Original Title: Guides et normes: Initier un traitement pharmacologique de la mucosite oropharyngée chez une personne qui reçoit un traitement antinéoplasique

Authors' objectives: The Ministère de la Santé et des Services sociaux (MSSS) tasked the Institut national d'excellence en santé et en services sociaux (INESSS) with hosting and updating the current national medical protocols and prescription templates, and with developing new protocols following a prioritization exercise overseen by the MSSS’s Direction nationale des soins et services infirmiers. Oropharyngeal mucositis is described as an inflammation of the mucous membranes lining the mouth, throat, and esophagus due to cancer therapy. It causes discomfort and severe pain, which can lead to difficulty eating and swallowing and thus affect the patient’s nutritional status and delay or interrupt their cancer treatments. The Direction asked INESSS to develop a national medical protocol, together with a collective prescription template, for initiating pharmacological treatment for oropharyngeal mucositis in a child or adult receiving cancer therapy.

Authors' results and conclusions: RESULTS: The data search yielded 2350 items, from which 11 clinical practice guidelines were selected. These guidelines were of sufficient methodological quality for use, based on the AGREE II instrument. In addition, five other publications useful for managing oropharyngeal mucositis in Québec and the other Canadian provinces were selected. Their contents were deemed to be of sufficient methodological quality for use, based on the AACODS checklist. From the review of the best clinical practice recommendations, the contextual data and the perspectives of the advisory committee’s members, a list was drawn up of the signs and symptoms of oropharyngeal mucositis and oral conditions that can be mistaken for it. While the severity of oropharyngeal mucositis is not critical for deciding whether to initiate treatment with an oncology mouthwash in an adult, this is not the case in the pediatric population, in which a rapid deterioration in overall health can occur more frequently, mainly because of dehydration. A major challenge in managing this condition in children is, therefore, to identify signs and symptoms suggestive of more advanced mucositis, which may require more aggressive management and for which the protocol should not be applied. Contraindications applicable only to children under 14 years of age were therefore included in the protocol to properly identify these situations. In addition, it was deemed appropriate to recommend two oncology mouthwash formulations in the national medical protocol. One contains a corticosteroid and should be used on a first-line basis, while the other contains lidocaine and should be used in cases of severe pain. All the ingredients in these mouthwashes are covered by the public prescription drug insurance plan to promote their use and limit the risk of a patient with mucositis not being able to afford them. Lastly, certain measures that should be taken to support the treatment of oropharyngeal mucositis were identified and were included among the items that are important to discuss with the patient to increase the chances of successful treatment and to limit the risk of a recurrence. CONCLUSION: This national medical protocol is based on best practice recommendations, which were supplemented with the perspectives of various experts and clinicians and with certain contextual aspects that had been identified. Given an analysis involving the triangulation of the data from these different sources, this document should enable the clinician to initiate pharmacological treatment for oropharyngeal mucositis in patients receiving cancer therapy and will support interdisciplinarity in the management of this condition and the standardization of the practice in the various settings. The advisability of updating the national medical protocol will be assessed at least every four years to allow for its revision within five years.

Authors' methods: A systematic review of clinical practice guidelines, expert consensus statements, guidance documents and other publications containing clinical recommendations was conducted across several databases in accordance with INESSS’s standards. The literature search was limited to items published between January 2008 and May 2021. The selected items concerned adult and pediatric populations with signs and symptoms of oropharyngeal mucositis. The search parameters were the criteria for evaluating this condition, the pharmacological treatments administered, the clinical situations for which the administration of medication is indicated or contraindicated, the necessary components of the follow-up based on the care setting, and the specific clinical situations requiring further investigation or reassessment with the prescriber. In addition, a manual literature search was conducted by consulting the websites of North American regulatory agencies, health technology assessment agencies, government agencies, and professional associations and bodies pertaining to the topic of interest. The bibliographies in the selected publications were scanned for other relevant items. The data were analyzed from the perspective of contextualizing practice in Québec, using mainly legislative, regulatory, and organizational contextual elements specific to Québec, and the perspectives of the different stakeholders consulted.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/thematiques/medicaments/protocoles-medicaux-nationaux-et-ordonnances-associees/protocoles-medicaux-nationaux-et-ordonnances-associees/mucosite-oropharyngee.html

Year Published: 2022

URL for published report: https://www.inesss.qc.ca/thematiques/medicaments/protocoles-medicaux-nationaux-et-ordonnances-associees/protocoles-medicaux-nationaux-et-ordonnances-associees/mucosite-oropharyngee.html

English language abstract: An English language summary is available

Publication Type: Other

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: Gouvernement du Québec