Chemotherapy-Induced Peripheral Neuropathy in Cancer Survivors

Upon reviewing JB's history for risks of peripheral neuropathy, it is important to consider her cancer treatment and health history. This patient completed her last course of chemotherapy 13 months ago. The risk of Grade 2, 3, and 4 CIPN is increased with weekly paclitaxel vs every-3-week dosing. [28] Coexisting diabetes in patients treated with paclitaxel or other neurotoxic chemotherapeutic agents also increases the likelihood for developing CIPN. [4,29] Lyme disease, if untreated, can result in peripheral neuropathy, and nicotine from cigarette smoking constricts blood vessels that supply nutrients to the peripheral nerves (see Table 1). She is referred to a neurologist for QST, which reveals sensory and motor neuropathy. JB is most likely experiencing long-term CIPN related to treatment with paclitaxel that is complicated by a peripheral neuropathy from her poorly controlled diabetes. The nurse practitioner consults with JB's medical oncologist, and they agree to initiate therapy with gabapentin at 200 mg twice a day for 5 days, then 200 mg three times a day for 5 days, followed by an increase to 300 mg three times a day. The effectiveness of gabapentin for CIPN has been documented, [30] but in one study it was not effective. [31] Gabapentin is beneficial, however, for treatment of diabetic neuropathy. [32] If JB's symptoms of depression persist after titrating gabapentin to an effective dose for pain relief, which can be up to 3,600 mg per day, then duloxetine (Cymbalta) at 60 mg per day could be added to her treatment regimen. Duloxetine is also useful not only for depression, but also for neuropathic pain from diabetic neuropathy. [32]