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Desenvolvimento de um protocolo hospitalar de tratamento da mucosite e estomatite oral em Pediatria
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As náuseas, os vómitos e a neutropenia febril eram consideradas as complicações mais limitantes da terapêutica oncológica, tendo surgido nas últimas décadas opções terapêuticas para o controlo das mesmas. Face a estes efeitos, o estudo de estratégias preventivas e terapêuticas para a mucosite oral foi subestimada, tendo recentemente emergido como um dos efeitos mais debilitantes. Com o surgimento das terapêuticas direcionadas, foi identificado um espetro de toxicidades orais distintas da mucosite, nomeadamente a estomatite oral. Apesar de frequentemente consideradas sinónimos na literatura, correspondem a processos fisiopatológicos diferentes, mas ambos podem comprometer o sucesso do tratamento.
Atualmente, ainda não existe uma abordagem profilática e terapêutica padrão. Embora estejam disponíveis diretrizes para a prática clínica em adultos, estas não são extensíveis à pediatria, verificando-se uma acentuada escassez de ensaios robustos nesta população. Perante esta realidade, a prevenção e tratamento destas patologias constitui um desafio singular, com poucas estratégias de gestão e ferramentas de avaliação adaptadas a esta coorte, o que conduz a uma necessidade iminente de uniformização das evidências disponíveis. Deste modo, o âmbito do presente trabalho prendeu-se com o desenvolvimento de um protocolo hospitalar de prevenção e tratamento da estomatite e mucosite oral, na população pediátrica. O protocolo foi projetado como uma importante ferramenta clínica de suporte, para orientar os farmacêuticos nas suas intervenções nas equipas multidisciplinares e na comunicação médico-farmacêutico. Simultaneamente, pretende aumentar a consciencialização entre os profissionais de saúde para reconhecer e classificar com precisão os efeitos ao nível da cavidade oral.
Através de uma exaustiva pesquisa bibliográfica, com análise das principais orientações clínicas internacionais, identificaram-se as abordagens farmacológicas e não farmacológicas utilizadas na prevenção e tratamento da mucosite e estomatite oral. O tratamento é essencialmente de suporte e paliativo, através do controlo da dor, suporte nutricional, prevenção de infeções secundárias e controlo da xerostomia. Para isso, recorrem-se a agentes como anestésicos tópicos, anti-inflamatórios, antimicrobianos, fotobiomodulação, crioterapia, agentes de revestimento e palifermina na mucosite, predominando a utilização de corticosteroides na estomatite. O estabelecimento de protocolos de higiene oral, a educação dos pais e da criança e uma avaliação periódica da cavidade oral constituem também intervenções de extrema relevância.
Nausea, vomiting, and febrile neutropenia were considered the most limiting complications of cancer therapy. In the last decades, therapeutic options to control these effects have emerged, but the study of preventive and therapeutic strategies for oral mucositis, now considered one of the most debilitating effects, was underestimated. With the emergence of targeted therapies, a spectrum of oral toxicities distinct from mucositis was identified, namely oral stomatitis. Although often considered synonymous in the literature, they correspond to different pathophysiological processes, but both can compromise treatment success. Currently, there is still no standard prophylactic and therapeutic approach. Although guidelines for clinical practice in adults are available, they do not extend to pediatrics, and there is a marked shortage of robust trials in this population. Given this reality, the prevention and treatment of these pathologies is a unique challenge, with few management strategies and assessment tools adapted to this cohort, which leads to an imminent need to standardize the available evidence. Thus, the scope of this work was related to the development of a hospital protocol for the prevention and treatment of oral mucositis and stomatitis in the pediatric population. The protocol was designed as an important clinical support tool to guide pharmacists in their interventions in multidisciplinary teams and physician-pharmacist communication. At the same time, it aims to raise awareness among health professionals to recognize and classify the oral cavity's effects accurately. Through an exhaustive literature review, with an analysis of the main international clinical guidelines, the pharmacological and non-pharmacological approaches used to prevent and treat mucositis and stomatitis were identified. Treatment is essentially supportive and palliative through pain control, nutritional support, prevention of secondary infections, and control of xerostomia. For this, agents such as topical anesthetics, anti-inflammatory drugs, antimicrobials, photobiomodulation, cryotherapy, coating agents and palifermin are used in mucositis, with the predominant use of corticosteroids in stomatitis. The establishment of oral hygiene protocols, parent and child education, and periodic assessment of the oral cavity are also highly relevant interventions.
Nausea, vomiting, and febrile neutropenia were considered the most limiting complications of cancer therapy. In the last decades, therapeutic options to control these effects have emerged, but the study of preventive and therapeutic strategies for oral mucositis, now considered one of the most debilitating effects, was underestimated. With the emergence of targeted therapies, a spectrum of oral toxicities distinct from mucositis was identified, namely oral stomatitis. Although often considered synonymous in the literature, they correspond to different pathophysiological processes, but both can compromise treatment success. Currently, there is still no standard prophylactic and therapeutic approach. Although guidelines for clinical practice in adults are available, they do not extend to pediatrics, and there is a marked shortage of robust trials in this population. Given this reality, the prevention and treatment of these pathologies is a unique challenge, with few management strategies and assessment tools adapted to this cohort, which leads to an imminent need to standardize the available evidence. Thus, the scope of this work was related to the development of a hospital protocol for the prevention and treatment of oral mucositis and stomatitis in the pediatric population. The protocol was designed as an important clinical support tool to guide pharmacists in their interventions in multidisciplinary teams and physician-pharmacist communication. At the same time, it aims to raise awareness among health professionals to recognize and classify the oral cavity's effects accurately. Through an exhaustive literature review, with an analysis of the main international clinical guidelines, the pharmacological and non-pharmacological approaches used to prevent and treat mucositis and stomatitis were identified. Treatment is essentially supportive and palliative through pain control, nutritional support, prevention of secondary infections, and control of xerostomia. For this, agents such as topical anesthetics, anti-inflammatory drugs, antimicrobials, photobiomodulation, cryotherapy, coating agents and palifermin are used in mucositis, with the predominant use of corticosteroids in stomatitis. The establishment of oral hygiene protocols, parent and child education, and periodic assessment of the oral cavity are also highly relevant interventions.
Descrição
Trabalho Final de Mestrado Integrado, Ciências Farmacêuticas, 2021, Universidade de Lisboa, Faculdade de Farmácia.
Palavras-chave
Mucosite oral Estomatite oral Pediatria Prevenção Tratamento Mestrado integrado - 2021