Hematologic neoplasms (lymphomas, leukemias, and myelomas) represent approximately 10% of all tumors. Antineoplastic treatments, including chemotherapy, targeted therapies, and immunotherapy, generate gastrointestinal toxicity that impacts therapeutic efficacy and nutritional status, establishing a vicious cycle of malnutrition and toxicity.
Materials and methodsA narrative review was conducted using a literature search of the electronic databases PubMed, Embase, UpToDate, and Medscape for chemotherapy, targeted therapies, and immunotherapy used in lymphomas, leukemias, and multiple myeloma. The frequencies of gastrointestinal adverse effects (diarrhea, nausea/vomiting, mucositis), as well as those of grade ≥3, were analyzed.
ResultsThe results are presented in tables showing the commonly used drugs along with the probability of experiencing gastrointestinal adverse effects. In acute lymphoblastic leukemia, therapies such as Tisa-Cel and Brexu-Cel, with or without cytotoxic agents, cause gastrointestinal toxicity in almost all patients. In acute myeloid leukemia, most drugs produce nausea and vomiting, while diarrhea and mucositis are less frequent (30%). In chronic lymphocytic leukemia, diarrhea is prominent with targeted therapies (ibrutinib [42%], idelalisib [47%]). In chronic myeloid leukemia, bosutinib causes the highest rate of gastrointestinal intolerance (68%). In non-Hodgkin lymphoma, most combinations induce nausea/vomiting (>90%). Regarding multiple myeloma, gastrointestinal effects are generally low, with the exception of some immunotherapies (selinexor, elranatamab, elotuzumab).
DiscussionDiarrhea, nausea, vomiting, and mucositis are common complications, with diverse mechanisms depending on the drug. These toxicities directly impact nutritional status and quality of life, potentially requiring modifications to treatments.
ConclusionsUnderstanding the frequency and severity of gastrointestinal side effects of drugs used to treat hematological malignancies can facilitate early diagnosis and medical-nutritional management, which can be key to reducing malnutrition and improving clinical outcomes in hematological tumors.
Las neoplasias hematológicas (linfomas, leucemias y mielomas) representan alrededor del 10% de los tumores. Los tratamientos antineoplásicos, incluidos la quimioterapia, las terapias dirigidas y la inmunoterapia, generan toxicidad digestiva que repercute en la eficacia terapéutica y en el estado nutricional, estableciendo un círculo vicioso desnutrición/toxicidad.
Material y métodosSe realizó una revisión narrativa mediante la búsqueda bibliográfica, para la que se han utilizado las bases de datos electrónicas: PubMed, Embase, Up To date y Medscape, de quimioterapia, terapias dirigidas e inmunoterapia usadas en linfomas, leucemias y mieloma múltiple. Se analizaron las frecuencias de efectos adversos digestivos (diarrea, náuseas/vómitos, mucositis), así como los de grado ≥3.
ResultadosLos resultados se expresan en forma de tablas donde aparecen los fármacos habitualmente utilizados junto con la probabilidad de presentar efectos adversos digestivos. En leucemia linfoblástica aguda, terapias como Tisa-Cel y Brexu-Cel, asociada o no a citotóxicos, presentan toxicidad digestiva en la práctica totalidad de los pacientes. En leucemia mieloide aguda, la mayoría de fármacos producen náuseas y vómitos, mientras que la diarrea y la mucositis son menos frecuentes (30%). En leucemia linfocítica crónica, la diarrea destaca en las terapias dirigidas (ibrutinib [42%], idelalisib [47%]). En leucemia mieloide crónica, bosutinib ocasiona mayor intolerancia digestiva (68%). En linfoma no Hodgkin, la mayoría de combinaciones inducen náuseas/vómitos (>90%). Por lo que respecta al mieloma múltiple, los efectos digestivos son generalmente bajos, con excepción de algunos inmunoterápicos (selinexor, elranatamab, elotuzumab).
