Chemotherapy-induced Peripheral Neuropathy Guidelines 

Updated: Nov 04, 2020
  • Author: Alexandre Chan, PharmD, MPH, FCCP, BCPS (AQ-ID), BCOP; more...
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Issuing Organizations

The following organizations have released guidelines for the management of chemotherapy-induced peripheral neuropathy (CIPN) in oncology patients:

  • American Society of Clinical Oncology (ASCO)

  • Oncology Nursing Society (ONS)

The ASCO guidelines were first published in 2014 and were updated in 2020. [1, 2] The ONS reaffirmed its 2007 guidelines in 2014. [3]

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ASCO Recommendations

Prevention

Due to lack of high-quality, consistent evidence, the ASCO guidelines do not recommend any agents for prevention of CIPN. The guidelines strongly recommend that clinicians should not offer, and should discourage use of, acetyl-l-carnitine for the prevention of CIPN in patients with cancer. The guidelines also include a moderate recommendation against offering the following agents for the prevention of CIPN [2] :

  • All-trans retinoic acid
  • Amifostine
  • Amitriptyline
  • Calcium magnesium
  • Calmangafodipir
  • Cannabinoids
  • Carbamazepine
  • l-carnosine
  • Diethyldithiocarbamate (DDTC)
  • Gabapentin/pregabalin
  • Glutamate
  • Glutathione (GSH) for patients receiving paclitaxel/carboplatin chemotherapy
  • Goshajinkigan (GJG)
  • Metformin
  • Minocycline
  • N-acetylcysteine
  • Nimodipine
  • Omega-3 fatty acids
  • Org 2766
  • Oxcarbazepine
  • Recombinant human leukemia inhibitory factor
  • Venlafaxine
  • Vitamin B
  • Vitamin E

ASCO advises that outside the context of a clinical trial, no recommendations can be made on the use of the following for the prevention of CIPN:

  • Acupuncture
  • Cryotherapy
  • Compression therapy
  • Exercise therapy
  • Ganglioside-monosialic acid (GM-1)

Treatment

The ASCO guidelines recommend duloxetine to treat painful CIPN. The guidelines advise that outside the context of a clinical trial, no recommendations can be made on the use of the following for the treatment of CIPN:

  • Exercise therapy
  • Acupuncture
  • Scrambler therapy
  • Gabapentin/pregabalin
  • Topical gel treatment containing baclofen, amitriptyline HCL, plus/minus ketamine
  • Tricyclic antidepressants
  • Oral cannabinoids

ASCO notes that although preliminary evidence suggests that exercise, acupuncture, and scrambler therapy offer potential benefit, larger sample-sized definitive studies are needed to confirm efficacy and clarify risks.

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ONS Recommendations

The ONS guidelines include the following recommendations for treatment of chemotherapy-induced peripheral neuropathy [3] :

  • Duloxetine is likely to be effective
  • Lamotrigine is unlikely to be effective
  • Carnitine/L-carnitine and human leukemia inhibitory factor are not recommended

In addition, the ONS guidelines note that the effectiveness of the following treatments could not be determined:

  • Acupuncture
  • Alpha lipoic acid
  • Amifostine
  • Amitriptyline
  • Bee venom
  • Calcium and magnesium infusion
  • Calcium channel blockers
  • Cannabis/cannabinoids
  • Carbamazepine
  • Cutaneous stimulation
  • Gabapentin and opioid combination
  • Gabapentin monotherapy
  • Glutamine
  • Glutathione
  • Goshajinkigan
  • KRN5500
  • Nortriptyline
  • Omega-3 fatty acids (eicosapentaenoic acid and others)
  • Palmitoylethanolamide
  • Pregabalin
  • Topical ketamine formulations
  • Venlafaxine
  • Vitamin E
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Summary

Peripheral neuropathy is a common adverse effect of chemotherapy, caused by agents 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 efficacy for the treatment of chemotherapy-related peripheral neuropathy.

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