para>Beers' list currently lists TCAs as "Avoid"¯ due to its sedating and orthostatic hypotension effects.
Anticonvulsants (gabapentin). Side effects include peripheral edema, dizziness, somnolence, and nausea. To minimize side effects, it is recommended to start low at 100-300 mg at bedtime or 100-300 mg three times a day and slowly titrate up by 100-300 mg as needed, with the maximum daily dose being 3,600 mg. Research showed that gabapentin had NNT comparable to older convulsants (5)[C].
Second Line
Opioid analgesics are avoided because high doses are needed for an effect, which causes too many side effects. The exception is tramadol, which has shown to decrease pain and use of antidepressants (NNT = 3.8). Common starting dose for tramadol is 100 mg/day. Needs further investigation. Side effects include nausea, constipation, dizziness, and orthostatic hypotension (5)[C].
Alert: Geriatric Considerations
Beers' list currently lists tramadol as "Avoid"¯ due to lowering the seizure threshold.
Issues for Referral
- Patients should be referred to a neurologist if their symptoms are out of proportion to what is expected, symptoms do not resolve but progress when discontinuing the drug (with the exception of cisplatin), or there are upper motor neuron signs (3)[C].
- Patients taking multiple medications for CIN should be referred to a pain clinician for monitoring of side effects and/or drug effects (5)[C].
Surgery/Other Procedures
Surgical decompression-benefit shown in small case studies (3)[C]
Complementary & Alternative Therapies
Acupuncture-benefit shown in small case studies, with no interactions with chemotherapy treatment (3)[C]
Ongoing Care
Patient Education
- Patients should be notified before their treatment if their therapy has the possibility for neuropathy and how it could present.
- Patients should be encouraged at every visit to share with their medical team any new side effect from their treatment.
Prognosis
Some drugs have a "coasting"¯ effect-continuation of symptoms 2-6 months after cessation of treatment.
- Cisplatin related: most studies in patients treated for testicular cancer-showed incomplete recovery in most patients (4)
- Oxaliplatin related: 40% completely resolved after 6-8 months after discontinuation with some coasting effect (4)
- Vinca alkaloids related: recovery seen by 3 months after discontinuation, with coasting effect seen in 30% (4)
- Taxanes related: recovery seen by 3-6 months after discontinuation (4)
- Thalidomide related: improvement after discontinuation-needs more investigation
- Bortezomib related: improvement to completely resolved 3-4 months after discontinuation (4)
References
1.Ferrier J, Pereira V, Busserolles J, et al. Emerging trends in understanding chemotherapy-induced peripheral neuropathy. Curr Pain Headach Rep. 2013;17(10):364.
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2.Grisold W, Caveletti G, Windebank AJ. Peripheral neuropathies from chemotherapeutics and targeted agents: diagnosis, treatment, and prevention. Neuro Oncol. 2012;14(suppl 4):iv45-iv54.
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3.Kaley TJ, Deangelis LM. Therapy of chemotherapy-induced peripheral neuropathy. Br J Haematol. 2009;145(1):3-14.
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4.Argyriou AA, Bruna J, Marmiroli P, et al. Chemotherapy-induced peripheral neurotoxicity (CIPN): an update. Crit Rev Oncol Hematol. 2012;82(1):51-77.
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5.Vadalouca A, Raptis E, Moka E, et al. Pharmacological treatment of neuropathic cancer pain: a comprehensive review of the current literature. Pain Pract. 2011;12(3):219-251.
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Codes
ICD09
- 995.29 Unspecified adverse effect of other drug, medicinal and biological substance
- 357.7 Polyneuropathy due to other toxic agents
ICD10
- T88.8XXA Oth complications of surgical and medical care, NEC, init
- G62.2 Polyneuropathy due to other toxic agents
SNOMED
- 423661009 Complication of chemotherapy
- 386033004 Neuropathy (disorder)
Clinical Pearls
- The goal of treatment is to reduce the tumor load, yet the patient's quality of life should still be a key consideration in continuing treatment.
- Most patients will first complain of a tingling sensation in the extremities. However, a positive Romberg test, abnormal coordination, or vibratory sensation may be the first sign of CIN in a patient.
- Some patients are afraid of sharing adverse reactions because they think it will prevent them from getting medical treatment, so it is important to make them feel safe in entrusting the team with their information.