eMedicine Specialties > Neurology > Neuromuscular Diseases
Chronic Inflammatory Demyelinating Polyradiculoneuropathy: Treatment & Medication
Updated: Jan 15, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
Untreated, chronic inflammatory demyelinating polyradiculoneuropathy is characterized by accumulating disability that requires physical and occupational therapy, orthotic devices, and long-term treatment. Close follow-up care with a physician knowledgeable in the field is necessary to adjust treatment.
Surgical Care
Surgical and orthopedic consultation may be required for sural nerve biopsy or in severe disease with joint deformities that require corrective surgery.
Consultations
- Consult a neurologist for evaluation, diagnosis, and treatment of CIDP and possible associated diseases.
- Consult a physical medicine and rehabilitation specialist for physical and occupational therapy and evaluation for orthotic devices.
- Other consultations (eg, internist, hematologist, oncologist, rheumatologist) may be necessary if associated diseases are present. Some treatments may be best accomplished with the assistance of a hematologist or rheumatologist.
Diet
No specific diet has been proven beneficial in CIDP.
Activity
Activity generally depends on the level of disability. Encourage physical therapy and an active lifestyle.
Medication
If associated conditions are identified (HIV infection, lupus, paraproteinemia, lymphoma), treat them accordingly. The mainstay of treatment is immunosuppressive or immunomodulatory intervention.
Immunomodulatory/immunosuppressive agents
These agents include intravenous immunoglobulin (IVIg), plasmapheresis, prednisone, azathioprine, methotrexate, mycophenolate, cyclosporine, and cyclophosphamide. Their use is based on the proposed pathogenesis of CIDP as an immune-mediated condition.
The FDA designated the IVIg product Gamunex as an orphan drug (September, 2008) for chronic inflammatory demyelinating polyneuropathy (CIDP). Approval was based on a clinical trial1 that showed Gamunex effective at improving certain motor functions for up to 48 weeks after initial treatment compared with placebo. The Inflammatory Neuropathy Cause and Treatment scale (INCAT) was used to measure patients’ ability to perform tasks (eg, walking, motor hand tasks). Twenty-eight of 59 patients (47%) treated with Gamunex had significantly improved INCAT scores compared with 13 of 58 patients (22.4%) treated with placebo (25% difference; 95% CI 7-43%; p=0.006). Patients with improved INCAT scores participated in a follow-up trial for an additional 24 weeks; 86% who continued receiving Gamunex maintained their improved INCAT scores compared with 61% who received placebo during the follow-up trial.
Plasmapheresis
Two controlled and blinded studies have confirmed benefit of plasmapheresis. Proposed mechanism is removal of antibodies and complement components that are responsible for immune-mediated damage of peripheral nerves. Plasma removed from blood through method similar to dialysis. Requires 2 large-bore needles, one to remove whole blood and other to return blood cells with albumin and saline. Patients whose veins are not large enough for repeated needle insertions have double-lumen catheter placed, either Quinton catheter (can be kept in for few weeks) or Permacath (can remain inserted indefinitely). Has been shown to have similar efficacy as IVIg in treatment of CIDP.
Adult
Based on body weight and size to determine plasma volume; commonly, patients undergo 3 plasma exchanges per wk for first 2 wk; after that, number and frequency of treatments determined by clinical response; response tends to last for 2-4 wk and must be repeated to sustain improvement; some patients require more frequent treatment; remission is uncommon if plasmapheresis is sole therapy
Pediatric
Based on body weight and size
Pheresis removes medications that are circulating in plasma; dosing adjustments may be necessary
Documented hypersensitivity; contraindications to permanent line placement; heart disease; cardiac risk factors; coagulation problems; hypocalcemia; sensitivity to fluid imbalance
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Can be classified as device or procedure related Device-related risk factors include RBC hemolysis, overheating of blood, and inaccurate delivery of anticoagulant and/or replacement fluids
Procedure-related risk factors include citrate-induced hypocalcemia; replacement with fluids depleted of coagulation factors, proteins, or electrolytes can lead to problems; replacement fluids containing plasma have capacity to transmit infection; allergic reactions can lead to anaphylaxis; hemorrhage and DIC can occur; activation of coagulation, complement, fibrinolytic cascades, and/or aggregation of platelets is potential risk
Problems with vascular access can be significant, such as sepsis, penetration, and thrombosis with subsequent systemic embolism; use special caution in patients with heart disease or risk factors
Immunoglobulin, intravenous (Gamunex)
Multiple clinical trials establish efficacy. Solution for IV infusion that is composed mostly of heterogenous human IgG but also small amounts of IgA and IgM. Its proposed mechanism of action based on thought that IVIg contains random set of antibodies that would neutralize immune factors, causing damage to peripheral nerve in CIDP. Used in infectious diseases to provide immediate passive immunity in situations in which time constraints do not allow development of active immunity via vaccination. Also used to treat multiple immune-mediated conditions, such as idiopathic thrombocytopenic purpura, GBS, and myasthenia gravis.
