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American Society of Clinical OncologyOncology2020advanced

Prevention And Management Of Chemotherapy-Induced Peripheral Neuropathy In Survivors Of Adult Cancers

Published by American Society of Clinical Oncology · ASCO standard criteria (Type and Strength of recommendation, Evidence quality)

7Recommendations
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Summary

AI-generated

Chemotherapy-induced neuropathy is a serious clinical problem caused by cytotoxic drugs like taxanes and platinums. Symptoms can acute or chronic, causing marked effects on the quality of life and potentially limiting cancer treatments.

CIPNchemotherapy-induced peripheral neuropathyduloxetineacetyl-L-carnitineASCOoncologyguidelinesrecommendations

Key Takeaways

  • 1
    No agents are recommended for the prevention of CIPN.
  • 2
    Acetyl-L-carnitine use is discouraged for CIPN prevention.
  • 3
    Clinicians should assess whether to delay, reduce, substitute, or stop chemotherapy for patients developing intolerable neuropathy.
  • 4
    Duloxetine is the only agent with appropriate evidence recommended for treating established painful CIPN.

What's New in This Version

The updated guideline no longer provides promising commentary regarding venlafaxine as a preventative agent due to longer follow-up data. Acetyl-L-carnitine is now explicitly recommended against for the treatment of established chemotherapy-induced neuropathy. There is also waning enthusiasm for tricyclic antidepressants, gabapentinoids, and a topical gel treatment containing baclofen, amitriptyline, and ketamine due to a lack of new supporting data or negative trial results.

Key Recommendations

Prevention of chemotherapy-induced peripheral neuropathy

  • 1.1

    Clinicians should assess the risks and benefits of agents known to cause CIPN among patients with underlying neuropathy and with conditions that predispose to neuropathy such as diabetes and/or a family or personal history of hereditary peripheral neuropathy.

    moderateEvidence: lowinformal consensus, benefits outweigh harms
  • 1.2

    Clinicians should not offer, and should discourage use of, acetyl-L-carnitine for the prevention of CIPN in patients with cancer.

    strongEvidence: highevidence based, harms outweigh benefits
  • 1.3

    Outside the context of a clinical trial, no recommendations can be made on the use of the following interventions for the prevention of CIPN: Acupuncture, Cryotherapy, Compression therapy, Exercise therapy, Ganglioside-monosialic acid (GM-1).

    not applicableEvidence: lowno recommendation
  • 1.4

    Clinicians should not offer the following agents for the prevention of CIPN to patients with cancer undergoing treatment with neurotoxic agents: 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.

    moderateEvidence: intermediateevidence based, no benefits

Treatment of chemotherapy-induced peripheral neuropathy that develops while patients are receiving neurotoxic chemotherapy

  • 2.1

    Clinicians should assess, and discuss with patients, the appropriateness of dose delaying, dose reduction, or stopping chemotherapy (or substituting with agents that do not cause CIPN) in patients who develop intolerable neuropathy and/or functional nerve impairment.

    moderateEvidence: lowinformal consensus, benefits outweigh harms

Treatment of chemotherapy-induced peripheral neuropathy for patients who have completed neurotoxic chemotherapy

  • 3.1

    For patients with cancer experiencing painful CIPN, clinicians may offer duloxetine.

    moderateEvidence: intermediateevidence based, benefits equal harms
  • 3.2

    Outside the context of a clinical trial, no recommendations can be made on the use of the following interventions 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.

    not applicableEvidence: lowno recommendation

Scope & Objectives

Clinical Topic

Chemotherapy-Induced Peripheral Neuropathy

Objectives

To update the ASCO guideline on the recommended prevention and treatment approaches in the management of chemotherapy-induced peripheral neuropathy (CIPN) in adult cancer survivors.

Target Patient Population

Adult cancer survivors with, or at risk for developing, chemotherapy-induced neuropathies

Diagnostic Criteria

Diagnosis generally made by clinical history (new or worsening numbness, tingling, and/or pain in hands and/or feet in patients receiving neurotoxic chemotherapy without other reason).

Target Providers

Health care practitioners who provide care to cancer survivorspatientscaregivers

Patient Criteria & Setting

Therapeutic Area

Oncology

Guideline Scope

PreventionTreatment

Inclusion Criteria

  • focused on chemotherapy-induced neuropathy
  • included cancer survivors
  • considered neuropathy as an important outcome of the study

Exclusion Criteria

  • phase I studies
  • other noncomparative studies
  • case reports
  • editorial letters
  • newspaper articles
  • individuals < 18 years of age
  • published in a language other than English
  • < 10 participants
  • radiation therapy-related neuropathy
  • stem-cell transplantation-related neuropathy

Special Populations

patients with underlying neuropathypatients with diabetespatients with a family or personal history of hereditary peripheral neuropathy

Evidence Grading

System: ASCO standard criteria (Type and Strength of recommendation, Evidence quality)

Safety & Contraindications

Contraindications

  • acetyl-L-carnitine for prevention

Monitoring Guidance

Neurologic physical examinations can be used. Neurologic tests like electromyography (EMG) are not usually necessary but can be used.

Authors & Contributors

Charles L. LoprinziMD; Christina LacchettiMHSc; Jonathan BleekerMD; Guido CavalettiMDPhD; Cynthia ChauhanMSW; Daniel L. HertzPharmDPhD; Mark R. KelleyPhD; Antoinette LavinoBS PharmRPh; Maryam B. LustbergMD; Judith A. PaicePhDRN; Bryan P. SchneiderMD; Ellen M. Lavoie SmithRNPhD; Mary Lou SmithJDMBA; Thomas J. SmithMD; Nina Wagner JohnstonMD; Dawn L. HershmanMD

Guideline Features

Dosing informationBased on systematic reviewMultidisciplinaryPatient involvement

Learning Context

Difficulty

advanced

Learning Paths

OncologyChemotherapy-Induced Peripheral Neuropathy (CIPN)Pain ManagementCancer SurvivorshipDuloxetine