BETA - What is mucositis?

What is mucositis? Mucositis is one of the side effects of the high dose therapy and radiation therapy to the head and neck. And it's one of the symptoms which causes the patients to have mouth sores. They're not necessarily present only in the mouth. They could be present in the whole GI tract. We mostly see that in the mouth. The most frequent culprit of therapies that can potentially cause that is high dose melphalan. So if we speak of the myeloma, high dose melphalan conditioning regimen prior to the bone marrow transplant is one of the most frequent culprits for the mucositis. Additional medications that can potentially cause that but much less frequently are Revlimid or lanolidamide. Usually the symptoms are quite mild if you compare it with a high dose melphalan therapy. I've seen that with carfilzomib but it's mostly one-offs. It's not very often. Someone who has to go through the radiation therapy of the head and neck very commonly can develop mucositis, especially if there is a concomitant therapy which we try to avoid in myeloma. But if there is a concomitant therapy, let's say someone has a, I had a patient with a plasma cytoma in the nasopharynx and the only way to get rid of it was to radiate that area which ultimately caused the patient to have mucositis and the symptoms could be pretty debilitating. So we could do everything possible to prevent it. One of the ways to prevent it is certainly to have a good oral hygiene. Make sure that the teeth are in a good standing, that someone is chewing on ice, it's called cryotherapy. We have a pretty significant success with our high dose melphalan and cryotherapy for our patients and seen significantly less amount of mucositis from that. In terms of the treatment, treatment is usually more symptomatic, symptoms related. If we use non-specific mouth rinses, magic mouthwash, baking soda salt rinses, or we can use some topical lidocaine just for the numbing of the area. So we can modify the diet in the severe cases, in the very severe cases. Patients could even have to be on fluid or TPA. I've seen just a couple of those, so hopefully we don't usually see too many with melphalan alone. Over time that gets better. It takes about maybe a month or so to recover if it develops. Sometimes most of the patients develop maybe one or two mouth sores. A lot of time it's just swelling in the gums and we just instruct them to be very careful of how they eat so they don't bite on the cheek from inside and cause that mouth sore. Thankfully with our regimens it's not that common. What is mucositis? Well again we don't see it very often. We still do a lot of transplants for myeloma where we use the high dose chemotherapy to achieve a deep response. And the melphalan is the standard of care, the standard chemotherapy is an alkylator agent. When we use it at high dose particularly it can cause, it's a very safe chemotherapy in a way because it doesn't cause a lot of end organ damage like cardiac toxicity, pulmonary toxicity. But we see the GI, so it kills the blood, the highly proliferative cells of the gut of the GI. And so it can cause what we call the mucositis where patients have difficult swallowing, sometimes they have esophagitis, irritation and some mouth soreness and they have problems eating and they require more support, IV fluids. We use ice chips a couple of hours before we start the infusion of melphalan and after to decrease the absorption of the melphalan in the gut and esophagus, the first part of the intestine. And it works actually so we don't meet a lot of patients with severe mucositis anymore. We are able to support, we perform this transplant in the outpatient clinic and the majority We are able to stay in clinic with more support, IV fluid, transfusion support, antibiotics, but we don't see a lot of the mucositis. As I said, the chemotherapy, the old fashioned chemotherapy, but we don't see the dosage that we use. We use some cytoxin in combination, cyclophosphamide with some of these regimens, but we don't see a lot of this mucositis. So I say with the high dose melphalan is probably the most common. I don't see a lot of patients with mucositis these days except in the transplant setting. How is mucositis managed? Supportive care, unfortunately, pain control, sometimes what we do, we switch the medication that we use to support patients during the transplant, the patients are on antibiotics, acyclovir, antiviral antibiotics, and we switch those antibiotics to a venous IV infusion. Fluids, electrolytes, supplementation, you know, with the mucositis of the entire gut we see some colitis, we see diarrhea, and so we know the absorption is not great. So IV fluid. It generally doesn't last for a long period of time, so you really don't have to go to the parenteral nutrition, you really don't need to. So I would say electrolytes, supplementation, some patients will require some pain medications and just, you know, waiting for the Y-sign to recover. Of course we use growth factors to expedite the recovery, but it's supportive care.