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Recommendations Summary

ONC: Glutamine and Oral Mucositis in Adult Oncology Patients 2013

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    ONC: Glutamine and Oral Mucositis in Adult Oncology Patients with Solid Tumors and Hematological Malignancies

    If use of parenteral glutamine is proposed to prevent or treat oral mucositis in oncology patients with solid tumors,  the registered dietitian nutritionist (RDN) should advise that its use may or may not be beneficial. Limited research in head and neck and stem cell transplantation patients receiving parenteral glutamine has not established the effectiveness of L-Alanyl-L-Glutamine in treating or preventing oral mucositis.

    Enteral or oral provision of glutamine was not evaluated.

    Rating: Weak
    Conditional

    • Risks/Harms of Implementing This Recommendation

      Risks associated with parenteral glutamine administration are similar to those of parenteral nutrition (i.e., increased risk of infection).

    • Conditions of Application

      • This recommendation is limited to the use of IV glutamine in patients with head and neck cancer receiving chemoradiation therapy
      • Availability and access to supplemental IV glutamine
      • Consider advance directives when planning nutrition intervention.

    • Potential Costs Associated with Application

      Additional cost of supplemental IV glutamine.

    • Recommendation Narrative

      The evidence summary below is based on research from searches completed through May 2008 (Harris et al, 2008) and Oncology Nursing Society Putting Evidence into Practice (ONS PEP) Mucositis Research Evidence Table, with searches completed through June 2011.

      L-Alanyl-L-Glutamine

      • The effectiveness of treating of oral mucositis with glutamine has not been established. One small study (N=29), in which patients were given a standard MFS in addition to IV glutamine, showed a moderate effect over mucositis intensity (P=0.044). In another study (N=32 allogeneic stem cell transplantation patients), in which patients were given parenteral (PN) supplemented with 0.57g/kg glutamine-dipeptide, the daily oral mucositis score (DMS) in the Glutamine Group vs. the Placebo Group results were NS and there was no difference in mean daily dose of morphine to alleviate the pain of mucositis. Prevention of mucositis using glutamine has not been demonstrated.
      • As of June 2011, ONS PEP included a third study (N=326), in which glutamine was administered orally to breast cancer patients. Glutamine was shown to significantly reduce the incidence of WHO grade 2 or higher and grade 3 or higher oral mucositis, compared to placebo. However, the rating (weight of evidence category) remained the same.
      • Weight of Evidence Category: Effectiveness Not Established.

    • Recommendation Strength Rationale

      • The Academy of Nutrition and Dietetics (AND) and the Oncology Expert Work Group concurs with the ONS Putting Evidence Into Practice (PEP) guideline on Evidence-based Interventions for the Management of Oral Mucositis and approved the following equivalency scale: External Guideline EAL Equivalency Rating.
        • Evidence to support the recommendation: Effectiveness not established (EAL Rating Equivalent: Weak).

    • Minority Opinions

      None.