Activates complement cascade and provides multitude of antibodies capable of neutralization of many microorganisms, toxins, viruses, and presumably autoantibodies. Latter mechanism possibly underlies effect in CIDP. Several studies showed significant benefit in CIDP; this makes it useful alternative to plasmapheresis. On average, improvement seen by day 10 and continues through day 42.
Serum half-life approximately 21-29 d. Patients usually require repeated treatments every few weeks or months to maintain remission or treat recurrences.
Adult
For treatment of CIDP, total dose is 2 g/kg, IV usually divided into 5 daily doses of 400 mg/kg; effect tends to be for 2-4 wk and must be repeated to sustain improvement; remission from IVIg as sole therapy is unusual ( <10%)
Pediatric
Not established; 2 g/kg (as in adults) recommended
Patients receiving IVIg are not to receive live virus vaccines for 2 wk before infusion and for 3 mo after because antibodies in IVIg can prevent immunization effect
Absolute: IgA deficiency
Relative: Documented hypersensitivity; hypogammaglobulinemia; pregnancy; breastfeeding; diabetes; cardiac disease; elderly patients; hypovolemia; maltose, sucrose, or egg hypersensitivity; renal insufficiency; sepsis
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Hypersensitivity (anaphylactic reactions have occurred); injection site reactions are possible as well as reaction to infusion, including chills, back pain, diaphoresis, fever, hypotension, myalgias, nausea, and vomiting; premedication with diphenhydramine (25-50 mg IV 30 min before infusion) recommended
Renal impairment (increased risk of renal tubular necrosis, particularly in presence of hypovolemia)
Crosses placenta (in increasing amounts after 30 wk gestation) and may be excreted into milk
During few weeks after IVIg therapy, some blood tests, such as complement components levels, sedimentation rate, protein electrophoresis, and serologic tests for antibodies, are not reliable
Prednisone (Deltasone, Orasone, Meticorten)
Oral corticosteroid that suppresses inflammation and immune responses by altering protein synthesis in cells. Naturally occurring hormone that crosses cell membranes to bind to cytoplasmic receptors. Some mechanisms of action in CIDP are altering mediator function at site of inflammation and suppressing immune response.
Controlled trial demonstrated efficacy of oral prednisone.
Adult
Doses vary; most patients are started on prednisone at 1 mg/kg/d PO initially (60-80 mg/d)
Improvement can be anticipated within next 2 mo; further on, dosing converted to alternate-day treatment and then titrated to lowest effective dose that allows maintaining patient in remission; some clinicians use weekly high-dose PO or IV corticosteroids (500 mg Solu-Medrol) instead of daily or alternate-day prednisone and believe this is at least as effective and better tolerated
Pediatric
Not established; because of severity of adverse effects in children, use lowest possible dose
Significant effects occur when taken together with a few medication groups, such as antithyroid and thyroid replacement medications (eg, hyperthyroidism increases and hypothyroidism decreases prednisone metabolism), anticoagulants (prednisone can increase coagulability and thus decrease effect), barbiturates (induce hepatic enzymes), cholinesterase inhibitors, and neuromuscular blockers (acutely prednisone can induce decreased neuromuscular junction conduction), diuretics, estrogens, NSAIDs, salicylates (GI adverse effects), vaccines, and others
Absolute: Cushing syndrome; fungal and some viral (measles, varicella) infections
Relative: Documented hypersensitivity; breastfeeding; children; acute infection; cataracts; glaucoma; coagulopathy; diabetes; infections; severe hypertension; GI problems; recent surgery or vaccination; osteoporosis; psychosis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Pregnancy Category B, but hydrocortisone classified as category D, probably reflecting more experience with use in pregnancy; miscarriages, stillbirth, and malformations are known to occur with use of prednisone in pregnant women; monitor infants and treat for adrenal insufficiency; precautions in children include growth retardation, altered bone development, and multiple other adverse effects, which should lead to use in children only when absolutely necessary and to precautions and careful monitoring
Do not stop abruptly—taper off over period of time, length of which depends on duration and dose of treatment, because of potential for withdrawal effects
Musculoskeletal system risks include osteoporosis, fractures, and avascular necrosis (institute prophylactic measures); myopathy can occur; cataracts are known adverse effect, as is exacerbation of glaucoma (follow-up care with ophthalmologist needed in long-term use); vigorous glucose control necessary in patients with diabetes mellitus because of tendency for increased blood glucose with prednisone use; ulcers are frequent complication (use prophylactic H2 blocker); increases risk for infections
Weight changes, variety of psychiatric adverse effects, sleep disorders, amenorrhea, and other problems encountered; patients must be aware of potential problems
Azathioprine (Imuran)
Purine analog that decreases metabolism of purines and also may inhibit DNA and RNA synthesis. Reduces disability and symptoms of CIDP by suppressing immune-mediated damage to nerves. A small trial did not show any beneficial effect but data are insufficient to draw conclusions.