DiscusiónLa diarrea, las náuseas, los vómitos y la mucositis son complicaciones habituales, con mecanismos diversos según el fármaco. Estas toxicidades impactan directamente en el estado nutricional y en la calidad de vida, pudiendo obligar a modificar los tratamientos.
ConclusionesConocer la frecuencia y la severidad de los efectos secundarios digestivos de los fármacos utilizados frente a las neoplasias hematológicas puede facilitar el diagnóstico precoz y el abordaje médico/nutricional, lo que pueden resultar clave para reducir la desnutrición y mejorar los resultados clínicos en los tumores hematológicos.
Hematologic neoplasms constitute a broad and heterogeneous group of diseases that can be broadly classified into lymphomas, leukemias, and myelomas, with non-Hodgkin lymphoma being the most frequent. Hematologic malignancies account for approximately 10% of all diagnosed tumors.1 The Spanish Network of Cancer Registries (Red Española de Registros de Cáncer [REDECAN]) estimates that 25,770 cases of hematologic neoplasms will have been diagnosed in Spain by 2025, representing adjusted rates of 34.9 and 13.6 cases per 100,000 inhabitants/year for lymphoid and myeloid neoplasms, respectively. Overall, these malignancies represent the fifth most widely diagnosed cancer, after colorectal, breast, lung, and prostate cancer. According to this report, despite advances in diagnosis and treatment, the 5-year survival rate for these neoplasms was 62%, with a better prognosis observed in lymphoid neoplasms (68%) compared with myeloid neoplasms (50%).2
It is well established that malnutrition is frequent in patients with cancer and worsens prognosis. Its prevalence depends on the type of cancer, stage at diagnosis, treatments received, patient age, associated comorbidities, and the nutritional assessment methods used.3 In hematologic malignancies, a high frequency of malnutrition has been described,4 resulting from direct gastrointestinal involvement due to infiltration of the digestive tract, as occurs in 25%–50% of leukemias and approximately 10% of lymphomas, or from the antineoplastic treatments used. Contributing factors include age, patient comorbidities at diagnosis, treatments received, and treatment response during follow-up.5 Similarly, sarcopenia is common in these patients, leading to lower functionality and poorer quality of life.6
Both conventional chemotherapy and targeted therapies directed against molecular targets, as well as immunotherapy, may damage the digestive system, causing different types of dysfunction such as diarrhea, constipation, intestinal perforation, nausea, vomiting, and mucositis, among others. This GI toxicity may affect patients through 3 mechanisms: the adverse effect itself (pain, dehydration, bleeding, etc.), decreased treatment effectiveness (dose delays, reductions, and discontinuations), and repercussions on nutritional and/or musculoskeletal status (sarcopenia). In addition, both the hematologic disease itself and many treatments induce an inflammatory state that contributes to malnutrition and sarcopenia through different mechanisms.7
In the case of conventional chemotherapy, a systemic inflammatory response occurs accompanied by increased secretion of glucocorticoids and proinflammatory interleukins in a context of increased oxidative stress, which induces muscle atrophy. Furthermore, many drugs used in hematologic neoplastic diseases (doxorubicin, cisplatin, cyclophosphamide, gemcitabine, methotrexate, taxanes, vinca alkaloids, etc.) may affect the musculoskeletal system through different pathways. Some tyrosine kinase inhibitors (TKIs) have also been associated with the onset or exacerbation of sarcopenia. This effect may be due to inhibition of the PI3K/AKT/mTOR pathway, which would affect muscle protein synthesis.8 Moreover, the presence of malnutrition and sarcopenia increases the risk of treatment toxicity, thereby creating a dangerous vicious cycle of malnutrition/toxicity that reduces the efficacy of antineoplastic treatments, treatment response, and quality of life, while increasing the incidence of complications and mortality.9,10
Our group previously conducted a review of the GI toxicity associated with oncologic treatments for solid tumors.11 In the present review, we describe the frequency of adverse events with nutritional impact associated with the antineoplastic treatments most commonly used in hematologic neoplasms, as well as strategies for early diagnosis and nutritional management adapted to each type of toxicity, although a specific review of the evidence regarding treatment of these complications was not performed.
