Joanne: Yes. Our practice has pretty much everything across the board from head and neck cancer patients with chemo/radiation, a significant amount of breast, lung, colon, and even melanoma patients. There's no distinct specialty. And because there's four doctors and have a lot of hospital consults, we see everything. And that's where we've noticed that mucositis doesn't have a particular favorite. It really spans across the board. And if patients become neutropenic (white blood cell reduction), they will more often than not develop mucositis. It's not necessarily even then dependent on the chemotherapy, but rather on your blood count.
Jeff: And based on your experience over the last decade, have you seen a rise in the incidence of oral mucositis due to patients living longer and being on more therapies, introduction of new therapies or introductions of cocktail therapies, for example?
Joanne: Yes. We definitely have chronic mucositis for chronic chemotherapies, because we have patients living for two, three, four years on chronic chemotherapy, even longer than that. So, we see it in many of our chronic chemotherapy cases. The more chemotherapy they're on, the more likely you're going to be neutropenic. Their defenses are very, very low. And the body, the first thing it does with low blood counts is allow increased mouth sores to develop.
Jeff: Now, most laypeople know that when you undergo chemotherapy or radiation, you very often are going to experience nausea and vomiting. And there is a obviously large market for anti-emetic therapies. You, as a caregiver or a nurse practitioner, treating these patients and caring for these patients, how do you view the side effect of oral mucositis in comparison to nausea and vomiting? Is it equally as big a problem or an issue for these patients? Bigger, smaller, depends on the patient?
Joanne: It's equally as big as nausea and vomiting. And if it isn't treated and it isn't treated upfront, it can halt chemotherapy. When patients end up in the hospital for oral mucositis that's grade three or four, they cannot eat or drink. So, it is as severe as nausea where someone can't eat and they get so dehydrated they end up in the hospital. Because severe mucositis, becomes to esophagitis and they have difficulty swallowing which interferes with their intake and leads to dehydration. When a patient becomes severely dehydrated, there is a higher risk of hospitalization.
Our goal, besides keeping them eating and keeping them out of pain, is to not delay the next cycle of chemo, because we want to keep their chemo on track. But, it's also keeping them out of the hospital. I mean, there are multiple goals here. But, number one, keeping chemo on track.
In our practice, MuGard has allowed us to become even more proactive in the treatment and prevention of mucositis because, before, we only had really Miracle Mouthwash, which wasn't used preventively. Magic mouthwash is given upon patients developing symptoms. Now, we're treating people upfront with MuGard. And we really see a big difference - much less incidence of mucositis.
Jeff: Before we get into your clinical experience with MuGard, historically before we knew about MuGard, what was typically done by you or your practice with respect to educating patients about what oral mucositis is, or the potential for this side effect? And then, you touched on it a little bit, but, what did you use in the past to treat patients once they got it?
Joanne: We did not educate proactively, because we didn't have a medication to treat it. So, we would advise about it and wait to see if a patient developed mucositis. Then, we would treat the symptoms of mucositis with Miracle Mouthwash, which is “swish and spit” or “swish and swallow”. You can use it either way. And I would say that that's really been our main line of defense, though it doesn't treat it mucositis. It doesn't increase how quickly they're going to heal. It numbs the sores for a short time.
Jeff: And how durable is that sort of palliative numbing effect of Magic Mouthwash?
Joanne: There is a pain relief benefit. Although, this alone is not as desirable as it's not treating the mucositis and patients are still in a significant amount of pain. I don't think it's a treatment, or it certainly isn't the answer. We're usually still searching for something else to go use in conjunction with it, as alone it does not solve the problem.
Jeff: So, you wouldn't have used anything prophylactically, because there was nothing really. You'd just use a Miracle or Magic Mouthwash after the patient presents with mucositis?
Joanne: Correct.
Jeff: Now, when did you start using MuGard, and what has your clinical experience been? Are patients using it prophylactically? Are they using it after the onset of symptoms? And what has your clinical experience with MuGard been?
Joanne: We've been using MuGard for about four months. We have about 80 patients using it and it has worked in all but one patient. We've used it very aggressively due to the positive results we have seen. We have a very large practice. We did not start with just new patients. We also started MuGard on people with active mouth sores. On these patients we saw improvement as well. So, we've used it in two ways; with new patients hoping they would use it prophylactically, and patients receiving treatment with mucositis. In patients receiving treatment with mucositis, we definitely saw a clear benefit. Their sores were healing quicker and their pain greatly decreased.
The new patients, we found, weren't really using it as indicated at first. It's important for us to also realize is, when patients are undergoing chemotherapy, prior to their first chemotherapy we provide them with multiple prescriptions. And it's just an overwhelming amount for any one person to understand. We also learned that some patients were not starting MuGard prior to treatment, but rather waiting for mouth sores to develop, and then initiating treatment after development of mouth sores we realized the need to restructure our teaching mechanisms on how important and effective it is to start using it beforehand.
Jeff: So you believe the clinical benefit seen, and a stronger education effort, will help move those who haven't been using MuGard prophylactically or preventively to do so next time around?
Joanne: Correct. And what we've seen is with some of our harder chemo regimens where they're getting the mouth sores, they're using MuGard, and then, they're healed. Now, we can tell them to before cycle two, "Start using it. Don't go off of it. This is how this drug is indicated”. If you use it before the sores appear, you're going to have a better benefit." Now, they'll believe us. So, what we're seeing is between cycles, after the first incidence of mucositis, they will use it all the time. And unfortunately, sometimes it takes that first incidence to keep them on it.
Jeff: Once a patient has used it even after getting oral mucositis, his next cycle of chemotherapy or his next regimen, if he progresses and they switch to a different regimen, would he be more likely to use it right upfront, having had the positive experience?
Joanne: Absolutely.
Jeff: Have you seen any other product that you've used in oral mucositis that provided as good a clinical benefit as MuGard that you've seen in the least few months?
Joanne: No. There is another competitive product, but it's labor intensive. It comes in two packages and it requires the patient to mix it together, which is rather difficult. These patients, after a few rounds of chemo, they aren't feeling particularly well. So, having to mix something together isn't always manageable for them.
Jeff: So, “ease of use” to the patient is important?
Joanne: Absolutely. Patients, after one or two rounds of chemo, are pretty knocked down. We need something straight up. Something that's easy to use, one, two, three. MuGard has made a huge impact in our practice. Our patients are thrilled. They call for prescriptions. I mean, they are absolutely ecstatic. It's the first product for oral mucositis we've had to give them that has made a difference.
Jeff: Well, that's all the questions I have. I appreciate you taking the time. Thank you very much, Joanne.
