Palliative : Prevention/Treatment of Radiation Mucositis/Proctitis

Radiation proctitis is a known complication of radiation therapy for prostate cancer. Commercially available treatments are often ineffective and have focused on relieving symptoms after damage has occurred, although options exist for prevention.

A prospective, randomized, placebo-controlled, double-blinded trial concluded that misoprostol rectal suppositories significantly reduce acute and chronic radiation proctitis symptoms in patients receiving radiation therapy for prostate cancer.

Am J Gastroenterol 2000 Aug;95(8):1961-6
A prospective randomized placebo-controlled double-blinded pilot study of misoprostol rectal suppositories in the prevention of acute and chronic radiation proctitis symptoms in prostate cancer patients.
Click here to access the PubMed abstract of this article.

Seven patients with radiation proctitis completed an open pilot study to evaluate the effectiveness of short chain fatty acid (SCFA) enemas. Four weeks of treatment resulted in clinical improvement in all patients, and modest changes in endoscopic and pathological parameters.

Am J Gastroenterol. 1996 Sep;91(9):1814-6
Evaluation of short-chain fatty acid enemas: treatment of radiation proctitis.
Click here to access the PubMed abstract of this article.

Topical sucralfate may induce a lasting remission in a majority of patients with moderate to severe rectal bleeding due to radiation proctosigmoiditis.

Dig Dis Sci 1999 May;44(5):973-8
Natural history of late radiation proctosigmoiditis treated with topical sucralfate suspension.
Click here to access the PubMed abstract of this article.

Topical morphine is effective in relieving mucositis-associated pain following concomitant chemoradiotherapy in head and neck carcinoma. Three patients, who had been treated previously with oral morphine with no relief from esophagitis pain, swallowed from 2 to 10 mL of 0.1% morphine viscous gel three times a day, 5 to 60 minutes before eating. The gel covered esophageal surfaces and produced topical anesthesia. Benefit continued to increase over several days of use. In prior studies, relief of oral mucositis pain was obtained by a topical 0.1% morphine solution. The major advantages of topical morphine administration are simplicity, low incidence of side effects, and low cost.

J Pain Symptom Manage. 2005 Aug;30(2):107-9.
Chemoradiotherapy-induced esophagitis pain relieved by topical morphine: three cases.
Click here to access the PubMed abstract of this article.

“Mucositis is a common adverse event related to many antineoplastic regimens... Ketamine is a potent N-methyl-D-aspartate (NMDA) receptor channel blocker that can lead to decreased nocioception and inhibit the inflammatory cascade… Also, ketamine acts on a number of other pathways that may attenuate pain.”

Ketamine mouthwash (20 mg/5 ml) administered using the “swish and spit” technique may be a viable treatment option in refractory mucositis pain.

J Palliat Med. 2009 Nov;12(11):989-91.
Ketamine mouthwash for mucositis pain.
Click here to access the PubMed abstract of this article.

Systemic doxepin, a tricyclic antidepressant, has been used for pain management of patients with chronic pain. Practitioners at major US universities and in private practice assessed pain reduction after topical doxepin rinse in fifty-one patients with painful oral mucositis attributable solely to cancer therapy. A significant reduction of oral pain was recorded after doxepin was administered. At 5 minutes, on average, patients reported a 41% decrease in pain, and the median duration of pain reduction lasted for almost 2˝ hours. Taste was acceptable and discomfort/burning with use was minimal. These findings are in contrast to typical complaints of taste and discomfort/burning associated with topical application of local anesthetics.

Anesth Analg 2006;103:465–70
Oral Doxepin Rinse: The Analgesic Effect and Duration of Pain Reduction in Patients with Oral Mucositis Due to Cancer Therapy
Click here to access the PubMed abstract of this article.