During HCV therapy dry mouth is a common irritating side effect, known
clinically as xerostomia.

Xerostomia can lead to an increased risk for dental problems such as tooth decay, gum  problems, mouth sores and other infections in the mouth.

Other drugs such as  antidepressants also cause dry mouth, however, giving up that antidepressant during therapy just isn't going to happen.  Unless you want channel your inner child, or Charlie Sheen, which isn't all that attractive. Well, either is interferon.

Anyhoo, today on the website we have a few tips on dealing with that annoying side effect, and some insight into what happens to the salivary gland during therapy. I figured the gland just sort of died, but apparently it comes back to life after treatment.

So tell me, which drug is the culprit, Ribavirin or Interferon ?

Well folks, from the December 2011 issue of Hepatitis Monthly we have a brief report entitled: "Ribavirin Impairs Salivary Gland Function in Hepatitis C  Patients During Combination Treatment With Pegylated Interferon  Alfa-2a," ya think?

 To read the full text Click Here , or read the discussion provided below.

We Begin With A Few Tips And Medications

Dry  Mouth

PREVENTIVE  STRATEGIES
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1. Maintain good oral  hygiene,  performing mouth care before and after meals and at bedtime. Gently floss the  teeth once daily after brushing.
 
2. Inspect the mouth daily for  patches while on therapy.
 
3. Maintain good denture care.
 
4. Maintain a high-protein  nutritional diet; avoid a high-carbohydrate diet, especially sugary foods that  provide “empty” calories.
 
5. Avoid alcohol and  tobacco.
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Symptomatic  patients  should be advised to:
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1. Choose moist foods (yogurts,  puddings, etc), adding sauces, gravies, and other lubricants to foods whenever  possible. Dry foods such as breads, crackers, or dry meats are not well  tolerated alone.
 
2. Use ice chips to keep mouth  lubricated and provide comfort.
 
3. Use topical salivary  stimulation methods, such as sugarless mints and gum, but avoid citric acid–containing solutions or foods, such as lemons. Products sweetened with Xylitol may have an antibacterial benefit.
 
4. Rinse mouth frequently with  saline solution.
 
5. Use fluoride treatment  regimen, as recommended by patient’s dentist.
 
6. Attend to any dental caries  that may exist and receive dental check for new-onset caries with prolonged  xerostomia.
 
7. Avoid carbonated beverages,  which can be painful ..

Solutions 
 
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What Is Magic Mouthwash  ?
Timothy Moynihan, M.D.   
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"Magic mouthwash" is the term  given to a solution prepared by pharmacists and used to treat mouth sores (oral  mucositis)
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Oral mucositis can be extremely  painful and can result in an inability to eat, speak or swallow.  Magic mouthwash  may be used to treat mouth sores that result from some forms of chemotherapy and  radiation therapy. 
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There are many versions of magic  mouthwash. Your doctor will likely write a prescription listing the ingredients  and the amount of each.

Magic mouthwash usually contains at least three of these  basic ingredients:
An antibiotic to kill bacteria around the sore
An  antihistamine or local anesthetic to reduce pain and discomfort
An antifungal to  reduce fungal growth
A corticosteroid to treat inflammation
An antacid to  enhance coating of the other ingredients inside the mouth . 
..
Most formulations of  magic  mouthwash are intended to be used every four to six hours, and to be held in  your mouth for one to two minutes before being either spit out or swallowed.  It's recommended that you don't eat or drink for 30 minutes after using magic mouthwash so that the medicine has time to produce an effect. 
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It's unclear how effective magic  mouthwash is in treating oral mucositis. That's because of the lack of  standardization in the formulations of mouthwash, and poorly designed studies  done to gather data. 
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If you have mouth sores that  cause you pain and discomfort, talk with your doctor. Side effects of magic  mouthwash may include problems with taste, a burning or tingling sensation in  the mouth, drowsiness, constipation, diarrhea, and nausea.
Click Here For More Information

Available Over The Counter

What Is Biotène?

Biotene Products:
Biotene Moisturizing Mouth  Spray
Biotene Oral Balance Liquid
Biotene Oral  Rinse
Biotene Dry Mouth Toothpaste
Biotene Dry Mouth Gum
Biotene
Oral Balance Gel
 
The strength of the Biotène products lies in their ingredients: they contain antibacterial enzymes found naturally in human saliva. 
Together, these ingredients re-create the natural oral protection found in the mouth, providing antibacterial and healing properties. Only Biotène's bio-enzyme  products can help maintain a healthy balance of oral flora, reducing harmful 
bacteria while sustaining beneficial bacteria. Recommended for everyone susceptible to cavities, bad breath, mouth sores, and gum disease.

Biotène contains three primary enzymes - Glucose Oxidase, Lactoperoxidase, and Lysozyme, which are carefully balanced for a special  function in boosting and replenishing saliva's own defenses. When used daily, Biotène reduces harmful bacteria, but leaves beneficial bacteria necessary for healthy teeth and oral tissues. 

Ribavirin Impairs Salivary  Gland Function in Hepatitis C Patients DuringCombination Treatment With Pegylated Interferon Alfa-2a

Alessio Aghemo 1, Maria Grazia Rumi 2*, Sara Monico 1, Matteo Banderali 3, Antonio Russo 4,Francesco Ottaviani 3, Mauro
Vigano 2, Roberta D’Ambrosio 1, Massimo Colombo 11 Migliavacca Center for Liver Disease, Division of Gastroenterology 1,  IRCCS Fondazione Ca’ Granda Hospital,  University of Milan, Milan, Italy2 Department of Hepatology, St. Joseph’s
Hospital, University of Milan, Milan, Italy 3 Department of Clinical Sciences, “L. Sacco “Hospital, University of Milan, Milan, Italy4 Departments of  Epidemiology and Biostatistics, San Carlo Borromeo Hospital, Milan,  Italy

Hepat Mon.2012;11(11) :in press. DOI: 10.5812/kowsar.1735143X.733

A B S T R A  C T

Background: Xerostomia is a common adverse event of unknown etiology observed during pegylated interferon (PegIFN)/Ribavirin (Rbv)  treatment.