The aim of this review is to provide a practical reference document describing the intestinal adverse effects caused by antineoplastic treatments used in hematologic malignancies, which may be useful for preventing their occurrence or for the early initiation of symptomatic treatments associated with these adverse effects to minimize complications.
Materials and methodsWe conducted a review of antineoplastic chemotherapy treatments routinely used in clinical practice in Spain, including cytotoxic drugs, immunotherapy, targeted therapies, and any combinations thereof for the treatment of the most common hematologic neoplasms: Hodgkin and non-Hodgkin lymphoma; acute lymphoblastic leukemia and acute myeloid leukemia; chronic myeloid leukemia, chronic lymphocytic leukemia, and multiple myeloma. The frequency (%) of gastrointestinal adverse events of any grade, such as diarrhea, nausea/vomiting, and mucositis, as well as grade 3 or higher events, was recorded.
After data collection, a narrative review was performed using a bibliographic search across the following electronic databases: PubMed, Embase, UpToDate, and Medscape. Appropriate modifications were made according to the requirements of each database, using the Boolean operators “AND” and “OR” and basic commands such as quotation marks (“”), truncation (*), and parentheses (). The term “cancer therapy” was sequentially combined with the following terms: “gastrointestinal toxicity” and “cancer chemotherapy.” Meta-analyses, systematic reviews, and clinical trials were included, as well as international guidelines providing strong evidence regarding the toxicity of hematologic treatments, together with all prescribing information sheets for medications routinely used in oncohematologic tumors within the Spanish Program of Hematology Treatments (Programa Español de Tratamientos en Hematología) of the Spanish Foundation of Hematology and Hemotherapy (Fundación Española de Hematología y Hemoterapia).12
ResultsThe results are presented in tables listing the drugs commonly used in the treatment of the most frequent hematologic neoplasms together with the probability of presenting any gastrointestinal adverse event and, in parentheses, the percentage of severe adverse events (grade ≥3) (Tables 1–3).
Common adverse effects of drugs used for the treatment of acute lymphoblastic leukemia (ALL) and chronic lymphocytic leukemia (CLL)18 and SmPC.
| Targeted therapies | Immunotherapy | Cytotoxic agents | Diarrhea: any grade (G ≥ 3) | Nausea/vomiting: any grade (G ≥ 3) | Mucositis: any grade (G ≥ 3) |
|---|---|---|---|---|---|
| ALL | |||||
| Imatinib | >10% | >10% | 0.1%–1% | ||
| Tisagenlecleucel (tisa-cel) | 31% (1%) | 30%–90% | 6% (1%) | ||
| Brexucabtagene autoleucel (brexu-cel) | 32% (6%) | 30%–90% | 1% | ||
| Rituximab | 1%–10% | <10% | 1%–10% | ||
| Inotuzumab | 17% (1%) | 30%–90% | 13% (2%) | ||
| Blinatumomab | 18% | <10% | 0.1%–1% | ||
| Methotrexate | 16% | 11%–31% | 11% | ||
| Idarubicin | 73% (15%) | 30%–90% | 50% (5%) | ||
| Fludarabine | 38% (5%) | 30%–90% | 2% | ||
| Cytarabine | >10% | 30%–90% | >10% | ||
| Vincristine | 0.1%–1% | <10% | 0.1%–1% | ||
| Daunorubicin | 10% | 30%–90% | 55% | ||
| Peg-asparaginase | 10% | <10% | 1%–9% | ||
| Cyclophosphamide | <1% | IV: 30%–90%/oral: 10%–30% | <1% | ||
| Ifosfamide | <1% | 30%–90% | <1% | ||
| Etoposide | 1%–10% | 10%–30% | 1%–10% | ||
| 6-mercaptopurine | >10% | 10%–30% | >10% | ||
| CLL | |||||
| Ibrutinib | 42% (3%) | 28% (1%) | 14% (1%) | ||
| Acalabrutinib | 36.7% (2.6%) | 13.3%–21.7% (1%) | |||
| Zanubrutinib | 21% (2%) | ||||
| Idelalisib | 47% | 15%–29% | 0.1%–1% | ||
| Venetoclax | >10% | >10% | |||
| Obinutuzumab | >10% | 5% | |||
| Ofatumumab | >10% | 1%–10% | 0.01%–0.1% | ||
| Chlorambucil | 1%–10% | 1%–10% | 1%–10% |
ALL, acute lymphoblastic leukemia; AML, acute myeloid leukemia; CLL, chronic lymphocytic leukemia; SmPC, summary of product characteristics.
