# Ice chips in the chair for every bolus fluorouracil and high-dose melphalan infusion

Source: https://onco.cc/ideas/idea-upgrade-oral-cryotherapy-with-bolus-chemotherapy/  
OnCo record `idea-upgrade-oral-cryotherapy-with-bolus-chemotherapy` (Idea). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Holding ice chips in the mouth for half an hour around a quick injection of fluorouracil, or high-dose melphalan before a stem cell transplant, cools the mouth while the drug level peaks. A review of 14 trials found it prevents mouth ulcers in about one in four people given fluorouracil, and a guideline recommends it. How often it is offered is not measured.

## Summary

The evidence. The 2015 Cochrane review included 14 randomised trials with 1,280 participants, all at high risk of bias, mostly in chemotherapy rather than head and neck radiotherapy. For adults receiving fluorouracil-based chemotherapy for solid cancers, oral cryotherapy probably reduces oral mucositis of any severity (risk ratio 0.61, 95 per cent confidence interval 0.52 to 0.72, five studies, moderate-quality evidence), with a number needed to treat of 4, and probably reduces severe mucositis (risk ratio 0.40, 0.27 to 0.61), number needed to treat 6. For high-dose melphalan before haematopoietic stem cell transplantation, severe mucositis is probably reduced (risk ratio 0.38, 0.20 to 0.72). Adverse effects were minor and rare.

The guideline. The 2020 MASCC/ISOO mucositis guideline states: "The panel recommends using 30 min of oral cryotherapy to prevent OM in patients receiving bolus 5-FU CT during the infusion of the CT" and "recommends using oral cryotherapy to prevent OM in patients undergoing autologous HSCT when the conditioning includes high-dose melphalan."

The limits. The rationale rests on a short peak in drug level, which a continuous infusion or a daily tablet does not produce, so the recommendation covers bolus fluorouracil and high-dose melphalan and nothing wider. OnCo found no survey or audit of how often eligible patients are offered it, so the gap between recommendation and practice is not measured; the tier records strong evidence for an intervention that costs a cup of ice.

## Fields

- Kind: Idea
- Last checked: 2026-10-20
- Tags: protocol-upgrade; upgrade:proven-unevenly-used; evidence:strong
- Hypothesis: A standing order for oral cryotherapy attached to every bolus fluorouracil and high-dose melphalan prescription raises delivery to eligible patients above 90 per cent and lowers the incidence of severe mucositis in those units towards the trial estimates.
- Rationale: When the evidence and the guideline are settled and the intervention is ice, the only failure left is that nobody brings the cup. An order-set default removes the step that depends on memory.
- Proposed test: An audit, across chemotherapy day units and transplant units, of the proportion of eligible infusions given with oral cryotherapy, followed by a stepped introduction of the standing order with severe mucositis on a standard scale as the outcome.
- Maturity: being-tested-at-scale
- Actor: clinic

## Sources

- Riley et al., Oral cryotherapy for preventing oral mucositis in patients receiving cancer treatment (Cochrane Database Syst Rev 2015): https://doi.org/10.1002/14651858.CD011552.pub2
- Elad et al., MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy (Cancer 2020): https://doi.org/10.1002/cncr.33100

## Connected records

- ideas: [Photobiomodulation and a taste and swallowing programme for mouth and throat toxicity](https://onco.cc/ideas/idea-moon-mucositis-taste-programme/)
- fronts: [Chemotherapy](https://onco.cc/fronts/chemotherapy/), [Supportive Care & Survivorship](https://onco.cc/fronts/supportive-care/)
- technologies: [Oral cryotherapy (ice chips) to prevent mucositis](https://onco.cc/technologies/oral-cryotherapy-mucositis/)
- drugs: [Fluorouracil (5-FU)](https://onco.cc/drugs/fluorouracil/), [Melphalan (including hepatic delivery system)](https://onco.cc/drugs/melphalan/)
- terms: [Mucositis and stomatitis](https://onco.cc/terms/mucositis/)
- bottlenecks: [Knowledge reaches practice too slowly](https://onco.cc/bottlenecks/b-knowledge-diffusion/), [Toxicity and quality of life are undervalued](https://onco.cc/bottlenecks/b-toxicity-qol/)
- key papers: [Interventions for preventing oral mucositis in patients with cancer receiving treatment: oral cryotherapy](https://onco.cc/key-papers/paper-riley-cochrane-database-syst-rev/), [MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy](https://onco.cc/key-papers/paper-elad-cancer/)

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