Adult
Initial dose: 50 mg PO qd, increased gradually to total daily dosage of 2-3 mg/kg/d PO
Therapeutic dose of azathioprine difficult to determine for each patient; some evidence suggests that elevations of RBC volume (MCV) indicate therapeutic dosing
Therapeutic response may take > 6 mo to become apparent
Pediatric
Not established
ACE inhibitors cause severe leukopenia and anemia; other immunosuppressants and vaccines also cause significant interactions; carbamazepine can worsen marrow suppression
Absolute: Pregnancy and breastfeeding
Relative: Documented hypersensitivity; bone marrow suppression; liver or kidney problems; infection
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Can lead to various GI symptoms and ulcer formation with delayed healing (use with prophylactic agent to prevent ulcers); can lead to severe leukopenia, anemia, and thrombocytopenia (strictly monitor blood counts: obtain CBC count before treatment, every 1-2 wk for first few months, then monthly; in author's practice, WBC count of 3000/µL considered warning, requiring closer monitoring of WBC counts and infection precautions; 2000/µL considered sign to stop medication)
As immune suppressant, places patients at risk for infections
Monitor hepatic enzymes because of risk of liver failure (same frequency as monitoring of CBC count); caution should be used if new elevation of liver enzymes up to twice normal level noted; if stopping drug brings liver enzymes back to normal, drug can be tried again at later date, although with special caution; an idiosyncratic reaction can occur within days of initiation of treatment, including fever, jaundice, nausea and vomiting, and elevation of hepatic enzymes
Discontinuation of drug usually results in complete resolution of symptoms; restarting drug does not always result in same reaction but should be considered carefully
Studies showed significant risk to fetus (on occasion benefits for mother can outweigh risk to fetus)
Mycophenolate (CellCept)
Prodrug for immunosuppressive agent mycophenolic acid. Inhibits lymphocyte purine synthesis by inhibiting enzyme inosine monophosphate dehydrogenase. Reports of efficacy but no large controlled trials.
Adult
250 mg to 3 g/d PO; adjust dose depending on clinical effect
Pediatric
Not established
Antacids decrease bioavailability; other immunosuppressive agents can worsen marrow suppression; thrombolytic agent or anticoagulant can increase risk of bleeding; has additive GI effect with salicylates and NSAIDs; can alter efficacy of oral contraceptives and vaccines
Documented hypersensitivity; bone marrow suppression; infections; GI problems; phenylketonuria; pregnancy; breastfeeding; renal failure; vaccination
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Can lead to various GI symptoms and ulcer formation with delayed healing (use with prophylactic agent; however, antacids impair bioavailability); can lead to leukopenia, anemia, and thrombocytopenia (monitor blood counts); as immune suppressant, places patients at risk of infections; monitor creatinine and liver enzymes (liver toxicity is much less likely than with azathioprine); effect on human pregnancy has not been studied but had teratogenic effects in animal studies
Cyclosporine (Sandimmune, Neoral)
Cyclic polypeptide consisting of 11 amino acids; effective in many autoimmune conditions. Inhibits first phase of T cell activation and does not affect humoral immunity. By suppressing T cells, may inhibit cell-mediated nerve damage at site of inflammatory/immune reaction. Small trial showed efficacy but data still insufficient to draw conclusions.
