Reactive Management for Stomatitis

General Recommendation

Stomatitis can significantly impair quality of life. Comprehensive oral care, aggressive pain management and adequate nutritional support are key considerations.1

Treatment Overview

Stomatitis associated with targeted therapies includes a range of subjective and objective symptoms and may differ from the oral mucositis associated with traditional chemotherapy.2

Use of sodium-containing mouthwashes is recommended and the frequency can be increased to hourly if needed.2 Symptomatic relief may be obtained using a mouthwash consisting of equal parts of 2% viscous lidocaine, diphenhydramine, and bismuth subsalicylate or aluminium/magnesium hydroxide, or alternative mouthwashes.3,4 If the patient finds mouthwash use painful, pain medication may be taken first (e.g. viscous lidocaine 2%,).2 Aggressive pain relief should be administered, including opioids for persistent severe pain.1,2

More effective approaches to preventing and treating stomatitis are needed.1 A recent Cochrane review of randomised controlled trials identified 10 interventions with some efficacy in either preventing or reducing the severity of oral mucositis during cancer treatment: aloe vera, amifostine, cryotherapy (ice chips), granulocyte-colony stimulating factor (G-CSF), intravenous glutamine, honey, keratinocyte growth factor, laser, polymyxin/tobramycin/amphotericin (PTA) antibiotic pastille/paste and sucralfate.5

Patients should be evaluated weekly. With the second or third occurrence of stomatitis intensifying supportive measures is advised. If symptoms worsen despite the intensified measures, interruption or discontinuation of the Multikinase inhibitor should be considered.

Treatment of NCI-CTCAE V4.03 Grade 12,3,4

  • Saline mouthwash

Treatment of NCI-CTCAE V4.03 Grade 22,3,4

  • Dietary modification (e.g. avoid hot, spicy and acidic food and drinks)
  • Increase the frequency of mouthwash (e.g., every 1–2 h)
  • Use currently available mouthwashes with an antiseptic and analgesic for symptomatic relief
  • If mouthwash is painful, take pain medication first (e.g. viscous lidocaine 2%, coating agents)
  • For moderate pain, consider a topical NSAID (e.g. benzocaine topical 20% mucous membrane spray, gel or liquid, benzocaine topical oral lozenge)
  • Consider initiation of systemic NSAIDs

Treatment of NCI-CTCAE V4.03 Grade 32,3,4

  • Intensify use of mouthwash to 8–12 rinses per day, or every hour
  • Eat soft foods at room temperature, cut into small pieces; use a straw for drinking liquids
  • Consider corticoid mouthwashes
  • Opioid analgesics if needed. Since oral complaints can complicate administration of drugs by mouth, one should consider other kinds of administration routes, such as transdermal or intranasal routes, e.g. 50 microgram fentanyl nasal spray to relief pain short-term, before dinner

Treatment of NCI-CTCAE V4.03 Grade 42,3,4

  • Requires tube feeding or hospitalisation

Products

  • Viscous lidocaine 2%
  • Topical NSAID (e.g. benzocaine)
  • Opioid analgesic

Multikinase Inhibitor Treatment

Continue with/withhold the selected multikinase inhibitor treatment regimen, as recommended in the current and relevant SPC and according to the patient’s condition.

References

1Lacouture ME, et al. Clinical practice guidelines for the prevention and treatment of EGFR inhibitor-associated dermatologic toxicities. Support Care Cancer. 2011; 19:1079-95.
2Boers-Doets CB. The TARGET SYSTEM. Approach to assessment, grading, and management of dermatological & mucosal side effects of targeted anticancer therapies. ISBN 978-94-92070-00-5. 2014
3Kollmannsberger C, et al. Sunitinib in metastatic renal cell carcinoma: recommendations for management of noncardiovascular toxicities. Oncologist. 2011; 16:543-53.
4De Wit M, et al. Prevention and management of adverse events related to regorafenib. Support Care Cancer. 2014; 22:837-46.
5Worthington HV, et al. Interventions for preventing oral mucositis for patients with cancer receiving treatment. Cochrane Database Syst Rev. 2011 Apr 13;(4):CD00097

Last update: 22 August 2014