Objectives: To assess the frequency and mechanisms of  xerostomia during PegIFN/Rbv therapy.

Patients and Methods: Thirty-one  naïve patients with chronic hepatitis C consecutively received PegIFN-α2a
(180 αg/week) plus Rbv (800–1200 mg/day). The controls were 10 patients with  chronic hepatitis B who received PegIFN-α2a (180 αg/week). During treatment and  follow-up, all patients underwent basal and masticatory stimulated sialometry,
otorhinolaryngoiatric (ORL) examination, and a questionnaire survey to subjectively assess symptoms of oral dryness.

Results: Twenty-seven  patients on PegIFN/Rbv and 4 on PegIFN (87% vs. 40%, P = 0.006) reported  xerostomia.

Thirty patients on PegIFN/Rbv combination therapy and 2 patients on monotherapy had ORL signs of salivary gland hypofunction (97% vs.  20%, P less then 0.0001). Mean basal (A) and stimulated (B) salivary flow rates  mL/min)progressively decreased during PegIFN/Rbv treatment (A, 0.49 at baseline  vs. 0.17 at the end of treatment, P less then 0.0001; B, 1.24 at baseline vs.  0.53 at the end of treatment, P = 0.0004).

At week 24 following  PegIFN/Rbv treatment, salivary flow rates were similar to baseline (A, 0.53 at  the end of follow-up vs. 0.49 at baseline; B, 1.19 at the end of follow-up vs.  1.24 at baseline). Salivary function was unaffected in monotherapy
patients.

Conclusions:Rbv causes salivary gland hypofunction in hepatitis  C patients receiving PegIFN/Rbv therapy,which promptly reverts to normal upon  cessation of treatment.

Discussion  Only

Click Here For PDF

Approximately 12% of all  patients with HCV infection receiving PegIFN/Rbv therapy ultimately develop  xerostomia, which in turn increases the risk of symptoms like dental cavities,  nausea, and constipation.

Our study demonstrates that dry mouth occurring  during anti-HCV therapy results from a reversible inhibition of salivary
gland function.At the same time, we show that symptoms of mouth dryness are  enhanced in HCV patients receiving PegIFN/Rbv therapy compared to HBV patients  receiving monotherapy with PegIFN, indicating a direct role of  Rbv.

Indeed, patients receiving PegIFN monotherapy showed no salivary  dysfunction, while only a few of them reported mild and transient symptoms of  mouth dryness. This is consistent with reports of the effects of other drugs  such as antidepressants,where, similar to our PegIFN monotherapy patients,  xerostomia is not directly caused by salivary gland impairment, as the secretory  function of salivary glands is preserved (17).

In our study, no HCV or  HBV patient required treatment with antidepressant drugs, ruling out any  influence of these drugs on observed salivary flow rates.While we ignore the  pathogenetic mechanisms of Rbv-induced hyposialia, we may speculate that the  changes in salivary flow in patients receiving PegIFN/Rbv might result from an  alteration of exocytosis and/or liquid transport of the exocrine glands  (18).

However,we acknowledge that unfortunately our study cannot provide  any information on this matter, as it was not designed for this endpoint.  Moreover, we believe that the exact pathogenic mechanisms behind this  observation can be unraveled only through studies evaluating sialochemistry and  eventually by salivary gland biopsies in patients undergoing Pe-gIFN/Rbv
therapy. Whatever the underlying mechanisms of Rbv-induced hyposialia, the absence of a correlation between hyposialia and Rbv dosing discourages Rbv dose-adjustment for patients with this undesired effect. Moreover, the recognition that salivary gland function is only temporarily impaired during PegIFN/Rbv treatment encourages counseling and treatment of the symptoms of  hyposialia with oral hydration or administration of saliva substitutes.

Treatment of xerostomia by ORL specialists may improve the patient’s quality of life by attenuating the impairment of the sense of taste, halitosis, and interference with functions such as speech, chewing, and swallowing (19), thereby not ompromising adherence to Rbv dosing.

This  finding has important clinical implications, since maintaining high Rbv doses will be essential in the future to maximize the antiviral effect of protease inhibitors of HCV replication, as recently shown by Phase II and III trials (20-23). While we acknowledge that the present study was conducted on a  relatively small number of patients, we think that the prospective enrollment  and the presence of a control group receiving PegIFN monotherapy allows the data  generated here to be confidently extrapolated to clinical practice  24).

Moreover, the risk of intrapatient variations due to age, smoking or other unrecognized environmental factors was attenuated by the saliva flow tests  carried out at different time points, and the risk of interpatient variation was  eliminated by the 100% compliance of the study participants (25).

The  enrollment of a control group of HCV patients receiving Rbv monotherapy in our  study would have further reinforced our findings, effectively eliminating the  possibility that HCV itself might play a role in the development of xerostomia,  whilst also allowing us to precisely determine which drug is the causal agent of  salivary gland hypofunction.

However,in the study design process we considered incorporating such a control group unethical, due to the minimal to
no antiviral effect associated with Rbv monotherapy, coupled with the potentially serious adverse events linked to its intake (18).

In  conclusion, this study demonstrates that Rbv is responsible for xerostomia occurring during anti-HCV therapy, causing transient salivary gland hypofunction  that does not appear to be dose-dependent and is promptly reverted upon  cessation of treatment.