Guideline sources The following summarized guidelines for the management of chemotherapy- and radiotherapy- induced mucositis are prepared by our editorial team based on guidelines from the American Society of Pain and Neuroscience (ASPN 2021), the Multinational Association of Supportive Care in Cancer (MASCC/ISOO 2020; 2014), and the Infectious Diseases Society of America (IDSA 2011). 1 2 3 4 5 5 5 6 Definition Chemotherapy- and radiation-induced mucositis refers to erythematous and ulcerative lesions of the oral mucosa in patients with cancer being treated with chemotherapy or radiation. 5 Epidemiology Chemotherapy- and radiation-induced mucositis is caused by direct toxicities (cell death and reduction in cell turnover) and indirect toxicity (myelosuppression). 6 Disease course Tissue injury, upregulation of inflammation and proinflammatory cytokines, and ulceration results in chemotherapy- and radiation-induced mucositis, which causes clinical manifestations of severe pain, bleeding, and weight loss impacting nutritional intake, oral hygiene, and quality of life; gastrointestinal mucositis can manifest as diarrhea. Mucositis complicated by infection during severe immunosuppression can lead to systemic sepsis. 5 Prognosis and risk of recurrence https://web.pathway.md/diseases/recR7F3jpri7cYYBk 1/5 6/29/23, 3:50 AM Chemotherapy- and radiotherapy-induced mucositis Pathway og os s a d s o ecu e ce Chemotherapy- and radiation-induced mucositis independently is not associated with increased mortality. 5 Guidelines 1. Medical management Management of oral mucositis, morphine: As per ISOO/MASCC 2020 guidelines, consider offering topical morphine 0.2% mouthwash the treatment of oral mucositis-associated pain in patients with head and neck cancer receiving concomitant radiotherapy and chemotherapy. C As per ISOO/MASCC 2014 guidelines, offer patient-controlled analgesia with morphine for the management of pain due to oral mucositis in patients undergoing HSCT. B Management of oral mucositis (ketamine): consider offering ketamine on a case-by-case basis in patients with refractory oral mucositis-related pain. C Management of oral mucositis (sucralfate): do not use sucralfate (combined topical and systemic) for the treatment of oral mucositis-associated pain in patients with solid cancer receiving chemotherapy. D Management of oral mucositis (antibiotics): consider administering fluoroquinolone prophylaxis, preferably with levofloxacin, in high-risk patients with expected prolonged and profound neutropenia (absolute neutrophil count 100/ L for > 7 days) at an increased risk for oral mucositis-related invasive viridans group streptococcal infection. B Management of enteritis (octreotide): offer octreotide SC 100 g BID for the treatment of diarrhea induced by standard- or high-dose chemotherapy associated with HSCT if loperamide is ineffective. B Management of enteritis (sucralfate): do not use oral sucralfate for the treatment of gastrointestinal mucositis in patients receiving radiotherapy for a solid tumor. D Management of proctitis (sucralfate enemas): consider offering sucralfate enemas for the treatment of chronic radiation-induced proctitis in patients with rectal bleeding. C Management of proctitis (hyperbaric oxygen therapy): consider offering hyperbaric oxygen therapy for the treatment of radiation-induced proctitis in patients with pelvic malignancy. C 2. Preventative measures Prevention of oral mucositis (general principles): consider implementing multiagent combination oral care protocols for the prevention of oral mucositis during chemotherapy, head and neck radiotherapy, and HSCT. C Show 2 more https://web.pathway.md/diseases/recR7F3jpri7cYYBk 2/5 6/29/23, 3:50 AM Chemotherapy- and radiotherapy-induced mucositis Pathway Prevention of oral mucositis (oral cryotherapy): Offer oral cryotherapy for the prevention of oral mucositis in patients undergoing autologous HSCT when the conditioning includes high-dose melphalan. B Offer oral cryotherapy for 30 minutes during the infusion of the chemotherapy for the prevention of oral mucositis in patients receiving bolus 5-fluorouracil chemotherapy. B Prevention of oral mucositis (intraoral photobiomodulation therapy): Offer intraoral photobiomodulation therapy using low-level laser therapy for the prevention of oral mucositis in adult patients receiving: HSCT conditioned with high-dose chemotherapy, with or without total body irradiation A head and neck radiotherapy without chemotherapy B concomitant head and neck radiotherapy and chemotherapy. A Prevention of oral mucositis (mouthwashes): consider offering saline and sodium bicarbonate rinses for maintaining oral hygiene and improving patient comfort. E Show 2 more Prevention of oral mucositis (recombinant keratinocyte growth factor 1): offer IV keratinocyte growth factor 1 for the prevention of oral mucositis in patients with hematologic cancer undergoing autologous HSCT with a conditioning regimen including high-dose chemotherapy and total body irradiation. A Prevention of oral mucositis (oral glutamine): consider offering oral glutamine for the prevention of oral mucositis in patients with head and neck cancer receiving concomitant radiotherapy and chemotherapy. C Prevention of oral mucositis (honey): consider offering