Neuropathy in Cancer Survivors

Neuropathy in Cancer Survivors Home

• Creado por Kaitlin Einhaus, modificado por última vez por Rose Morrison el abr 20, 2014
This is an original JCO publication from 2014. Please visit the JCO website to access the full article.
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Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline
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Authors
THE BOTTOM LINE


Guideline Question

What are the optimum prevention and treatment approaches in the management of chemotherapy-induced neuropathies in adult cancer survivors?

Target Population

Adult cancer survivors with chemotherapy-induced neuropathies.

Target Audience

Health care practitioners who provide care to cancer survivors.

Recommendations

The following recommendations are evidence-based, informed by small RCTs, and guided by clinical experience. The recommendations were developed by a multi-disciplinary group of experts. Ratings for benefits, harms, evidence quality and recommendation strength are provided in Table 4 (see Appendix I for rating definitions).
Prevention of Chemotherapy-induced peripheral neuropathy:
There are no established agents recommended for the prevention of CIPN in cancer patients undergoing treatment with neurotoxic agents. This is based on the paucity of high-quality, consistent evidence and a balance of benefits versus harms.

Clinicians should not offer the following agents for the prevention of CIPN to cancer patients undergoing treatment with neurotoxic agents:
• acetyl-L-carnitine (ALC)
• amifostine
• amitriptyline
• CaMg for patients receiving oxaliplatin-based chemotherapy
• diethyldithio-carbamate (DDTC)
• glutathione (GSH) for patients receiving paclitaxel/carboplatin chemotherapy
• nimodipine
• Org 2766
• all-trans retinoic acid
• rhuLIF
• vitamin E

Venlafaxine is not recommended for routine use in clinical practice. While the venlafaxine data supports its potential utility, the data were not strong enough to recommend its use in clinical practice, until additional supporting data become available.
No recommendations can be made on the use of N-acetylcysteine, carbamazepine, glutamate, glutathione for patients receiving cisplatin or oxaliplatin-based chemotherapy, goshajinkigan (GJG), omega-3 fatty acids, or oxycarbazepine for the prevention of CIPN at this time.
Treatment of Chemotherapy-induced peripheral neuropathy
For cancer patients experiencing CIPN, clinicians may offer duloxetine.

No recommendations can be made on the use of:
• Acetyl-L-carnitine, noting that a positive phase III abstract supported its value, but this work has not yet been published in a peer-reviewed journal and a prevention trial suggested that this agent was associated with worse outcomes.
• Tricyclic antidepressants; however, based on the limited options that are available for this prominent clinical problem and the demonstrated efficacy of these drugs for other neuropathic pain conditions, it is reasonable to try a tricyclic antidepressant (e.g., nortriptyline or desipramine) in patients suffering from CIPN following a discussion with the patients about the limited scientific evidence for CIPN, potential harms, benefits, cost, and patient preferences.
• Gabapentin, noting that the available data were limited regarding its efficacy for treating CIPN. However, the panel felt that this agent is reasonable to try for selected patients with CIPN pain given that only a single negative randomized trial for this agent was completed, given the established efficacy of gabapentin and pregabalin for other forms of neuropathic pain, and given the limited CIPN treatment options. Patients should be informed about the limited scientific evidence for CIPN, potential harms, benefits, and costs.
• A topical gel treatment containing baclofen (10 mg), amitriptyline HCL (40 mg), and ketamine (20 mg), noting that a single trial supported that this product did decrease CIPN symptoms. Given the available data, the panel felt that this agent is reasonable to try for selected patients with CIPN pain. Patients should be informed about the limited scientific evidence for the treatment of CIPN, potential harms, benefits, and costs.

Note: The guide for rating recommendations and strength of evidence is provided in Appendix I.


