Peripheral Neuropathy

Irritation or damage to nerves outside
the brain and spinal cord
 Causes difficulty in communication
between nerves or group of nerves
Long, wire-like fibers
 Transmit nerve impulses and sensory
information from the body to the spinal
 Carry motor signals for muscle
movement and other functions from the
brain and spinal cord to rest of body and
Chronic diabetes and uremia
 Infection which affects nerves such as
shingles (post herpetic neuralgia)
 Excess alcohol
 Tumor pressing on a nerve
 Spinal cord injury
 Low vitamin B levels (especially B12)
 Poor circulation
Damage to nerves can occur with:
› Surgery
› Radiation therapy
› Chemotherapy
Can cause damage to nerves near the
surgical site
 Side effects reported with damage:
› Burning
› Shooting pain
› Electric tingling
› Numbness in skin around surgical site
More common in 1960s with older
 Much less common today but still can
 Side effects can include:
› Weakness
› Pain
Polyneuropathy most common form of
neuropathy (affects several nerves)
 Usually affects both sides of the body
 Symptoms usually begin in feet and can
progress to hands (referred as
“stocking/glove distribution”)
Platinums (cisplatin, carboplatin,
 Taxanes (Taxol or paclitaxel, Taxotere or
 Epothilones (Ixabepilone or Ixempra)
 Plan alkaloids (vinblastine, vincristine,
vinorelbine, etoposide)
 Thalidomide and lenalidomide (Revlimid)
 Bortezomib (Velcade)
Pain (can be constant or come and go,
shooting, electric or stabbing)
 Burning
 Tingling (“pins and needles”)
 Numbness (decreased sensation of
pressure, touch, temperature)
 Increased sensitivity to temperature
(especially cold), touch or pressure
Difficulty using fingers to pick up, hold or
handle things such as buttons, writing
 Problems with balance
 Tripping or stumbling with walking
 Shrinking or weak muscles
 Loss of or reduced reflexes
Difficulty swallowing
 Urinary incontinence
 Constipation
 Impotence
 Dizziness with standing
3-7% in those treated with single agents
 38% in those treated with multiple agents
Can begin anytime after treatment starts
 Sometimes occurs at end of treatment
 Can worsen as treatments go on
Can be short term
› Last a few days
› Stop after treatment ends
Can be long term
› Persist between treatments
› Continue 6-24 months after treatment ends
Can become a permanent problem
 Genetic predisposition
 Chronic conditions (diabetes, kidney
failure, HIV)
 Amount of each dose of chemo
 Total dose of chemo
 Drug combination
 Previous chemo
 Previous problems with PN
Talk to your doctor or nurse immediately
after symptoms begin
 Do not delay telling
 Failure to disclose symptoms can lead to
life-altering problems
Reduce dose of chemo (this is safe and
still give you the same benefit as higher
 Give smaller doses 2-3X vs. 1X per week
 Give dose over longer period of time
 Give longer breaks between chemo
 Alter chemo cycle
Wear gloves and warm socks especially in
the cold
Wear shoes inside and outside your home
Protect your hands when working
Keep your house well lit/keep night light
Use nonskid surface in shower/tub
Clear floor of objects and watch for rugs
Test temperature of water with nonaffected body part
Check your feet at end of each day
Avoid alcohol
 If diabetic, control your blood sugar
 Treat your pain as prescribed
 Pay attention to your shoes
 Sit down as much as possible if feet are a
Several preventions and treatments
have been tried with mixed results
 There is no sure way to prevent CIPN to
 Mixed results with treatments
 Research needs to continue
May protect nerves from damage due to
cytotoxic drugs
3 studies examined effect giving 300 to 600
mg during and 3 mths after treatment
Evidence of less nerve damage in group
who took Vitamin E
Other study found deficient Vitamin E levels
in pts receiving cisplatin who had PN
Tested in pts who received oxaliplatin
which binds to calcium and magnesium
 Given 1g of calcium and magnesium
before and after infusion
 65% of those treated vs. 37% of nontreated had no PN symptoms
 Retrospective, nonrandomized study
Amifostine which detoxifies
chemotherapy drugs and facilitates DNA
 Three studies examined effect on PN
 No differences in sensory or motor
symptoms found in pts treated with
Carbamezapine (Tegretol) with
 No neuropathy in treated group vs. 30%
in historical control group
 Need placebo controlled trial
Nonessential amino acid
 Thought to have neuroprotective effects
for paclitaxel
 8% of those treated vs. 40% not reported
PN symptoms in one study (10g daily)
 Other study (10 g 3X/d) in those treated
noted less symptoms
 Larger, randomized, placebo studies
Thiol tripeptide may hamper platinum
accumulation in nerves
 Three studies to date
 1st 1500 mg/m2 IV, no grade 3-4 toxicity
 2nd 3 g/m2, 58% vs. 39% able to receive
all cycles of chemo and improved QOL
 3rd 1.5 g/m2 17 vs. 88% had clinical
evidence of PN
 Need further randomized trials
Fatty acid which converts sugar into
energy and is also an antioxidant
 Some studies with diabetics
 4 randomized, double-blind, placebo
controlled studies
 600 mg/d IV
 Clinically significant improvements in
pain, burning and numbness after 5 wks
 Need studies for CIPN
Nutritional supplement which functions
as an antioxidant
 2 studies in pre-existing CIPN
 1 g/d IV or 1 g/tid orally
 Studies limited by small sample size and
not randomized
Nortriptyline – blocks reuptake of
serotonin and norepinephrine in pain
modulating system of CNS
 Analgesic effect
 Escalating dose of up to100 mg/d
 Modest benefit in study of cisplatin
induced PN
Antidepressants (amitriptyline,
nortriptyline, and desipramine)
 Anticonvulsants (gabapentin or
Neurontin, pregabalin or Lyrica)
 Steroids (short term use only)
 Local anesthetics (capsaicin, EMLA,
lidocaine 5%)
 Opioids and methadone
Only ones approved by FDA for
treatment of neuropathic pain
› Duloxetine (cymbalta) – diabetic PN
› Pregabalin (lyrica) – diabetic PN and post
herpetic neuralgia
› Lidocaine patches 5% - post herpetic
› Gabapentin (neurontin) – post herpetic
 Assistive devices
 Physical activity and exercise
 Pulsed infrared light therapy
 Transcutaneous nerve stimulation
 Spinal cord stimulation
Relaxation therapy
 Guided imagery
 Distraction
 Biofeedback
PT - can help improve balance, strength
and safety
 OT – can help improve fine motor
coordination such as writing and help
adapt your home and work environment
 Pain specialists – can educate you
about treatment options and help
manage your symptoms
 Podiatrist – can help you find the right
shoes for your symptoms
Talk to your oncology team
 Consider support groups
 Visit respected internet websites
Don’t suffer in silence

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