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Pot of honey with honey dipper

NIHR Signal Honey may help painful mouth inflammation caused by cancer treatments

Published on 19 February 2019

doi: 10.3310/signal-000735

Compared to usual care, honey was more likely to reduce moderate or severe pain for patients after radiotherapy and/or chemotherapy treatment.

This systematic review looked at trials from around the world comparing different types of honey with other treatments such as chamomile, golden syrup or placebo. The main outcome was the onset of moderately severe oral mucositis as measured by a range of standardised assessment scales.

The findings suggest that honey might be useful, although whether the type of honey used makes a difference is uncertain. It may be prudent to choose sterilised medical honey, rather than raw natural honey, in people with reduced immunity.

Possible biases in the underlying studies make it is difficult to know how certain we can be in the review’s estimates of an effect. As most trials of honey seemed to show an improvement compared to their comparator treatments, better quality research seems justified.

Share your views on the research.

Why was this study needed?

Chemotherapy and radiotherapy can cause distressing and painful damage to the lining of the mouth and the upper gut. People have great pain swallowing even their own saliva, and there are few effective treatments

People are advised to have soft, bland food and avoid alcohol and tobacco. Ice and painkillers can also be helpful. Antibiotics may be required if an infection occurs.

NICE has recently published recommendations on the use of low-level laser therapy, but the use of honey is not currently advised. This study was designed to review the use of honey in preventing onset of the moderate to severe form of the condition and compare it to a range of other existing interventions.

What did this study do?

This systematic review looked at 17 randomised trials of 1,265 patients comparing the use of honey with other interventions for people receiving chemotherapy or radiotherapy.

Several different types of honey including manuka, dabur, pure natural and local honey were evaluated. These were compared with controls such as chamomile or golden syrup. The studies focused mainly on patients with head and neck cancers and most were conducted outside the UK; in India, USA, Canada, Turkey, Iran or New Zealand, for example.

The lack of a consistent usual care arm and poor reporting of methods increases the risk of bias in the underlying studies and reduces any confidence in the review itself.

What did it find?

  • Honey reduced onset of moderate to severe mucositis, when measured at two weeks to six months, by 75% compared with usual care (odds ratio 0.25, 95% confidence interval 0.14 to 0.46).
  • Honey did not show a statistically significant effect on the risk of adverse effects, such as bacterial or fungal colonisation.

What does current guidance say on this issue?

Honey is not currently recommended by NICE guidance. Recently published NICE interventional procedures guidance (2018) focuses on the use of low-level laser therapy which helps healing by reducing inflammation and increasing cell metabolism.

It states in addition good oral hygiene is required as well as a bland, soft diet and avoidance of alcohol and tobacco. Water-based moisturisers, painkillers and non-steroidal anti-inflammatory drugs provide symptom relief. Antibiotics may be necessary if an infection sets in.

What are the implications?

Honey is a relatively simple, cheap treatment, and for people with moderate to severe oral mucositis it may be an option worth trying. Antibacterial properties are claimed for some forms of honey, but these were not supported by the evidence presented here.

Natural honey contains inactive bacteria and spores which may pose some risk to people with reduced defences. Sterilised ‘medical’ honeys are available.

These results are of research interest. Larger carefully designed studies are needed to decide how useful honey might be in mucositis alongside other current treatments as well as the best dosage and timing, and any important side effects.

Citation and Funding

Yang C, Gong G, Jin E et al. Topical application of honey in the management of chemo/radiotherapy-induced oral mucositis: a systematic review and network meta-analysis. Int J Nurs Stud. 2018;89:80-7.

The authors reported no funding was received for this study.

Bibliography

Lalla RV, Bowen J, Barasch A  et al. MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer. 2014;120(10):1453-61.

NICE. Low-level laser therapy for preventing or treating oral mucositis caused by radiotherapy or chemotherapy. IPG615. London: National Institute for Health and Care Excellence; 2018.

Why was this study needed?

Chemotherapy and radiotherapy can cause distressing and painful damage to the lining of the mouth and the upper gut. People have great pain swallowing even their own saliva, and there are few effective treatments

People are advised to have soft, bland food and avoid alcohol and tobacco. Ice and painkillers can also be helpful. Antibiotics may be required if an infection occurs.

NICE has recently published recommendations on the use of low-level laser therapy, but the use of honey is not currently advised. This study was designed to review the use of honey in preventing onset of the moderate to severe form of the condition and compare it to a range of other existing interventions.

What did this study do?

This systematic review looked at 17 randomised trials of 1,265 patients comparing the use of honey with other interventions for people receiving chemotherapy or radiotherapy.

Several different types of honey including manuka, dabur, pure natural and local honey were evaluated. These were compared with controls such as chamomile or golden syrup. The studies focused mainly on patients with head and neck cancers and most were conducted outside the UK; in India, USA, Canada, Turkey, Iran or New Zealand, for example.

The lack of a consistent usual care arm and poor reporting of methods increases the risk of bias in the underlying studies and reduces any confidence in the review itself.

