January 21, 2018 at 1:14 am #4610Expert NurseKrista Rubin
Curious how others would manage.
65 year old generally healthy male on ADJUVANT PD-1 for high risk melanoma (Stage IIIB). He is currently 10 cycles into treatment. Overall- he has experienced persistent and worsening dry mouth- now Grade 2. He has had to change to a soft diet consisting of pastas, soups, slippery foods, etc. He struggles with any carbs and other dry foods, including bread, crackers, etc. He very much enjoys eating, and is discouraged by how much he has had to change his diet. He has lost about 5 lbs; and that is recently (past 6 weeks). Otherwise, he is tolerating treatment well- no other limiting toxicities. He does have Grade 1 joint pains- but these are managed with low dose NSAIDs when needed.
Numerous xerostomia management strategies have been initiated- all minimally effective. Speech and swallow eval was obtained to ensure he was not at risk for aspiration (which he was not).
– this is adjuvant therapy. Expected course is one year
– on paper- he is tolerating extremely well
– QOL has been significantly impacted by treatment
Would love to hear how others would manage. I have some thoughts- but would very much appreciate feedback from others.
ThanksJanuary 21, 2018 at 2:53 pm #4611Expert NurseKathleen Madden
These are tough situations with patients receiving adjuvant treatment. Just a few questions, has treatment been with held at all to allow time for resolution? What is the patients level of motivation to continue in light of this persistent irAE which is impacting QOL? Was Sjogren’s considered or investigated with labs?
So taking inventory that:
This irAE being one of the less common one but it is no less impactful that other irAE’s & we don’t know potential long term issues ( ie dental issues)
It can be difficult to treat and and have prolonged resolution
The pt is almost half finished with therapy
My thoughts are; this is adjuvant I would hold treatment allow all toxicity to resolve, let the patient regain the lost weight if appropriate and see if patient can be restarted on therapy to complete a 12 month course of therapy successfully.
Thanks for bringing this challenging case for discussion, Looking forward to your reply!
-KathyJanuary 22, 2018 at 11:17 pm #4615Expert NurseSuzanne McGettigan
These side effects do have different implications in the adjuvant setting than in the metastatic setting. hold therapy is definitely a consideration.
it sounds like you have tried all of the conservative management strategies, but all of the things we would typically try for xerostomia from other anti-cancer therapies might be useful. It is important to ensure that patients are getting adequate hydration in general and also implementing strategies to keep their mucous membranes moist. Sugar-free gum and hard candy can occasionally be helpful in stimulating saliva production. Dry mouth can certainly be associated with dental complications, so making sure your patient is receiving regular dental care will be important.
There are numerous saliva substitutes available for patients currently–many are over the counter and a few are available by prescription. I won’t list all of the brand names here, but I do tend to have patients try one and quickly switch to another if they are not achieving good effect. I find the sprays easier to tolerate during daytime hours, saving the gels for the evening.
Acupuncture has been shown to have some benefit in radiation induced xerostomia, so also might be something to consider.
Hope that helps,
SuzanneJanuary 23, 2018 at 8:51 pm #4618Expert NurseBrianna Hoffner
Lots of great thoughts to consider in the management of this patient. One thing for us to keep in mind for our patients with dry mouth is that many of the OTC dry mouth remedies contain xylitol. I recently had a patient on immunotherapy who developed dry mouth and began using ACT Dry Mouth Lozenges. She presented to clinic with abdominal bloating and diarrhea and we were concerned that she had developed colitis. Work up was negative and ultimately we realized that her symptoms were secondary to the xylitol in the dry mouth lozenges. We have now prescribed PreviDent 5000 for Dry Mouth (toothpaste) and she has had improvement in dry mouth and resolution of abdominal bloating and diarrhea.
BriannaOctober 8, 2018 at 2:38 am #4900
It is interesting to read your blog post and I am going to share it with my friends.October 9, 2018 at 2:43 am #4902Expert NurseKathleen Madden
So glad that you are finding the forum valuable and of interest. Please do share & we welcome questions so please feel free to join in as there is an expert nurse overseeing this Q & A forum everyday.
thanks again for stopping by!
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