Mucositis Treatment for Cancer Patients: Compounded Options Offer Relief

Mucositis Treatment for Cancer Patients: Compounded Options Offer Relief

i-timeOncologists experience it first hand and, in spite of maintaining a professional distance, they feel the ravages of chemotherapy and radiation almost as deeply as their patients. One oncologist expressed his compassion by saying he didn’t think he could tolerate the therapies he routinely prescribed. As if adding insult to injury, many cancer patients will develop a debilitating side effect of cancer treatment—oral mucositis—which can cause severe pain, make it impossible to eat, and imperil the course of treatment, which may be discontinued to allow healing. The best mucositis treatment for cancer patients comes from compounded oral rinses formulated to relieve pain and fight infection.

Facts About Oral Mucositis

The toxic effects of chemotherapy and radiation take a significant toll on the mucosal lining of the oral cavity. While patients with head and neck cancers are virtually guaranteed to develop oral mucositis—which increases the number of hospitalizations—it also occurs in nearly 40 percent of all patients receiving chemotherapeutic agents and/or radiation.1 Oral mucositis begins seven to 10 days after cytotoxic therapy begins and lasts about two to four weeks after therapy ends. During that time, the risk of infection increases and malnutrition associated with typical loss of appetite is exacerbated when painful ulcerations stop patients from eating.

Diverse chemotherapeutic agents may cause mucositis; a short list includes:

  • Methotrexate
  • Cisplatin, carboplatin and oxaliplatin
  • 5-fluorouracil
  • Docetaxel and paclitaxel
  • Cyclophosphamide
  • Doxorubicin
  • Vincristine
  • Etoposide
  • Ifosfamide
  • Vinorelbine

Oral mucositis is graded subjectively and objectively, taking into consideration the patient’s reported level of pain and ability to eat, as well as visible erythema and ulceration. When pain and lesions persist despite intervention, cancer therapy may be affected, requiring changes in the treatment schedule, dose reduction or discontinuation.2

The State of Oral Care or Why Pharmacists Should Get Involved

Comprehensive dental care before chemotherapy and/or radiation and diligent oral care during cancer treatment are so widely recommended that it’s hard to believe they’re not common practice—but they’re not. The National Institute of Dental and Craniofacial Research says patients with cancer often don’t receive oral care until serious complications develop.3 Reasons for the lack of oral care are diverse, ranging from the health care available where patients live and inability to pay, to the urgency of starting cancer treatment versus waiting for dental work. Oral care is further influenced by factors such as:

  • Few cancer centers have dental practitioners or even a nurse with responsibility for oral education on the cancer team.4
  • Lack of funding for dental services creates a significant roadblock.
  • Community dentists often don’t have the experience or the specialized training needed to treat cancer patients.
  • A survey of 235 pediatric oncology nurses found that 60 percent didn’t have any oral-care training.5

The logical destination for cancer patients needing oral care is the community pharmacy. Whether they seek pain relief, an oral rinse, or dental supplies, pharmacists should be prepared to answer questions and talk about compounded options.

Recommended Mucositis Treatment for Cancer Patients

The Multinational Association of Supportive Care in Cancer, the International Society of Oral Oncology (MASCC/ISOO), and the National Institutes of Health recommend oral hygiene to help lower the risk of oral mucositis. Oral care protocols for all patients include:

  • Dental assessment: If possible, patients should get a dental check-up to identify and treat any existing infections, fractured teeth and other oral injuries. Dental work must be complete at least two weeks before chemotherapy or radiation, however. Daily application of high-potency fluoride gel to prevent demineralization is also recommended.
  • Basic oral care: Using an extra-soft toothbrush, cancer patients should brush four times daily using a mild, fluoride-containing, non-foaming toothpaste. If they already use floss, they can continue, but patients should not start flossing during cancer treatment because they may damage the gums.
  • Mouth rinses: With the goal of keeping bacteria growth to a minimum, patients should rinse for one minute after brushing with an alcohol-free mouthwash or a solution made from warm water, baking soda and salt.6 They shouldn’t eat or drink for 1/2 hour after rinsing.