honey for the prevention of oral mucositis in patients with head and neck cancer receiving either radiotherapy or concomitant radiotherapy and chemotherapy. C Prevention of oral mucositis (chewing gum): avoid offering chewing gum for the prevention of oral mucositis in pediatric patients with hematological or solid cancer receiving chemotherapy. D Prevention of oral mucositis, therapies with no evidence for benefit: As per ISOO/MASCC 2020 guidelines, avoid using chlorhexidine for the prevention of oral mucositis in patients undergoing head and neck radiotherapy. D Show 3 more As per ISOO/MASCC 2014 guidelines: Do not use the following for the prevention of oral mucositis: polymyxin, tobramycin, and amphotericin B lozenges and paste in patients with head and neck cancer receiving radiotherapy D bacitracin, clotrimazole, and gentamicin lozenges in patients with head and neck cancer receiving radiotherapy D iseganan antimicrobial mouthwash in patients with head and neck cancer receiving radiotherapy or concomitant radiotherapy and chemotherapy. D https://web.pathway.md/diseases/recR7F3jpri7cYYBk 3/5 6/29/23, 3:50 AM Chemotherapy- and radiotherapy-induced mucositis Pathway iseganan antimicrobial mouthwash in patients receiving high-dose chemotherapy, with or without total body irradiation, for HSCT. D Avoid using the following for the prevention of oral mucositis: oral pentoxifylline in patients undergoing BMT D oral pilocarpine in patients with head and neck cancer receiving radiotherapy D or patients receiving high-dose chemotherapy, with or without total body irradiation, for HSCT. D Prevention of esophagitis (amifostine): consider offering IV amifostine for the prevention of concomitant chemotherapy and radiotherapy-induced esophagitis in patients with non-small cell lung carcinoma. C Prevention of enteritis (probiotics): consider offering probiotics containing Lactobacillus species for the prevention of radiotherapy-induced or radiotherapy-chemotherapy-induced diarrhea in patients with pelvic malignancy. C Prevention of enteritis (sulfasalazine): consider offering oral sulfasalazine 500 mg BID for the prevention of radiation-induced enteropathy in patients receiving pelvic radiotherapy. C Prevention of enteritis (5-aminosalicylic acid): do not use oral 5-aminosalicylic acid, mesalazine, or olsalazine for the prevention of acute radiation-induced diarrhea in patients receiving radiotherapy for pelvic malignancy. D Prevention of proctitis (amifostine): offer IV amifostine 340 mg/m for the prevention of radiation-induced proctitis in patients receiving radiotherapy. B Prevention of proctitis (misoprostol suppositories): do not use misoprostol suppositories for the prevention of acute radiation-induced proctitis in patients receiving radiotherapy for prostate cancer. D Clinical findings Symptoms Past medical history Abdominal cramps Chemotherapy for previous cancer Abdominal pain Malignancy Chest pain Radiation therapy to the head area Diarrhea Fever Radiation therapy to the neck area Hematochezia Malaise Mouth sores Head and neck exam Nausea Oral mucosal erythema Neck pain Oral plaques Odynophagia Oral ulcers Painful oral lesions Pharyngeal erythema Poor feeding Rectal pain https://web.pathway.md/diseases/recR7F3jpri7cYYBk 4/5 6/29/23, 3:50 AM Chemotherapy- and radiotherapy-induced mucositis Pathway Vomiting Hematological findings Weight loss blood neutrophil count oral intake Anthropomorphic exam Malnutrition Integument exam Dehydration Mucosal bleeding References 1. Rajesh V Lalla, Joanne Bowen, Andrei Barasch et al. MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer. 2014 May 15;120 10 1453 61. Open 2. Sharon Elad, Karis Kin Fong Cheng, Rajesh V Lalla et al. MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer. 2020 Oct 1;126 19 4423 4431. Open 3. Freifeld AG, Bow EJ, Sepkowitz KA et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the Infectious Diseases Society of America. Clin Infect Dis. 2011 Feb 15;52 4):e56 93. Open 4. Mansoor M Aman, Ammar Mahmoud, Timothy Deer et al. The American Society of Pain and Neuroscience ASPN Best Practices and Guidelines for the Interventional Management of Cancer- Associated Pain. J Pain Res. 2021 Jul 16;14 2139 2164. Open 5. Rajesh V Lalla, Stephen T Sonis, Douglas E Peterson. Management of oral mucositis in patients who have cancer. Dent Clin North Am. 2008 Jan;52 1 61 77, viii.2008 Jan;52 1 61 77, viii. Open 6. Maddireddy Umameshwar Rao Naidu, Gogula Venkat Ramana, Pingali Usha Rani et al. Chemotherapy- Induced and/or Radiation Therapy-Induced Oral Mucositis Complicating the Treatment of Cancer. Neoplasia. 2004 Sep; 6 5 423 431. Open 7. Rajesh V. Lalla, Stephen T. Sonis, and Douglas E. Peterson. Management of Oral Mucositis in Patients with Cancer. Dent Clin North Am. 2008 Jan; 52 1 61 viii. Open 8. Renata Zajaczkowska, Magdalena Kocot-Kepska, Wojciech Leppert et al. Mechanisms of Chemotherapy-Induced Peripheral Neuropathy. Int J Mol Sci. 2019 Mar 22;20 6 1451.2019 Mar 22;20 6 1451. Open 9. D E Peterson, C B Boers-Doets, R J Bensadoun et al. Management of oral and gastrointestinal mucosal injury: ESMO Clinical Practice Guidelines for diagnosis, treatment, and follow-up. Ann Oncol. 2015 Sep;26 Suppl 5:v139 51. Open https://web.pathway.md/diseases/recR7F3jpri7cYYBk 5/5