Common adverse effects of drugs used for the treatment of acute myeloid leukemia (AML) and chronic myeloid leukemia (CML).12,13
| Combination | Immunotherapy | Cytotoxic agents | Diarrhea: any grade (G ≥ 3) | Nausea/vomiting: any grade (G ≥ 3) | Mucositis: any grade (G ≥ 3) |
|---|---|---|---|---|---|
| AML | |||||
| IDA/ARAC (3 + 7) | >10% | >10% | >10% | ||
| FLAGIDA | >10% | >10% | >10% | ||
| FLUGA | 1%–10% | 30%–90% | Mild | ||
| Azacitidine-venetoclax | 43% (5%) | 30%–90% | 18% (1%) | ||
| BU-CY | >10% | >10% | >10% | ||
| BU-FLU | >10% | >10% | >10% | ||
| Gemtuzumab ozogamicin | 33.9% (14.8%) | 30%–90% | 30.1% (12.3%) | ||
| Daunorubicin | >10% | 30%–90% | >10% | ||
| Cytarabine | >10% | 30%–90% | >10% | ||
| Idarubicin | >10% | 30%–90% | >10% | ||
| Fludarabine | 13%–15% | <10% | 1%–10% | ||
| Azacitidine | 36.9% | 10%–30% | 1%–10% | ||
| Decitabine | 31% (2%) | <10% | 7% (1%) | ||
| Mitoxantrone | 1%–10% | 10%–30% | 1%–10% | ||
| Clofarabine | 20% | 30%–90% | 11% | ||
| CML | |||||
| Imatinib | 32.8%–56% (1.8%–6%) | nausea: 43.7%–50% (0.7%–3%)/vomiting: 15%–28% (1.5%) | — | ||
| Bosutinib | 68%–81% (8%–11%) | nausea: 31%–43% (<1%)/vomiting: 32% (1%–3%) | — | ||
| Dasatinib | 17%–29% (1%–4%) | nausea: 31%–43% (<1%)/vomiting: 5%–13% (<1%) | — | ||
| Nilotinib | 6%–12% (<2%) | nausea: 11%–25% (<1%)/vomiting: 5%–13% (<1%) | — | ||
| Asciminib | 22.5% | 20.8% | |||
| Ponatinib | nausea: 3%–19% (<1%) | — |
AML, acute myeloid leukemia; BU-CY, busulfan + cyclophosphamide; BU-FLU, busulfan + fludarabine; CML, chronic myeloid leukemia; FLAGIDA, fludarabine + cytarabine + filgrastim + idarubicin; FLUGA, fludarabine + filgrastim + azacitidine; IDA/ARAC, idarubicin + cytarabine.