Several preventive measures may benefit patients receiving specific types of chemotherapy. Cryotherapy with ice chips helps decrease the incidence of oral mucositis in patients receiving 5-fluorouracil chemotherapy and high-dose melphalan, while palifermin is FDA-approved for patients receiving myelotoxic therapy requiring hematopoietic stem cell support.

Mucositis treatment for cancer patients focuses on managing pain and preventing infection. Since multiple pharmaceutical agents are often required and the current guidelines recommend a patient-centered approach, compounded products give patients the best—and sometimes the only—treatment option:

  • Antifungals such as fluconazole, nystatin and clotrimazole can be formulated in bland oral rinses and used as prophylaxis against candidiasis. Compounding pharmacists can also recommend a clotrimazole troche.
  • Magic mouthwash is available in pre-measured kits or can be compounded using bulk APIs. This rinse contains multiple agents, including viscous lidocaine 2 percent, diphenhydramine, magnesium hydroxide or aluminum hydroxide, nystatin and corticosteroids.
  • Mouthwash containing 2 percent morphine may treat pain in patients receiving chemoradiation for head and neck cancer.
  • Doxepin 0.5 percent, which has anesthetic and analgesic properties when used topically in an oral rinse, is recommended by the MASCC/ISOO for any patient with oral mucositis.7
  • Gelclair adheres to the mucosal surface of the mouth to form a protective coating that relieves pain.
  • Transdermal fentanyl may relieve pain caused by oral mucositis in patients receiving conventional or high-dose chemotherapy, with or without irradiation.

When oral rinses and topical treatments fail to relieve the pain, systemic fentanyl and morphine are recommended by MASCC/ISOO. Compounding pharmacists can further help patients with oral mucositis or dysphagia by formulating pain medications in transdermal form.

Reach Out to Oncologists and Patients to Improve Outcomes

The medical complexity of cancer patients demands a multidisciplinary approach, states the National Cancer Institute.8 Since optimal mucositis treatment for cancer patients comes in the form of compounded pharmaceuticals, it makes sense for compounding pharmacists to establish collaborative relationships with oncologists and to reach out by creating a visible display of oral products for patients with cancer. In the process, you’ll improve patients’ quality of life and increase the odds of surviving their fight against cancer.

Pharmaceutica North America provides high-quality bulk APIs, including pharmaceuticals used in treatments for cancer patients with oral mucositis. Contact us today to talk about how we can help you develop optimal treatments through compounded options.

Show 8 footnotes

  1. “Mucositis in Cancer Patients: A Review,” March 2016, http://www.uspharmacist.com/content/d/featured_articles/c/59959/
  2. “Management of Oral and Gastrointestinal Mucosal Injury: ESMO Clinical Practice Guidelines for Diagnosis, Treatment, and Follow-up,” July 2015, https://annonc.oxfordjournals.org/content/26/suppl_5/v139.full
  3. “Oral Complications of Cancer Treatment: What the Dental Team Can Do,” July 2015, http://www.nidcr.nih.gov/oralhealth/Topics/CancerTreatment/OralComplicationsCancerOral.htm
  4. “Appropriate and Necessary Oral Care for People with Cancer: Guidance to Obtain the Right Oral and Dental Care at the Right Time,” March 2014, http://headandneck.org/wp-content/uploads/2015/08/Obtaining-Oral-Care-for-Cancer-Patients-JSCC-2014.pdf
  5. “Knowledge, Perceived Ability and Practice Behaviors Regarding Oral Health Among Pediatric Hematology and Oncology Nurses,” August 2015, http://www.ncbi.nlm.nih.gov/pubmed/26304946
  6. “Managing Chemotherapy Side Effects: Mouth and Throat Changes,” February 2012, http://www.cancer.gov/publications/patient-education/mouth-and-throat.pdf
  7. “MASCC/ISOO Clinical Practice Guidelines for the Management of Mucositis Secondary to Cancer Therapy,” May 2014, http://www.mascc.org/assets/ISOO/documents/13_clinical_practice_guidelines_management_mucositis_secondary.pdf
  8. “Oral Complications of Chemotherapy and Head/Neck Radiation—Health Professional Version,” January 2016, http://www.cancer.gov/about-cancer/treatment/side-effects/mouth-throat/oral-complications-hp-pdq
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