Peripheral neuropathy
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Peripheral Neuropathy. Evelyn Robles-Rodriguez RN, MSN, APN Cooper 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 ?.

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Peripheral Neuropathy

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Peripheral neuropathy

Peripheral Neuropathy

Evelyn Robles-Rodriguez


Cooper University Hospital

What is peripheral neuropathy pn

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

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

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

What about cancer treatment?

  • 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

Radiation therapy

Radiation Therapy

  • 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”)

Chemotherapy likely to cause peripheral neuropathy

Chemotherapy likely to cause peripheral neuropathy

  • Platinums(cisplatin, carboplatin, oxaliplatin)

  • Taxanes (Taxolor 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

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

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

Less common symptoms

  • Difficulty swallowing

  • Urinary incontinence

  • Constipation

  • Impotence

  • Dizziness with standing

How common is cipn

How common is CIPN?

  • 3-7% in those treated with single agents

  • 38% in those treated with multiple agents

When do symptoms start

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

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

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

What can you do to treat peripheral neuropathy?

First step

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

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

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

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

What treatments are available?

Prevention of and treatment for cipn

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

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

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



  • 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

  • 2nd3 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

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

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

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

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

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

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

Other Things to Consider

  • Relaxation therapy

  • Guided imagery

  • Distraction

  • Biofeedback

Other approaches

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

Emotional support

  • Talk to your oncology team

  • Consider support groups

  • Visit respected internet websites






Help is available

Help is available!

  • Don’t suffer in silence

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