Everolimus and other mTOR inhibitors are associated with a distinct set of adverse events, including stomatitis. This class of agents requires a unique strategy for managing toxicity, since stomatitis has a tendency of occurring very rapidly, notes Sara Hurvitz, MD. In addition to stomatitis, other adverse events should be monitored, notes Hurvitz. It is important to follow glucose levels and to watch for coughing or shortness of breath, since there is a risk of developing pneumonitis.

The first step in the management process requires patient education on proper oral care. Stomatitis can be effectively addressed using dose reductions, notes Hurvitz. In general, she starts with the 10-mg dose and reduces to 7.5-mg and even as low as 5-mg, if necessary. However, Hurvitz does not recommend reducing the dose below 5 mg daily.

While not all of the panelists agree on the use of steroid mouthwashes, Hope S. Rugo, MD, does utilizes this method prophylactically. However, in a subanalysis of the BOLERO-2 trial, dose reductions and delays were not associated with a worse outcome. In many situations, patients with mucositis or stomatitis who received dose reductions had similar, if not better, outcomes compared with those who did not experience this adverse event, Rugo notes.

Clinical trials are beginning to examine the effectiveness of steroid mouth rinses at reducing the rate of stomatitis. Initially, a formulation with hydrocortisone tablets was utilized; however, this was changed to a commercially available dexamethasone solution, Rugo notes. Data should be available soon on the effectiveness of this prophylactic approach.