Common adverse effects of drugs used for the treatment of lymphomas (HL, NHL) and multiple myeloma (MM).15–22,30
| Combination | Immunotherapy | Cytotoxic agents | Diarrhea: any grade (G ≥ 3) | Nausea/vomiting: any grade (G ≥ 3) | Mucositis: any grade (G ≥ 3) |
|---|---|---|---|---|---|
| HL/NHL | |||||
| CHOP | >90% (1%–2%) | 2% | |||
| R-CHOP | >90% (1%–2%) | 2% | |||
| R-CHOEP | 13%–16% | >90% (1%–2%) | 8% | ||
| CVP | 0.1%–1% | ||||
| ESHAP/DHAP | 100% (<1%) | 2%–5% | |||
| GEMOX | 10%–30% | 1% | |||
| ICE | >90% (<1%) | 2%–5% | |||
| BEAM | >10% | >10% | 52% | ||
| Rituximab | 1%–10% | >10% | 1%–10% | ||
| Polatuzumab | 30.8% (3.9%) | 41.6%/14.9% (1.1%) | |||
| BCNU | 1%–10% | >10% | 1%–10% | ||
| Vincristine | 1% | 10% | |||
| Cyclophosphamide | >90% (1%–2%) | ||||
| Adriamycin | 10% | 34%–37% (5%) | 1%–2% | ||
| Etoposide | 1%–13% | 10%–30% (<1%) | 1%–6% | ||
| Cisplatin/oxaliplatin | 0.1%–1% | 76%–100% | 2% | ||
| Cytarabine | >10% | >10% | >10% | ||
| Ifosfamide | 0.1%–1% | >10% | 0.1%–1% | ||
| Gemcitabine | 1%–10% | >10% | 1%–10% | ||
| Bendamustine | >10% | 1%–10% | 1%–10% | ||
| Fludarabine | >10% | >10% | 1%–10% | ||
| Mitoxantrone | >10% | >10% | 1%–10% | ||
| MM | |||||
| Bortezomib | 12% | 9%–28% (6%) | 22% | ||
| Carfilzomib | 27% (3%) | >10% | |||
| Ixazomib | 29% | 27%–29% | |||
| Pomalidomide | >10% | >10% | 1%–10% | ||
| Thalidomide | >10% | ||||
| Lenalidomide | 38.5% | >10% | >10% | ||
| Cyclophosphamide | — | — | — | ||
| Melphalan | — | — | — | ||
| Talquetamab | 30% | 30% | 0.01%–0.1% | ||
| Selinexor | 41% (5%) | 37%–68% (6%) | |||
| Daratumumab | >10% | >10% | |||
| Isatuximab | 19% (1%) | 17%–32% | |||
| Teclistamab | 28.5% (3.6%) | 27.3% (0.6%) | |||
| Elranatamab | 42.3% (1.6%) | 26.8% | |||
| Belantamab | 12%–23% (11%) | 24%–31% | |||
| Elotuzumab | 47% (5%) | ||||
| Talquetamab | SC: 30%/IV: 28% (4%) | SC: 30%/IV: 23% |
BCNU, carmustine; BEAM, carmustine + cytarabine + melphalan; CHOP, cyclophosphamide + adriamycin + vincristine + prednisone; CVP, cyclophosphamide + vincristine + prednisone; ESHAP/DHAP, etoposide + prednisone + cytarabine + cisplatin/dexamethasone + cytarabine + cisplatin; GEMOX, gemcitabine + oxaliplatin; HL, Hodgkin lymphoma; ICE, ifosfamide + carboplatin + etoposide; MM, multiple myeloma; NHL, non-Hodgkin lymphoma; R-CHOEP, rituximab + cyclophosphamide + adriamycin + vincristine + etoposide + prednisone; R-CHOP, rituximab + cyclophosphamide + adriamycin + vincristine + prednisone; SC, subcutaneous; IV, intravenous.
In patients undergoing treatment for acute lymphoblastic leukemia, the presence of GI symptoms (diarrhea, nausea) with systemic repercussions is highly relevant and affects, to a greater or lesser extent, almost all patients, particularly when targeted therapies (tisa-cel, brexu-cel) are used, either alone or in combination with certain cytotoxic agents such as idarubicin, fludarabine, and others, without overlooking the potent emetogenic effect of some immunotherapeutic agents such as inotuzumab. The occurrence of severe diarrhea and mucositis is less frequent, except with idarubicin use, which affects 73% and 50% of treated patients, respectively.
