Methylene blue may transform mucositis management in head and neck cancer

Methylene blue (MB) is a panacea with a wide range of therapeutic applications. While oncology nurses may be most familiar with the use of MB in treating ifosfamide-associated encephalopathy and mapping sentinel lymph nodes during breast cancer surgery, new and exciting uses for MB include treatment of oral mucositis. Pain management in patients with oral mucositis (OM) associated with inflammation (OM). Oral mucosa.

OM is a common side effect associated with both chemotherapy and radiotherapy.¹ It occurs in up to 40% of patients receiving chemotherapy and in up to 91% of head and neck cancer patients receiving radiation therapy.² As mucosal pain is a frequent symptom of OM, this condition can have a significant impact on patients’ quality of life.¹ Ultimately, the patient’s prognosis may be affected if the patient does not tolerate treatment, necessitating dose reduction or delay due to uncontrolled OM. OM can also pose a risk of infection, including bacteremia, if mucosal ulcers become infected.¹

Nurses can suggest preventive measures to patients to reduce the risk of OM. These measures include maintaining good oral hygiene habits, such as brushing twice a day with a soft toothbrush, flossing daily, and rinsing your mouth with solutions such as sodium bicarbonate. .² Dietary modifications may be recommended, such as avoiding acidic or harsh foods. In some cases, patients at high risk for OM may be advised to have a prophylactic gastrostomy tube (PEG tube) placed.²

Despite taking precautions, many patients still require additional prescription medications to manage OM and associated pain. Unfortunately, many commonly prescribed drugs, such as sucralfate, are ineffective.¹ Moreover, the formulation of “magic mouthwashes” lacks standardization in terms of their ingredients and proportions.² For most patients dealing with severe OM, systemic opioids, including intravenous opioids and patient-controlled analgesia, are required for pain management.¹

Insights from clinical trials of methylene blue in oral mucositis management

MB is used as a topical treatment to manage certain painful conditions such as anal fissures. It is also a subject of research for OM treatment. In a recent study published in cancerthe authors investigated the efficacy of MB mouthwash as a treatment for pain associated with OM in head and neck cancer patients undergoing radiotherapy with or without concurrent chemotherapy.³

This retrospective cohort study utilized electronic medical records to identify patients evaluated for pain related to OM in the pain management department of a major academic cancer center. These patients received radiation therapy to treat head and neck cancer between December 2019 and December 2020. The study included patients of all ages, genders, head and neck cancer diagnoses, and stages. Patients receiving radiation therapy in combination with chemotherapy or surgery were also included.

In addition to maintaining ongoing pain management strategies, including the use of systemic analgesics and other topical oral treatments, patients were given specific instructions regarding the use of MB. The subject was advised to gargle 10 mL of her MB oral solution for 5 minutes, then spit it out, and repeat this process every 6 hours until pain control was achieved. MB solution was prepared at a 0.05% dilution in either water or saline provided by the pharmacy.

Study outcome measures included patient-reported numerical rating scale scores for oral pain on an 11-point Likert scale ranging from 0 (no pain) to 10 (worst imaginable pain) and oral functional burden (OFB). changes (changes in oral functional load (OFB)). Seven-point scale from 0 (normal) to 6 (complete inability to eat, swallow, or speak; each category is scored as impossible = 2, difficult = 1, and possible = 0). The incidence, indication, and timing of PEG tube placement were also recorded.

The study included 58 adult patients, all of whom were already receiving topical treatment and opioid analgesics for OM pain. Using the National Cancer Institute Common Terminology Criteria for Adverse Events, all patients had grade 3 mucositis. Most patients (n=42, 72%) experienced a pain level reduction of more than 5 points, 11 patients (19%) had a pain reduction of 2 to 5 points, and 5 patients (9 %) showed a reduction in pain. Less than 2 points. The mean pain score was 7.59 before methylene blue treatment and 2.05 after treatment, a decrease in mean pain score of 5.53 points. In particular, most patients (n = 49) [84%]) reported the greatest pain relief with the first two doses of MB within 12 hours of treatment initiation. Five patients reported maximum pain relief after 3 to 4 doses within 24 hours of starting treatment.

The mean OFB score before MB treatment was 3.55 (SD, ±1.33; median, 3.5), but after MB treatment, this decreased to 0.52 (SD, ±0.86; median, 0). The mean decrease in OFB score was 3.03 (SD, ±1.54, median 3; P < .0001).

Eleven patients (19%) had a PEG tube inserted before starting MB therapy. Four of these patients (36%) were able to eat orally after using MB to control their pain. Two patients (3.44%) had their PEG tube placed after starting MB therapy.

Nursing considerations

Oncology nurses are often the first to learn that a patient has OM. Patients may share their symptoms while in the clinic or contact the triage nurse regarding symptoms of OM. Oncology providers may also ask nursing colleagues for suggestions for patient management based on the patient’s symptom burden. For a patient with refractory OM, the nurse may consider offering her MB as an option for pain management.

Nurses can also advise patients about potential side effects of MB therapy. Patients should be aware that, as the name suggests, MB causes a temporary blue staining of the mouth. Some patients may also experience a burning sensation in the oral cavity while using methylene blue, especially during the first treatment.³

This study shows that MB may be a promising breakthrough in analgesia for head and neck cancer patients undergoing radiotherapy. Promising results, including significant pain relief and improved oral function, highlight the potential of MB as a valuable addition to existing treatments.

References

1. Lara RV, Brennan MT, Gordon SM, Sonis ST, Rosenthal DI, Keefe DM. Oral mucositis due to high-dose chemotherapy and/or head and neck radiation therapy. J Natl Cancer Inst Monogr.. 2019;2019(53):lgz011. doi:10.1093/jncimonographs/lgz011
2. Brown TJ, Gupta A. Management of oral mucositis associated with cancer treatment. JCO Oncol Practo. 2020;16(3):103-109. doi:10.1200/JOP.19.00652
3. Roldan CJ, Rosenthal DI, Koyyalagunta D, Feng L, Warner K. Methylene blue for the treatment of radiation-induced oral mucositis during head and neck cancer treatment: an uncontrolled cohort. Cancers (Basel). 2023;15(15):3994. doi:10.3390/Cancer15153994