Adult
5 mg/kg/d PO divided bid initially; increase dose according to response and monitoring of trough concentrations
Trough and peak levels should be monitored to register efficacy and avoid toxicity; although no definitive desirable trough level has been identified specifically for CIDP, usual trough levels utilized for immunologic disorders are between 100 and 250
Pediatric
Not established
Significant interactions exist with multiple medications, such as ACE inhibitors (causes severe leukopenia and anemia), other immunosuppressants, vaccines, antibiotics such as aminoglycosides and vancomycin (additive nephrotoxicity), androgens (decrease cyclosporine clearance), corticosteroids, estrogens, NSAIDs (additive GI adverse effects), neuromuscular blockers (prolonged effect), diuretics, and others
Absolute: Documented hypersensitivity; breastfeeding
Relative: Liver, biliary tract, or kidney disease; children (since no well-controlled studies have been performed); elderly patients; females of childbearing age; infections; hyperuricemia; pregnancy; radiation treatments; vaccinations; skin abnormalities
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor elderly patients particularly carefully because of risk of systolic hypertension and decreased CrCl; females of childbearing age should use contraception because of effects on fetus; known to be embryotoxic and fetotoxic, causing premature birth, low birth weight, and malformations; can be used if benefit for mother outweighs risks to fetus; excreted in breast milk, and breastfeeding is contraindicated; monitoring of creatinine and liver enzymes, bilirubin, and alkaline phosphatase important
Cyclophosphamide (Cytoxan)
Cell-cycle phase-nonspecific antineoplastic agent and immunosuppressant that acts as alkylating agent.
Adult
1-2 mg/kg/d PO or monthly pulse IV; dosing based on body size used; usually a 6-mo treatment period used; dose adjusted to reduce WBC count to 2000-3000/µL; reports describe high-dose ablative therapy (which reduces WBC counts to 0) having efficacy in patients with otherwise severe and refractory disease
Pediatric
Not established
Other immunosuppressive agents can worsen marrow suppression; thrombolytic agent or anticoagulant can increase risk of bleeding; has additive GI effect with salicylates and NSAIDs; enzyme inducers such as phenytoin and barbiturates can increase toxic effects; multiple medications, including prednisone, can alter efficacy; can alter efficacy of vaccines
Absolute: Breastfeeding; dehydration; infection
Relative: Documented hypersensitivity; bone marrow suppression; dental work; gout; hyperuricemia; hemorrhagic cystitis; pregnancy; radiation treatment; vaccinations
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Hemorrhagic cystitis is serious complication, and vigorous hydration has to be instituted in all patients; can lead to various GI symptoms and ulcer formation with delayed healing (use with prophylactic agent); can lead to leukopenia, anemia, and thrombocytopenia (monitor blood counts); as immune suppressant, places patients at risk for infections
Teratogenic—use in pregnancy should be greatly discouraged, particularly in first trimester
Variety of other adverse effects must be monitored, and patients must be aware of them, including alopecia, allergic reactions, infertility, myocarditis and pericarditis, nephrolithiasis, and secondary malignancy
Antiepileptic medications
In patients with CIDP, a variety of medications is used for treatment of neuropathic pain. Antiepileptic medications are quite effective. The 2 most frequently used medications, gabapentin and carbamazepine, are described.
Gabapentin (Neurontin)
Known to effect to GABA, but exact binding site unknown. Also has effects on calcium channels. Mostly used for treatment of epilepsy and neuropathic pain; 100-, 300-, and 400-mg cap and 600- and 800-mg film-coated tab are available.
