BOF: Malignant (Supportive Care)

A 50 year old man being treated for diffuse large B cell lymphoma with R-CHOP chemotherapy develops painful legs and hands after completion of treatment. Clinical examination suggests a peripheral neuropathy that is ascribed to his vincristine. What of the following would be a reasonable first line agent in treatment of this painful neuropathy?

a) Amitryptyline

b) Gabapentin

c) Ibuprofen

d) Lamotrigine

e) Morpine sulphate solution

Answer:

c) Ibuprofen

Explanation:

Peripheral neuropathy is a relatively common side effect of many chemotherapeutic regimes. The following drugs routinely used in haematology practice commonly include painful neuropathy as a side effect: Vinca alkaloids, Platinum drugs, Procarbazine, Bortezomib, Thalidomide, Etoposide, Cytarabine, 5-Azacytidine, Fludarabine. The first principle is to stop the causative drug, if possible, or consider dose reduction.

There is no consensus on best treatment, and guidelines have little to offer. Drugs such as NSAIDs are effective in painful neuropathy, and are considered first line therapy, although should be used with caution and opioids are considered an effective second-line agent. Despite efficacy in other painful neuropathies, gabapentin, anti-convulsants and tricyclic antidepressants have disappointing efficacy in chemotherapy-induced painful neuropathy. Preventive treatments such as vitamin E also have had poor efficacy in trials.

Duloxetine, an 'SNRI'-class antidepressant (a serotonin/noradrenaline reuptake inhibitor) has shown most promise particularly in oxaliplatin induced neurotoxicity in a large randomised controlled trial, but this trial was limited to patients with solid tumours and has not been demonstrated in haematological malignancy.

References:

Kaley TJ & Deangelis LM. Therapy of chemotherapy-induced peripheral neuropathy. British Journal of Haematology 2009: 145; 3-14

Smith E, Pang H, Cirrincione C, et al. Effect of Duloxetine on Pain, Function, and Quality of Life Among Patients With Chemotherapy-Induced Painful Peripheral Neuropathy: A Randomized Clinical Trial. JAMA. 2013;309(13):1359-1367

D.L. Hershman, C. Lacchetti, R.H. Dworkin, et al. Prevention and management of chemotherapy-induced peripheral neuropathy in survivors of adult cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol, 32 (2014), pp. 1941–1967