In patients with chronic lymphocytic leukemia, GI intolerance related to antineoplastic therapy is much less frequent, perhaps with the exception of diarrhea associated with targeted therapies such as ibrutinib (42%), zanubrutinib (21%), and idelalisib (47%). The remaining drugs used in the treatment of chronic lymphocytic leukemia generally do not impair gastrointestinal tolerance to regular food intake (Table 1).12
In acute myeloid leukemia, it should be highlighted that combinations of the antineoplastic agents filgrastim, fludarabine, and cytarabine (FLUGA), the use of azacitidine for intensive or semi-intensive induction therapy, as well as the use of the immunotherapeutic agent gemtuzumab together with various cytotoxic drugs such as daunorubicin, cytarabine, idarubicin, or cladribine, are associated with nausea/vomiting in nearly all cases, whereas diarrhea (decitabine: 31%) and mucositis (gemtuzumab: 30.1%) are less frequent in most patients.
Regarding patients on antineoplastic treatment for chronic myeloid leukemia, targeted therapy with bosutinib is associated with the greatest gastrointestinal involvement (diarrhea: 68%; nausea/vomiting: 43% of treated patients),13 although other treatments within the same pharmacologic group (imatinib, dasatinib, and asciminib) are also associated with emetogenic effects in approximately 40% of cases14 (Table 2).
The presence of nausea/vomiting associated with any combination of antineoplastic drugs used in the treatment of non-Hodgkin lymphoma affects the vast majority of patients (90%–100%), with the exception of the GemOx combination (gemcitabine and oxaliplatin: 30%), and even less frequently with BEAM (BCNU, etoposide, cyclophosphamide, melphalan: 10%), although the latter combination is associated with a higher incidence of mucositis (52%) and greater nutritional repercussions.15,16
Finally, in patients treated for multiple myeloma, the incidence of gastrointestinal complications is low (<30%) with most drugs. The main exception is diarrhea associated with several immunotherapeutic agents (selinexor 41%; elranatamab 42.3%; or elotuzumab 47%), although in only <2% of cases does this complication require parenteral nutrition (Table 3).17–22
DiscussionDigestive adverse effects are a common problem during antineoplastic treatment in patients with hematologic malignancies. It is not uncommon for patients referred to the Endocrinology and Nutrition Department to present with overt malnutrition or for the first consultation to occur during hospital admission because of intestinal complications with nutritional repercussions. In addition to significantly reducing patients’ quality of life, this situation may lead to the need for suboptimal treatments.
Diarrhea is a very frequent adverse effect of drugs used against hematologic neoplasms. Among conventional chemotherapeutic agents, those most widely associated with the onset of diarrhea are idarubicin, fludarabine, azacitidine, and decitabine. The underlying mechanism is usually acute damage to the intestinal mucosa, leading to secretory diarrhea 5–7 days after drug administration.13
Regarding targeted therapies, diarrhea occurs particularly with the use of tisa-cel or brexu-cel in association with certain cytotoxic agents (idarubicin or fludarabine), or when used alone, as occurs with ibrutinib, acalabrutinib, zanubrutinib, and idelalisib. Bosutinib, and to a lesser extent imatinib, have also been associated with the onset of diarrhea.23
On the other hand, immune-mediated colitis is the main GI adverse effect caused by immunotherapy following the the production of autoreactive T lymphocytes. These symptoms usually occur early during treatment. However, diarrhea and/or colitis may recur months after treatment discontinuation or completion, mimicking chronic inflammatory bowel disease. Within this pharmacologic group, these adverse effects are mainly associated with the use of elotuzumab, elranatamab, and selinexor.24
Furthermore, the high doses of conventional chemotherapy used in leukemia, especially with etoposide, taxanes, platinum compounds, and gemcitabine, may produce neutropenic enterocolitis. This condition is characterized by abdominal pain, fever, neutropenia, and increased thickness of the colonic wall.25
Another sign of GI toxicity associated with drugs used in the treatment of hematologic neoplasms is nausea and vomiting. Conventional chemotherapeutic agents can be categorized as highly emetogenic (with >90% probability of vomiting, such as cisplatin, high-dose cyclophosphamide, daunorubicin, idarubicin, cytarabine, cladribine, etc.), moderately emetogenic (30%–90%, such as carboplatin, oxaliplatin, and anthracyclines), low emetogenic risk (10%–30%, such as taxanes, gemcitabine, or topotecan, etc.), and minimally emetogenic chemotherapy (<10%, such as vinca alkaloids or oral methotrexate, among others).
