Jessica Latchman APRN AGACNPBC AOCNP ACHPN Ann Guastella APRN AOCN ACHPN December 13 2022 INTRODUCTION Chemotherapy induced peripheral Neuropathy is common problem facing cancer patients ID: 998599
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1. Management of Chemotherapy-Induced Peripheral Neuropathy: Assessment & Treatment Jessica Latchman APRN, AGACNP-BC AOCNP, ACHPNAnn Guastella, APRN, AOCN, ACHPNDecember 13, 2022
2. INTRODUCTION Chemotherapy induced peripheral Neuropathy is common problem facing cancer patients Due to nerve damaging side effect of many chemotherapy agentsThe incidence varies from 10% to 100% Associated with taxanes, platinums, bortezomib, thalidomide, lenolidamide, and vinca alkaloids
3. Chemotherapy- Induced Peripheral Neuropathy (CIPN) Neuropathy is defined as” an adverse change in sensory and/or motor function caused by toxic or physical nerve damage process.” (Cleeland et al., 2010)
4. Effects of CIPNCIPN leads to sensory, motor, and autonomic deficits Most effects are sensory Impacts quality of life, functional ability, sleep and balance and is associated increased fall risk
5. Progression Starts distally in the hands and feet moving proximally with Worsens with cumulative chemotherapy doses
6. CIPN ASSESSMENT
7. Objective Instruments Good neurologic exam Neurology evaluation- Nerve conduction, nerve excitability, nerve ultrasound, myography, and intra- epidermal nerve fiber density (IENFD)
8. Subjective Instruments Patient reported Impact on physical function and interference with activities Quality of life (QOL)Neuropathy symptoms
9. PreventionDue to lack of high-quality, consistent evidence, the ASCO guidelines do not recommend any agents for use in prevention of CIPN
10. Guidelines for the management of chemotherapy-induced peripheral neuropathy (CIPN) in oncology patients:American Society of Clinical Oncology (ASCO) Recommends DuloxetineOncology Nursing Society Duloxetine is likely to be effective The ASCO guidelines were first published in 2014. The ONS reaffirmed its 2007 guidelines in 2014.
11. Pharmacologic ManagementTricyclic Antidepressants Amitriptyline, Nortriptyline, Desipramine AnticonvulsantsGabapentin, LyricaSerotonin Norepinephrine Reuptake InhibitorsCymbalta OpioidsMorphine, oxycodone, Dilaudid, fentanyl, methadoneTopical analgesicsLidocaine, Capsaicin
12. Adjuvant AnalgesicsUsed to:Enhance analgesic effect of opioidsTreat concurrent symptomsProvide independent analgesic activity
13. Tricyclic Antidepressants Amitriptyline, Nortriptyline, Desipramine Start low dose usually 10-25 mg at bedtime and then titrateMechanism of ActionInhibit the reuptake of mostly norepinephrine, as well as serotonin & enhance descending initiating pathwaysSide effects: mainly anticholinergic such as sedation, constipation, urinary retention, dry mouth, orthostatic hypotension, blurred vision, dysphoria, agitation, weight gain, tachyarrhythmias, dizziness
14. Serotonin Norepinephrine Reuptake InhibitorsDuloxetineStarting dose at 20-30 mg dailyMechanism of action: inhibitors of serotonin and norepinephrine and dopamine reuptakeSide effects: serotonin syndrome, HTN, withdrawal, sexual dysfunction, elevated LFTs, dry mouth, somnolence, fatigue, nausea, constipation, anorexia
15. AnticonvulsantsGabapentin and PregabalinGabapentin 900 mg -3600 mg dailyPregabalin150 mg to 300 mg daily Mechanism of action: Unknown, however it is suspected to act as calcium channel antagonist Side effects: Sedation, edema, fatigue, confusionPrecautions: Use cautiously in patients with renal insufficiency
16. OpioidsMorphine, oxycodone, hydromorphone, fentanyl, methadone, tramadolDose: start low dose and titrateMechanism of action: activating opioid receptorsSide effects: Sedation, nausea, vomiting, fatigue, pruritus, respiratory depressionPrecautions: Start low and titrate cautiously especially in Naïve patientsCaution when using with other sedating medications such as benzodiazepines
17. MethadoneUsed for refractory neuropathic painOpiate naïve patient – start with 5 mg BIDOpiate tolerant patient – start with 5-10 mg TIDTitrate every three to seven daysCaution with patients with sleep apnea, respiratory infection
18. Topical AnalgesicsLidocaine and CapsaicinApply to site of painMechanism of action: work as a local anesthetic, numbing the pain in the area where you apply them Side effects: Rash, burning, numbnessPrecautions:Use of gloves when applying Apply to intact skin only
19. Capsaicin Cream0.025% or 0.075% topicalUseful for relief of pain related to rheumatoid arthritis or osteoarthritis and neuropathic painApply four times a day
20. Lidoderm 5% PatchNeuropathic painBlock voltage-gated sodium channels within neuronal cell membranesConsists of 700 mg Lidoderm and other agentsSystemic absorption is insignificantMaximum of 3 patches dailyDuration of trial: 2 weeks$$$$
21. Interventional Procedures
22. Non Pharmacologic ManagementPhysical and Occupational therapyTo improve overall functional statusImprove balance & strengthen weakened musclesHelp patients adapt to and compensate for physical challenges
23. Non Pharmacologic ManagementAcupuncture originated in China over 4,000 years agoBased on the existence of acupuncture pointsMechanism is not clear, but acupuncture appears to work peripherally by stimulating afferent nerve fibers and central nerve fibers through the endorphin system
24. SupplementsPer ONS use of the following treatments for CIPN have not been determinedAlpha Lipoic acidsVitamin EOmega-3 fatty acids
25. Best approachUse combination therapy in managing CIPNPharmacologicNon pharmacologic
26. Clinical TrialsClinical trials with CIPN are lacking
27. SummaryPeripheral neuropathy is a common adverse effect of chemotherapyAgents such as paclitaxel, docetaxel, vinorelbine, and vinblastine, among others. Multiple studies and meta-analyses have failed to identify any drug that can prevent chemotherapy-related neuropathy. Duloxetine is the only drug that has demonstrated some efficacy for the treatment of chemotherapy-related peripheral neuropathy.
28. ReferencesHershman et. Al. (2014). Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline. Journal of Clinical OncologyNational Institutes of Health. National Institute of Neurological Disorders and Stroke. Peripheral Neuropathy Fact Sheet. (https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Peripheral-Neuropathy-Fact-Sheet) Accessed 5/18/2022.Tofathagen,C., Visovsky, C., and Rodriguez, R. ( 2013). Chemotherapy- Induced Peripheral Neuropathy: An Algorithm to Guide Nursing Management. Clinical Journal of Oncology Nursing, 17(2), 138-144Wallace, M. (2014). Interventional and Nonpharmacological Therapies for Neuropathic Pain. International Association for the Study of Pain, 15th World Congress on Pain.28
29. Questions?