Managing Chemotherapy-Induced Peripheral Neuropathy in Adult Cancers Survivors: ASCO guidelines

The new guidelines have been published in the Journal of Clinical Oncology.

Chemotherapy-induced peripheral neuropathy can markedly affect the quality of life (QOL) of patients. In addition, it may be detrimental to their cancer outcomes, as it may limit the amount of chemotherapy that clinicians can give.

The purpose of this guideline update is to systematically review new evidence reported in the literature since the original guideline was published, compare outcomes among trials, and provide updated guidance on the effectiveness of prevention and treatment options for CIPN in adults with a history of cancer.

Updated Recommendations

The following recommendations are evidence based, informed by randomized trials, and guided by clinical experience. The recommendations were developed by a multidisciplinary group of experts.

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 neuropathy (Type of recommendation: Informal consensus, benefits outweigh harms; Evidence quality: low; Strength of recommendation: moderate).

1.2 Clinicians should not offer, and should discourage use of, acetyl-l-carnitine for the prevention of CIPN in patients with cancer (Type of recommendation: evidence based, harms outweigh benefits; Evidence quality: high; Strength of recommendation: strong).

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)

(Type of recommendation: no recommendation; Evidence quality: low; Strength of recommendation: not applicable).

Note: While preliminary evidence suggests a potential for benefit from these interventions, larger sample–sized definitive studies are needed to confirm efficacy and clarify risks.

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

(Type of recommendation: evidence based, no benefits; Evidence quality: intermediate; Strength of recommendation: moderate).

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 (Type of recommendation: informal consensus, benefits outweigh harms; Evidence quality: low; Strength of recommendation: moderate).

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 (Type of recommendation: evidence based, benefits equal harms; Evidence quality: intermediate; Strength of recommendation: moderate).

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

ASCO believes that cancer clinical trials are vital to inform medical decisions and improve cancer care, and that all patients should have the opportunity to participate.

The identified data reconfirmed that no agents are recommended for the prevention of CIPN. The use of acetyl-l-carnitine for the prevention of CIPN in patients with cancer should be discouraged. Furthermore, clinicians should assess the appropriateness of dose delaying, dose reduction, substitutions, or stopping chemotherapy in patients who develop intolerable neuropathy and/or functional impairment. Duloxetine is the only agent that has appropriate evidence to support its use for patients with established painful CIPN. Nonetheless, the amount of benefit from duloxetine is limited.

For further reference log on to:

www.asco.org/survivorship-guidelines.