Opioid Dosing and Duration for Managing Chemo-Induced Oral Mucositis in Children

Oral mucositis can be a side effect of chemotherapy treatment and may result in severe pain. This condition can be managed with intravenous (IV) opioids; however, management protocols vary, according to the authors of a study published in Pediatric Anesthesia. In this study, researchers conducted a systematic review, and a large single-center case series to investigate IV opioid management protocols in children with cancer experiencing chemotherapy-induced oral mucositis.

The researchers queried Medline, PubMed, and Cochrane databases to identify studies of younger patients with chemotherapy-induced oral mucositis. Eligible studies included data on opioid administration duration and/or dose requirements for this condition. In addition, the team analyzed the pain service database at their center to characterize opioid administration by patient-controlled analgesia (PCA), or nurse-controlled analgesia (NCA) for children with mucositis or other cancer treatment-related pain across a seven-year timespan.

For the systematic review, the researchers identified 17 studies: six randomized trials, two prospective observational, three retrospective cohort, six retrospective case series. In total, data from 618 patients, aged between 0.3 to 22.3 years, were analyzed. Reported parameters varied across studies. Opioid administrated lasted between three to 68 days, at variable dose trajectories ranging from 0 to 97 mcg/kg of morphine or equivalent per hour. The authors noted that “mucositis severity and chemotherapy indication influenced IV opioid requirements.”

In the case series, 364 episodes of severe mucositis in 302 patients were included in the analysis. Patients were aged between 0.12 and 17.2 years. Administration duration ranged from 1 to 107 days. Dose requirements in the first three days of administration ranged from 1 to 110 mcg/kg per hour. Patients’ age or sex was not associated with longer duration of opioid treatment. Factors associated with longer duration of PCA/NCA administration included: higher initial morphine requirements (P = 0.46), subsequent increased pain, and need for ketamine co-analgesia. There were 118 episodes of ketamine co-analgesia in this cohort. Duration in these cases lasted for a median of 13.9 days for ketamine and 6.0 days for opioid only.

In conclusion, the authors wrote, “Management of severe mucositis pain can require prolonged IV opioid therapy. Individual and treatment-related variability in analgesic requirements highlight the need for regular review, titration, and management by specialist services.”