SUMMARY OF RECOMMENDATIONS


Prevention and treatment approaches in the management of chemotherapy-induced neuropathies in adult cancer survivors
What are the optimum prevention approaches in the management of chemotherapy-induced neuropathies in adult cancer survivors?
Recommendation Evidence Rating


There are no established agents recommended for the prevention of CIPN in cancer patients undergoing treatment with neurotoxic agents. This is based on the paucity of high-quality, consistent evidence and a balance of benefits versus harms. Type: Evidence-based
Harms outweigh benefits
Evidence quality: Ranges from low to high
Strength of Recommendation: Ranges from inconclusive to strong against


Clinicians should not offer the following agents for the prevention of CIPN to cancer patients undergoing treatment with neurotoxic agents:
• acetyl-L-carnitine (ALC)
• amifostine
• amitriptyline
• CaMg for patients receiving oxaliplatin-based chemotherapy
• diethyldithio-carbamate (DDTC)
• glutathione (GSH) for patients receiving paclitaxel/carboplatin chemotherapy
• nimodipine
• Org 2766
• all-trans retinoic acid
• rhuLIF
• vitamin E
Venlafaxine is not recommended for routine use in clinical practice. While the venlafaxine data supports its potential utility, the data were not strong enough to recommend its use in clinical practice, until additional supporting data become available.
Type: Evidence-based
Balance of benefits and harms
Evidence quality: Intermediate
Strength of Recommendation: Inconclusive


No recommendations can be made on the use of N-acetylcysteine, carbamazepine, glutamate, glutathione for patients receiving cisplatin or oxaliplatin-based chemotherapy, goshajinkigan (GJG), omega-3 fatty acids, or oxycarbazepine for the prevention of CIPN at this time.
Type: Evidence-based
Balance of benefits and harms
Evidence quality: Low
Strength of recommendation: Inconclusive

What are the optimum treatment approaches in the management of chemotherapy-induced neuropathies in adult cancer survivors?

Recommendation Evidence Rating


For cancer patients experiencing CIPN, clinicians may offer duloxetine.
Type: Evidence-based
Benefits outweigh harms
Evidence quality: Intermediate
Strength of Recommendation: Moderate


No recommendations can be made on the use of acetyl-L-carnitine, noting that a positive phase III abstract supported its value, but this work has not yet been published in a peer-reviewed journal and a prevention trial suggested that this agent was associated with worse outcomes. Type: Evidence-based
Harms outweigh benefits
Evidence quality: Low
Strength of Recommendation: Inconclusive


No recommendations can be made on the use of tricyclic antidepressants. However, based on the limited options that are available for this prominent clinical problem and the demonstrated efficacy of these drugs for other neuropathic pain conditions, it is reasonable to try a tricyclic antidepressant (e.g., nortriptyline or desipramine) in patients suffering from CIPN following a discussion with the patients about the limited scientific evidence for CIPN, potential harms, benefits, cost, and patient preferences. Type: Evidence-based
Balance of benefits and harms
Evidence quality: Intermediate
Strength of Recommendation: Inconclusive


No recommendations can be made on the use of gabapentin, noting that the available data were limited regarding its efficacy for treating CIPN. However, the panel felt that this agent is reasonable to try for selected patients with CIPN pain given that only a single negative randomized trial for this agent was completed, given the established efficacy of gabapentin and pregabalin for other forms of neuropathic pain, and given the limited CIPN treatment options. Patients should be informed about the limited scientific evidence for CIPN, potential harms, benefits, and costs.
Type: Evidence-based
Balance of benefits and harms
Evidence quality: Intermediate
Strength of Recommendation: Inconclusive


No recommendations can be made on the use of a topical gel treatment containing baclofen (10 mg), amitriptyline HCL (40 mg), and ketamine (20 mg), noting that a single trial supported that this product did decrease CIPN symptoms. Given the available data, the panel felt that this agent is reasonable to try for selected patients with CIPN pain. Patients should be informed about the limited scientific evidence for the treatment of CIPN, potential harms, benefits, and costs. Type: Evidence-based
Benefits outweigh harms
Evidence quality: Intermediate
Strength of Recommendation: Inconclusive