Management of Chemotherapy-Induced Mucositis

Prevention Strategies

The European Society for Medical Oncology recommends implementing basic oral care protocols universally for all patients receiving cancer treatment to reduce mucositis risk 1, 2, 3
For bolus 5-FU chemotherapy, administer 30 minutes of oral cryotherapy to prevent mucositis, which is a Level II recommendation with strong evidence 1, 2, 3, 6
For high-dose chemotherapy with stem cell transplant, use palifermin at 60 μg/kg/day for 3 days before conditioning treatment and 3 days after transplant, which is a Level I/II recommendation for autologous HSCT with TBI 2, 3, 6
Consider low-level laser therapy for HSCT patients receiving high-dose chemotherapy with or without TBI, which is a Level II recommendation requiring specialized equipment and training 1, 2, 3, 6
Use oral cryotherapy for patients receiving high-dose melphalan conditioning, which is a Level III suggestion for melphalan-based regimens 2, 3
For head and neck radiation therapy, use benzydamine mouthwash to prevent oral mucositis, which is a Level I recommendation 1, 2, 3, 6
Consider low-level laser therapy for patients undergoing radiotherapy without chemotherapy, which is a Level III suggestion 2, 3

The European Society for Medical Oncology recommends using patient-controlled analgesia with intravenous morphine for pain management in patients undergoing HSCT, which is a Level II recommendation and the strongest evidence-based approach for severe mucositis pain 1, 2, 3
For localized oral mucositis pain, use 0.2% morphine mouthwash, which is a Level III evidence 2, 3, 4
For general mucositis pain, use 0.5% doxepin mouthwash, which is a Level IV evidence 1, 2, 3, 4
Transdermal fentanyl may be effective for patients receiving conventional or high-dose chemotherapy with or without TBI, which is a Level III evidence 2, 3, 4

Do NOT use chlorhexidine mouthwash for prevention, which has Level III evidence against 1, 2, 6
Do NOT use sucralfate mouthwash for prevention, which has Level I evidence against 2, 7, 6
Do NOT use intravenous glutamine for HSCT patients, which has Level II evidence against 1, 2
Do NOT use GM-CSF mouthwash for HSCT patients, which has Level II evidence against 1, 2, 6
Do NOT use Iseganan antimicrobial mouthwash, which has Level II evidence against 1, 2
Do NOT use pentoxifylline for HSCT patients, which has Level III evidence against 1, 6
Do NOT use chlorhexidine or sucralfate mouthwash to treat established mucositis, which has Level II evidence against 7, 6, 1, 2

Consider zinc supplementation for oral cancer patients receiving radiation or chemoradiation, which is a Level III evidence 2, 3
For radiation-induced chronic proctitis with rectal bleeding, consider sucralfate enemas, which is a Level III evidence 7, 6