythema, soreness
Grade 2: Ulcers, still able to eat solid food
Grade 3: Ulcers, require liquid diet
Grade 4: Ulcers, not able to take PO
Grade 5: Death

*Grade 3-4 patients may require enteral or parenteral nutrition

Question 5

Risk factors for mucositis (*Patient)

Answer 5

Patient-related factors

• Autoimmune disorders
• Diabetes
• Female
• Caucasians > African Americans
• Genetic predisposition to tissue damage
• Folic acid or Vit B12 deficiency
• Smoking
• Alcohol consumption
• Xerostomia
• Infection

Question 6

Risk factors for mucositis (*Treatment)

Answer 6

Treatment-related factors

Chemotherapy:

• S-phase agents
• Longer duration
• Prolonged dose or repetitive low doses have higher risk than bolus doses
• Schedule
• Number of cycles

Renal or hepatic impairment

Previous therapies toxic to mucosa

Previous episodes of mucositis

Radiation

Question 7

Prevention of Oral Mucositis

Answer 7

• Basic oral care (tooth brushing, flossing, saline and sodium bicarbonate inert and bland rinses, chlorhexidine rinses)
• IV KGF-1 (Palifermin 60mcg/kg/day x 3 days)
• Benzydamine HCl mouthwash
• Photobiomodulation - LLLT
• Cryotherapy - ice chips

Question 8

Palifermin MOA and Dose

Answer 8

MOA:

• Keratinocyte growth factor (KGF-1)

Dose:

• IV 60mcg/kg/day x3d (before, and after therapy - total 6 doses)
• 3rd dose given 24-48h before therapy
• 4th dose at least 4 days after the 3rd dose

Efficacy:

• Reduce incidence, duration, and severity of oral mucositis after myelotoxic therapy requiring HSCT

Question 9

Treatment of oral mucositis

Answer 9

• 0.2% Morphine mouthwash
• Oracare suspension (Nystatin + Tetracycline + Hydrocortisone + Diphenhydramine)
• Mylocaine suspension (Diphenhydramine + Lignocaine)
• Morphine sulfate solution 1mg/ml

Others:
- Oracort, Medigel, Soragel, Difflam gargle etc.

Question 10

Non-pharmaco tx of OM

Answer 10

Oral7 mouthwash
Bioxtra mouthwash

*These are alcohol free, with neutral pH
*Avoid alcohol-based as have astringent (drying) effect that can cause more xerostomia which can cause mucositis