What did it find?

  • Honey reduced onset of moderate to severe mucositis, when measured at two weeks to six months, by 75% compared with usual care (odds ratio 0.25, 95% confidence interval 0.14 to 0.46).
  • Honey did not show a statistically significant effect on the risk of adverse effects, such as bacterial or fungal colonisation.

What does current guidance say on this issue?

Honey is not currently recommended by NICE guidance. Recently published NICE interventional procedures guidance (2018) focuses on the use of low-level laser therapy which helps healing by reducing inflammation and increasing cell metabolism.

It states in addition good oral hygiene is required as well as a bland, soft diet and avoidance of alcohol and tobacco. Water-based moisturisers, painkillers and non-steroidal anti-inflammatory drugs provide symptom relief. Antibiotics may be necessary if an infection sets in.

What are the implications?

Honey is a relatively simple, cheap treatment, and for people with moderate to severe oral mucositis it may be an option worth trying. Antibacterial properties are claimed for some forms of honey, but these were not supported by the evidence presented here.

Natural honey contains inactive bacteria and spores which may pose some risk to people with reduced defences. Sterilised ‘medical’ honeys are available.

These results are of research interest. Larger carefully designed studies are needed to decide how useful honey might be in mucositis alongside other current treatments as well as the best dosage and timing, and any important side effects.

Citation and Funding

Yang C, Gong G, Jin E et al. Topical application of honey in the management of chemo/radiotherapy-induced oral mucositis: a systematic review and network meta-analysis. Int J Nurs Stud. 2018;89:80-7.

The authors reported no funding was received for this study.

Bibliography

Lalla RV, Bowen J, Barasch A  et al. MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer. 2014;120(10):1453-61.

NICE. Low-level laser therapy for preventing or treating oral mucositis caused by radiotherapy or chemotherapy. IPG615. London: National Institute for Health and Care Excellence; 2018.

Topical application of honey in the management of chemo/radiotherapy-induced oral mucositis: A systematic review and network meta-analysis

Published on 24 October 2018

Yang, C.,Gong, G.,Jin, E.,Han, X.,Zhuo, Y.,Yang, S.,Song, B.,Zhang, Y.,Piao, C.

Int J Nurs Stud Volume 89 , 2018

BACKGROUND: Mucositis is an inflammatory response of mucosal epithelial cells to the cytotoxic effects of chemotherapy and radiation therapy. To assess the comparative efficacy of honey for patients with cancer undergoing chemo/radiotherapy-induced oral mucositis through a systematic review and network meta-analysis. METHODS: A network meta-analysis was used to identify evidence from relevant randomized controlled trials (RCTs). We searched PubMed, Embase, and the Cochrane Library for publications up to November 2017. The prespecified primary efficacy outcome was the treatment effect of moderate-severe oral mucositis with honey. We performed subgroup analyses and meta-regressions according to the age group, cancer type, mucositis cause, honey type, control arm and type of assessment scale. Moreover, secondary efficacy outcomes were treatment completed, onset time of mucositis, swallowing diary, fungal colonization, bacterial colonisation and analgesic use. And, we did standardize meta-analyses using the random-effects model, later completing the random-effects network meta-analyses by different treatment/control arms. RESULTS: A total of 17 RCTs were eligible (22 analyses), involving 1265 patients and 13 arms. Honey treatment arm significantly increased the therapeutic effect of chemo/radiotherapy-induced moderate-severe oral mucositis (0.25, 0.14-0.46); significant efficacy was observed in a large proportion of subgroups. The meta-regression may have identified the causes of heterogeneity as the honey type (P = 0.038). Therefore, we need to perform further comparisons of difference in honey types and controls by network meta-analysis, and the results from network meta-analysis revealed that pure natural honey was superior in therapeutic effect (0.05, 0.01-0.46). For secondary outcomes, significant effect was found in decreasing onset time of mucositis (0.41, 0.08-0.73), while no increase in adverse effects was observed. The study is registered with PROSPERO (CRD42017070873). CONCLUSIONS: The adjuvant treatment honey is effective and safe for patients with cancer undergoing chemo/radiotherapy-induced oral mucositis, especially applied pure natural local honey can be invoked as a first-line adjuvant therapy agent.

Expert commentary

Cancer patients who receive prolonged courses of radiotherapy to the head and neck region or high dose chemotherapy, for example with stem cell transplantation, frequently experience intensely painful oro-pharyngeal mucositis.

Current therapies for its prevention and palliative management, as recommended by the international Multinational Association for Supportive Care in Cancer (MASCC) guideline, may have limited evidence and availability.

Topical honey has been used in the management of open wounds, and so this novel approach for mucositis merits further attention. Lower cost and lack of toxicity may be important factors in favour of honey. Head to head comparisons with current MASCC guideline recommended interventions would now be justified. 

Sam H Ahmedzai, Emeritus Professor, The University of Sheffield

The commentator declares no conflicting interests