The use of drug combinations such as FLUGA and azacitidine is very frequently associated with nausea and vomiting. In the treatment of some hematologic neoplasms, such as non-Hodgkin lymphoma, these symptoms occur in almost all patients, with the exception of the GemOx and BEAM combinations.
Regarding targeted therapies, treatment with tisa-cel or brexu-cel is frequently accompanied by nausea and vomiting, and this risk increases when associated with idarubicin, daunorubicin, and fludarabine. Likewise, imatinib, bosutinib, and dasatinib commonly produce nausea/vomiting syndromes. With respect to immunotherapy, inotuzumab and gemtuzumab are very frequently associated with nausea and vomiting.26
Inflammatory or ulcerative lesions of the oral and/or GI mucosa (mucositis) may be caused by infectious diseases, immunodeficiency states, or drugs. Oral mucositis is a toxicity frequently due to conventional chemotherapeutic treatments and may worsen nutritional status in severe or prolonged cases. It usually begins with painful erythematous lesions that may progress to mucosal ulceration and, in severe cases, prevent oral intake. Poor oral hygiene and preexisting malnutrition are predisposing factors; therefore, preventive measures are necessary.12 Chemotherapeutic agents affecting DNA synthesis (such as alkylating agents, anthracyclines, and antimetabolites) and the BEAM regimen produce mucositis more frequently.
The risk of mucositis is relatively low with immunotherapy, except for gemtuzumab used in acute myeloid leukemia. Regarding targeted therapies, ibrutinib and bortezomib are most closely associated with the onset of mucositis.27
Medical nutritional treatment for GI toxicity associated with antineoplastic drugsToxicities affecting the digestive system should be diagnosed and treated early to prevent malnutrition and sarcopenia, and management strategies are similar to those published in our previous article.11
Both physicians and patients, together with their caregivers, should be aware of the risk of these toxicities. Prevention of chemotherapy-induced nausea and vomiting should be based on emetogenic risk according to local protocols derived from the latest international guidelines. Regarding antidiarrheal drugs, their use should follow a stepwise approach according to the severity of symptoms; in general, treatment begins with loperamide, progressing to octreotide in severe or persistent cases. In certain situations, the use of antibiotics (fluoroquinolones or metronidazole), budesonide, or bile acid sequestrants, among others, may be necessary.28 Regarding prevention and management of mucositis (topical agents, cryotherapy, palifermin, laser therapy, etc.), local protocols should be established based on the best available evidence.3
With respect to medical nutritional treatment, according to severity grade and the presence of risk factors or warning signs of complications, we propose the following management algorithms (Fig. 1).3 Dietary recommendations for each digestive toxicity indicated in the algorithm are presented in Table 4.29
Dietary/nutritional treatment of digestive disorders related to oncologic treatment. Source: Adapted by the authors from López-Delgado et al.29 Available at: SEOM updated guide on toxicity of oncologic treatments.
Digestive adverse effects affect a significant number of patients receiving antineoplastic treatment for hematologic malignancies. The use of targeted therapies associated with cytotoxic drugs in acute lymphoblastic leukemia, immunotherapy in acute myeloid leukemia, or most combinations of antineoplastic agents in the treatment of non-Hodgkin lymphoma are the treatments associated with the highest GI morbidity (>90%),30 compared with patients with chronic lymphocytic leukemia and chronic myeloid leukemia (40%–50%) or multiple myeloma (<30%).
Knowledge of the GI adverse effects associated with antineoplastic treatment for hematologic malignancies may help prevent their occurrence and reduce the risk of malnutrition. Furthermore, as established in the previous article,11 the importance of diagnosing the risk of malnutrition and implementing medical nutritional therapy early, ideally immediately after diagnosis while the patient evaluation is still ongoing, should not be overlooked to prevent the negative consequences associated with malnutrition.
None declared.
