Irritation or damage to nerves outside Causes difficulty ... · Peripheral Neuropathy Author: Evelyn Created Date: 8/6/2015 6:33:07 PM ...

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

cord

Carry motor signals for muscle

movement and other functions from the

brain and spinal cord to rest of body and

organs

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

treatments

Much less common today but still can

occur

Side effects can include:

› Weakness

› Pain

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”)

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)

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

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

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

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

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

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

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

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

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

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

Carbamezapine (Tegretol) with

oxaliplatin

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

needed

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

Acupuncture

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

› cancer.gov

› cancer.org

› neuropathy.org

› cancercare.org

› lbbc.org

Don’t suffer in silence