What is the treatment for chemotherapy-induced neuropathy?

Treatment of Chemotherapy-Induced Peripheral Neuropathy

Duloxetine at 30mg daily for one week, then increased to 60mg daily, is the only treatment with moderate-quality evidence supporting its efficacy for chemotherapy-induced peripheral neuropathy (CIPN). 1

First-Line Treatment

• Duloxetine: Start at 30mg daily for one week, then increase to 60mg daily 1, 2
  • Provides modest but clinically meaningful benefit for painful CIPN
  • Currently the only agent recommended with moderate-quality evidence
  • Should be considered before other alternatives

Second-Line Options (Limited Evidence)

For patients who don't respond to or cannot tolerate duloxetine:

1. Tricyclic antidepressants (e.g., nortriptyline) 1, 3

   • Note: Amitriptyline specifically has shown no benefit in controlled studies 4

2. Anticonvulsants

   • Gabapentin or pregabalin may help with neuropathic pain control 1, 2
   • Avoid lamotrigine as evidence does not support its use 4

3. Topical treatments

   • Compounding gel containing baclofen, amitriptyline HCL, and ketamine 1
   • Avoid topical ketamine-amitriptyline (4% ketamine and 2% amitriptyline) as evidence does not support its use 4

4. Non-pharmacological approaches (consider when medication options fail)

   • Photobiomodulation (low-level laser therapy) shows moderate benefit 4
   • Exercise: Home-based, low-to-moderate walking and resistance exercise may reduce CIPN severity 2
   • Physical therapy may help address symptoms 3
   • Acupuncture may be tried, though evidence is limited 3

Monitoring and Dose Modification

• Regularly assess severity and functional impact of neuropathy symptoms 1
• Consider chemotherapy dose modifications when neuropathy becomes intolerable or causes functional impairment:
  • Dose delay
  • Dose reduction
  • Substitution with non-neurotoxic agents
  • Discontinuation of the neurotoxic agent 1

Important Considerations

• CIPN affects 30-60% of patients receiving neurotoxic chemotherapy 2
• Common causative agents: taxanes, platinum compounds, vinca alkaloids, bortezomib, thalidomide, epothilones, and eribulin 1, 5
• Platinum agents (particularly oxaliplatin) are considered the most neurotoxic 5
• Patients with pre-existing neuropathy (diabetes, alcohol use disorder) are at higher risk for severe CIPN 1
• CIPN can progress from acute to chronic and may worsen even after treatment cessation (coasting phenomenon) 5

Prevention

• No agents are currently recommended for CIPN prevention 1, 2
• Specifically avoid acetyl-L-carnitine as it may worsen CIPN 1
• Pre-habilitation and rehabilitation should be recommended for all patients receiving cytotoxic chemotherapies 2

Clinical Pitfalls

• CIPN is often underdiagnosed, leading to delayed intervention 2
• Severe CIPN may necessitate chemotherapy dose reductions or discontinuation, potentially impacting cancer treatment outcomes 3, 5
• Patient education before starting neurotoxic chemotherapy is essential to encourage early reporting of symptoms 1
• Set realistic expectations about treatment efficacy and potential persistence of symptoms 1