Treatment of Chemotherapy-Induced Peripheral Neuropathy
Duloxetine is the only agent with sufficient evidence to recommend for the treatment of chemotherapy-induced peripheral neuropathy (CIPN), starting at 30mg daily for one week, then increasing to 60mg daily. 1, 2
First-Line Treatment
- Duloxetine:
- Dosing: 30mg daily for one week, then increase to 60mg daily
- Evidence level: Moderate quality evidence
- Expected benefit: Modest but clinically meaningful reduction in pain
- Note: When discontinuing, taper slowly to avoid withdrawal symptoms 1
Alternative Options for Non-Responders
When duloxetine fails or is not tolerated, the following agents may be considered, despite limited evidence specifically for CIPN:
- Tricyclic antidepressants (e.g., nortriptyline)
- Gabapentinoids (gabapentin, pregabalin)
- Topical compounded gel containing baclofen, amitriptyline HCL, and ketamine
These alternatives are supported primarily by their efficacy in other neuropathic pain conditions rather than specific evidence in CIPN 1, 2.
Non-Pharmacological Approaches
Several non-pharmacological approaches show promise but require further research:
- Exercise therapy: Low-to-moderate walking and resistance exercise may reduce severity of CIPN symptoms, particularly in older patients 3
- Photobiomodulation (low-level laser therapy): Moderate evidence of benefit 4
- Scrambler therapy: Limited evidence but appears reasonably safe 1
- Acupuncture: Limited evidence but appears reasonably safe 1
Prevention Strategies
No agents are recommended for the prevention of CIPN 1, 2. Specifically:
- Acetyl-L-carnitine should be avoided as it may worsen CIPN 1, 2
- Previous promising agents (venlafaxine, vitamin E, glutathione, etc.) have not shown consistent benefit in clinical trials 1
Chemotherapy Modification Considerations
For patients with intolerable neuropathy or functional impairment, consider:
- Dose delay
- Dose reduction
- Substitution with non-neurotoxic agents
- Discontinuation of the neurotoxic agent 1, 2
Clinical Pearls and Pitfalls
- High-risk patients: Those with pre-existing neuropathy (diabetes, alcohol use disorder) are at higher risk for developing severe CIPN 2
- Monitoring: Regular assessment of symptoms and functional impact is crucial
- Patient education: Inform patients about potential CIPN symptoms before starting neurotoxic chemotherapy and encourage early reporting of symptoms 2
- Coasting phenomenon: Particularly with oxaliplatin, neuropathy may worsen for 2-3 months after cessation of therapy before improvement begins 1
- Diagnosis: Clinical history is usually sufficient; specialized neurologic testing like EMG is not routinely necessary 1
Despite numerous treatment strategies being tried by patients (with 47% using exercise and 49% using at least one non-prescribed medication), evidence-based options remain limited 5. The field requires larger trials with standardized outcome measurements and longer follow-up periods to identify more effective treatments.