Adult
Starting dose depends on patient age and renal function; initial maintenance dose usually 300 mg PO tid; slow increase in dose may minimize adverse effects
Many patients require 1800-3600 mg/d to reach therapeutic effect; adjust dose for CrCl in patients with renal failure
Pediatric
Not established; may use 30-60 mg/kg/d PO tid; as in adults, begin with lowest possible dose
Not appreciably metabolized; does not interfere with metabolism of most medications; cimetidine mildly decreases renal excretion of gabapentin; minimally decreases level of norethindrone (oral contraceptive pill component); give at least 2 h following Maalox administration (otherwise Maalox reduces bioavailability)
Documented hypersensitivity; children; elderly patients; pregnancy; breastfeeding; renal impairment; driving or operating machinery
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not discontinue abruptly because of increased risk of seizure; dose adjustment required for patients with renal failure; caution in patients with jobs demanding high alertness, in elderly patients, and with driving because of potential to cause somnolence and fatigue; most common adverse reactions are somnolence, dizziness, ataxia, nausea, vomiting, and fatigue; has been shown to cause delayed ossification of several bones in skull, vertebrae, forelimbs, and hindlimbs in rodents; because animal reproduction studies are not always predictive of human response, use during pregnancy only if potential benefits justify potential risk to fetus
Carbamazepine (Tegretol)
Blocks use-dependent sodium channels and inhibits sustained repetitive firing as well as reduces posttetanic potentiation of synaptic transmission in spinal cord. Potent enzyme inducer that can induce own metabolism. Used as anticonvulsant and for treatment of neuropathic pain.
Available in chewable 100-mg tab, in tab of 200 mg, XR tab of 100, 200, and 400 mg, and as susp of 100 mg/5 mL.
Adult
400 mg PO divided bid; slowly increase in divided doses (tid for regular, bid for XR)
Pediatric
10-35 mg/kg/d PO bid/qid; as in adults, use/begin with lowest possible dose
Induces hepatic microsomal enzymes, which, in turn, accelerate carbamazepine metabolism or metabolism of other drugs; interactions between carbamazepine and other anticonvulsants are variable and complicated; can decrease effectiveness of oral contraceptive pills, phenothiazines, antidepressants, barbiturates, corticosteroids, and antiretroviral protease inhibitors; in turn, enzyme-inducing medications can alter metabolism of carbamazepine; antineoplastic agents can exacerbate hematologic toxicity
Absolute: Documented hypersensitivity; agranulocytosis; bone marrow suppression; cardiac conduction block
Relative: Renal impairment; atonic, myoclonic, or absence seizures; barbiturate or hydantoin hypersensitivity; cardiac disease including coronary artery disease; driving or operating machinery; alcoholism; breastfeeding; pregnancy; elderly patients; glaucoma; hematologic disease; hepatic disease; hyponatremia; jaundice; neonates; psychosis
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Monitor WBC counts closely because of risk of agranulocytosis and aplastic anemia; monitor sodium levels because of possibility of hyponatremia and SIADH; monitor liver enzymes because of possibility of elevation with risk of hepatic failure with or without hepatitis
Patients should report any rash immediately—toxic epidermal necrolysis, Stevens-Johnson syndrome, and exfoliative dermatitis are observed with use
Cardiac adverse effects include arrhythmia exacerbation, worsening of preexisting block, and new conduction block
Neurological adverse effects include ataxia, diplopia, aseptic meningitis, confusion, drowsiness, and nystagmus
Due to teratogenicity, should be used in pregnancy only if benefits outweigh risks; has been implicated in a number of fetal abnormalities, particularly neural tube defects
Tricyclic antidepressants
These medications are used frequently for the treatment of neuropathic pain. The most traditionally used medication, amitriptyline, is discussed.
Amitriptyline (Elavil)
Tertiary amine TCA known to decrease reuptake of serotonin and norepinephrine. Has been used more than other newer TCAs and has more proven benefits, although other TCAs, such as desipramine and nortriptyline, are also quite potent and have fewer adverse effects.
Tab available in 10, 25, 50, 75, 100, and 150 mg.
Adult
10-150 mg/d PO can be used; start at low doses hs, then increase doses depending on clinical response
Pediatric
Not established
Interacts with multiple medications; anticonvulsants may require increased doses for adequate seizure control; clonidine can lead to dangerous hypertension; antimuscarinics may cause additive anticholinergic effects; other psychiatric medications such as hypnotics and sedatives can worsen depressant effects and lead to hypotension, somnolence, and respiratory depression; MAOIs can lead to hypertension, hyperthermia, and seizures; increases pressor effects of sympathomimetics; thyroid hormones may increase receptor sensitivity to amitriptyline
Absolute: Documented hypersensitivity; acute MI; heart block; prolonged QT; ileus; use of radiographic contrast metrizamide
Relative: Alcohol or substance abuse; breastfeeding; pregnancy; agranulocytosis; use of anticholinergic medications; asthma; bipolar disorder; children; elderly patients; glaucoma; diabetes mellitus; driving or operating machinery; liver disease; GI disease; hematologic problems; thyroid problems; prostatic hypertrophy; urinary retention; Parkinson disease; seizures; thrombocytopenia
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Obtain ECG and detailed cardiac history prior to beginning treatment, since drug increases risk of conduction abnormalities; ECG also is suggested when dose raised to >75 mg/d; do not use in patients with risk factors or cardiac history
Lowers seizure threshold and may induce seizures or compromise seizure control in patients with epilepsy; monitor level of anticonvulsants
Decreased libido, impotence, ejaculatory dysfunction, galactorrhea, and gynecomastia may occur (make patients aware)
Use in pregnancy only when benefits clearly outweigh risks; risk of malformation, developmental delay, and withdrawal at birth
Variety of other adverse effects must be monitored, and patients must be aware of them, including anxiety, blurred vision, sedation, urinary retention, and withdrawal symptoms after rapid cessation
Pregabalin (Lyrica)
Thought to have similar mode of action to gabapentin. Clinical trials have shown efficacy for diabetic neuropathy and shingles induced neuropathic pain.
