Irritation or damage to nerves outside the brain and spinal cord Causes difficulty in communication between nerves or group of nerves.

Peripheral NeuropathyEvelyn Robles-Rodriguez

RN, MSN, APNCooper University Hospital

What is peripheral neuropathy (PN)?

Irritation or damage to nerves outside the brain and spinal cord

Causes difficulty in communication between nerves or group of nerves

What are peripheral nerves?

Long, wire-like fibers Transmit nerve impulses and sensory

information from the body to the spinal cord

Carry motor signals for muscle movement and other functions from the brain and spinal cord to rest of body and organs

What can cause PN?

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

What about cancer treatment?

Damage to nerves can occur with:› Surgery› Radiation therapy› Chemotherapy

Surgery

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

Radiation Therapy

More common in 1960s with older treatments

Much less common today but still can occur

Side effects can include:› Weakness› Pain

Chemotherapy

Polyneuropathy most common form of neuropathy (affects several nerves)

Usually affects both sides of the body equally

Symptoms usually begin in feet and can progress to hands (referred as “stocking/glove distribution”)

Chemotherapy likely to cause peripheral

neuropathy Platinums (cisplatin, carboplatin,

oxaliplatin) Taxanes (Taxol or paclitaxel, Taxotere or

docetaxel) Epothilones (Ixabepilone or Ixempra) Plan alkaloids (vinblastine, vincristine,

vinorelbine, etoposide) Thalidomide and lenalidomide (Revlimid) Bortezomib (Velcade)

Symptoms of Chemotherapy Induced Peripheral Neuropathy (CIPN)

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

More symptoms of CIPN

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

Less common symptoms

Difficulty swallowing Urinary incontinence Constipation Impotence Dizziness with standing

How common is CIPN?

3-7% in those treated with single agents

38% in those treated with multiple agents

When do symptoms start?

Can begin anytime after treatment starts

Sometimes occurs at end of treatment Can worsen as treatments go on

How long do symptoms last?

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

What affects PN longevity?

Age 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

What can you do to treat peripheral neuropathy?

First Step

Talk to your doctor or nurse immediately after symptoms begin

Do not delay telling Failure to disclose symptoms can lead

to life-altering problems

What may your doctor do?

Reduce dose of chemo (this is safe and still give you the same benefit as higher doses)

Give smaller doses 2-3X vs. 1X per week

Give dose over longer period of time Give longer breaks between chemo Alter chemo cycle

What can you do to stay safe if affected by PN?

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 non-

affected body part Check your feet at end of each day

What else can you do?

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 problem

What treatments are available?

Prevention of and treatment for CIPN?

Several preventions and treatments have been tried with mixed results

There is no sure way to prevent CIPN to date

Mixed results with treatments Research needs to continue

Vitamin E

Antioxidant May protect nerves from damage due to

cytotoxic drugs 3 studies examined effect giving 300 to

600 mg during and 3 mths after treatment ended

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

Calcium and Magnesium

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 non-treated had no PN symptoms

Retrospective, nonrandomized study

Chemoprotectants

Amifostine which detoxifies chemotherapy drugs and facilitates DNA repair

Three studies examined effect on PN No differences in sensory or motor

symptoms found in pts treated with amifostine

Anticonvulsants

Carbamezapine (Tegretol) with oxaliplatin

No neuropathy in treated group vs. 30% in historical control group

Need placebo controlled trial

Glutamine

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 needed

Glutathione

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

Alpha lipoic acid

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

Acetyl L-carnitine

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

Tricyclic antidepressants

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

Treatment for nerve pain

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

Which approved?

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

Non-pharmacology Interventions Studied

Acupuncture Assistive devices Physical activity and exercise Pulsed infrared light therapy Transcutaneous nerve stimulation Spinal cord stimulation

Other Things to Consider

Relaxation therapy Guided imagery Distraction Biofeedback

Other approaches

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

Emotional support

Talk to your oncology team Consider support groups Visit respected internet websites

› cancer.gov› cancer.org› neuropathy.org› cancercare.org› lbbc.org

Help is available! Don’t suffer in silence