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Chemotherapy-induced peripheral neuropathy

Definition
CIPN is a common complication of chemotherapy, that is predominantly characterized by sensory neuropathy and may be accompanied by motor and autonomic changes.
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Pathophysiology
CIPN can occur in patients with platinum-based antineoplastic agents (oxaliplatin, cisplatin, carboplatin), epothilones (ixabepilone), taxanes (paclitaxel, docetaxel), immunomodulatory drugs (thalidomide), vinca alkaloids (vincristine, vinblastine, vinorelbine, vindesine), and proteasome inhibitors (bortezomib).
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Disease course
CIPN may affect sensory, motor, and/or autonomic functions to varying degrees. Symptoms include numbness, tingling, altered touch sensation, impaired vibration, paresthesias, dysesthesias, spontaneous burning, shooting or electric shock-like pain, allodynia, hyperalgesia, distal weakness, gait and balance disturbances, impaired movements, orthostatic hypotension, constipation, and altered sexual/urinary function. Disease progression may lead to loss of sensation, paresis, complete patient immobilization, severe disability, and reduced QoL.
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Prognosis and risk of recurrence
CIPN is not independently associated with increased mortality.
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Key sources
The following summarized guidelines for the evaluation and management of chemotherapy-induced peripheral neuropathy are prepared by our editorial team based on guidelines from the European Oncology Nursing Society (EONS/EANO/ESMO 2020), the American Society of Clinical Oncology (ASCO 2020), and the American Cancer Society (ACS 2013).
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Guidelines

1.Diagnostic investigations

Initial assessment
Obtain standardized assessment of CIPN including:
baseline assessment and risk profile
B
long-term follow-up at > 2-3 months after treatment
B
calculation of Total Neuropathy Score or Total Neuropathy Score clinical version
A
objective evidence of neurological deficits
A
patient-reported outcomes, such as FACT/GOG-Ntx, EORTC QLQ-CIPN20, PNQ, CIPN-R-ODS
A
nerve conduction studies in the clinical trials setting.
A
Provide education regarding symptoms. Obtain ongoing patient surveillance
B
and assess the impact on function and QoL.
A
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2.Medical management

General principles: as per ESMO 2020 guidelines, focus on reduction or relief of neuropathic pain in patients experiencing chronic CIPN.
B

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  • Modification/discontinuation of chemotherapy

  • Duloxetine

  • Other systemic agents

  • Topical agents

3.Nonpharmacologic interventions

Physical therapies: as per ASCO 2020 guidelines, insufficient evidence to recommend exercise therapy or scrambler therapy for the treatment of CIPN outside the context of a clinical trial.
I

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  • Acupuncture

4.Specific circumstances

Patients with central neurotoxicity: do not use exogenous albumin for the prevention of ifosfamide-induced acute encephalopathy. Do not use methylene blue, thiamine, and/or glucose 5% for the prevention or treatment of ifosfamide-induced acute encephalopathy.
D
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5.Preventative measures

Primary prevention: as per ASCO 2020 guidelines, assess the risks and benefits of agents known to cause CIPN in patients with underlying neuropathy and with conditions predisposing to neuropathy, such as diabetes and/or a family or personal history of hereditary neuropathy.
B
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6.Follow-up and surveillance

Monitoring for ototoxicity
Obtain a pure tone audiometry (including the wide spectrum of frequencies 500-8,000 Hz) for early detection of ototoxicity in adult patients receiving platinum agents.
B
Insufficient evidence to recommend prophylactic treatment with sodium thiosulfate because of the uncertainty regarding a possible tumor protection and lack of evidence in adult patients with cancer.
I