Adult
Starting dose: 150 mg/d PO divided bid/tid
Maintenance dose: 300 mg/d PO divided bid/tid
Pediatric
Not established
Not appreciably metabolized; does not interfere with metabolism of most medications; no effect on level of norethindrone (oral contraceptive pill component)
Documented hypersensitivity; children; elderly patients; pregnancy; breastfeeding; renal impairment; driving or operating machinery
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not discontinue abruptly because of increased risk of seizure; dose adjustment required for patients with renal failure; caution in patients with jobs demanding high alertness, in elderly patients, and with driving because of potential to cause somnolence and fatigue; most common adverse reactions are somnolence, dizziness, ataxia, nausea, vomiting, and fatigue; edema and weight gain may occur
Duloxetine (Cymbalta)
Duloxetine clinical trials have shown efficacy in diabetic neuropathy pain and for depression.
It is a selective serotonin and norepinephrine reuptake inhibitor.
Adult
Starting dose: 30 mg PO qd
Maintenance dose: 60 mg PO qd in either one or two divided doses (30 mg bid)
Pediatric
Not established
CYP1A2 and CYP2D6 responsible for metabolism; interacts with paroxetine, fluoxetine, and quinidine (CYP2D6 inhibitors); TCAs, phenothiazines, antiarrhythmics (propafenone, flecainide) may interact (CYP2D6 metabolized drugs); alcohol-CNS acting drugs; MAOIs; gastric acidity drugs
Documented hypersensitivity; uncontrolled narrow-angle glaucoma; within 14 d of stopping MAOI use (do not initiate MAOIs within 5 d of stopping duloxetine)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Observe closely for clinical worsening and suicidality when initiating treatment or following dosage change; gradually decrease dose when discontinuing, do not abruptly discontinue; caution with hepatic impairment or end-stage renal disease; recommended not to prescribe to patients with substantial alcohol use or evidence of chronic liver disease; may cause slight blood pressure increase; may activate mania or hypomania; common adverse effects include nausea, dry mouth, constipation, decreased appetite, fatigue, somnolence, and increased sweating
More on Chronic Inflammatory Demyelinating Polyradiculoneuropathy |
| Overview: Chronic Inflammatory Demyelinating Polyradiculoneuropathy |
| Differential Diagnoses & Workup: Chronic Inflammatory Demyelinating Polyradiculoneuropathy |
 Treatment & Medication: Chronic Inflammatory Demyelinating Polyradiculoneuropathy |
| Follow-up: Chronic Inflammatory Demyelinating Polyradiculoneuropathy |
| Multimedia: Chronic Inflammatory Demyelinating Polyradiculoneuropathy |
| References |
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References
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Further Reading
Keywords
chronic inflammatory demyelinating polyneuropathy, CIDP, chronic acquired demyelinating polyneuropathies, CADP, acute inflammatory demyelinating polyradiculoneuropathy, AIDP, Guillain-Barre Syndrome #233; syndrome, GBS, chronic inflammatory demyelinating polyradiculoneuropathy, monoclonal gammopathies, multifocal motor neuropathy, MMN, acquired purely motor neuropathy, lower motor neuron-type deficits, multifocal sensorimotor neuropathy, sensorimotor mononeuropathy multiplex, Lewis-Sumner neuropathy, sensory predominant CADP, polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, POEMS, CADP associated with diabetes mellitus, sensorimotor disorder
