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256 Mucositis and stomatitis
evidence is needed for definitive recommendations, but small uncontrolled
studies of topical indomethacin formulations (one a gel, the other a 0.25%
spray) have reported that its application reduced both pain and need for
opioids in CTAM. 9,10 The indomethacin spray is well tolerated and has few or
no significant side effects, although the potential for systemic absorption
(and accompanying toxicity) must be acknowledged. 10 Benzydamine, available
in some countries as a mouthwash, may have some prophylactic utility
for CTAM mucositis but a 2007 Cochrane review found no role for the agent
in acute care pain relief. 2,11
One trial of an oral rinse with doxepin (5 mg/mL) showed effective CTAM
relief as soon as 15 minutes after dosing. 12 At least for refractory CTAM pain,
doxepin rinse seems to have a role for acute care prescription. Pain relief
persists for at least 3–4 h after the mouthwash, and the average patient’s pain
decreases by 70%. 12 The capsule form of doxepin is not as effective, being
shown to be substantially inferior to PO opioids. 13
Preliminary reports suggest CTAM utility for topical rinse with ketamine. 14
No methodologically rigorous trial data exist but ketamine, like doxepin,
may be a reasonable choice for refractory CTAM pain.
Local anesthetics such as tetracaine or lidocaine (in a viscous formulation)
are often recommended for CTAM, but their utility is not definitively
demonstrated. 15–18 A preliminary (phase II) trial suggests topical tetracaine
gel reduces the pain of radiation-related CTAM in about 80% of patients. 19
Further studies may demonstrate utility of the local anesthetics. This class
does exhibit some systemic absorption after topical oral therapy, but toxicity
is unexpected given the minimal blood concentrations. One trial has shown
that rinsing for 1 min (followed by expectoration) with 5 mL of a 2% lidocaine
solution results in subtherapeutic blood levels of the drug. 20
The local anesthetics have also been applied topically as part of multidrug
compounds. One such compound is administered as a mucosal adhesive watersoluble
film, containing tetracaine, ofloxacine, miconazole, guaiazulene, and
triacetin. The preparation is effective at relieving CTAM, but the evidence is
insufficient to warrant a recommendation for ED use of the preparation. 21
Perhaps the best known multidrug compound incorporating local anesthetics
is “magic mouthwash,” which comprises equal parts viscous lidocaine,