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Have you ever experienced peripheral neuropathy? Did it feel like a numbness or tingling in your hands or feet? Did it last several weeks, or several years? Join us, as Cindy S. Tofthagen, PhD, ARNP, AOCNP, University of South Florida College of Nursing Assistant Professor and Concentration Director of Oncology, will discuss this important topic and ways to manage it. Although peripheral neuropathy is a known common side effect of some chemotherapy regimens, there are many different types of peripheral neuropathy, and many different causes. Cindy will explain exactly what it is that's happening, why it happens, and what causes it to happen. And then, most importantly, will provide tips on the best ways to manage it. You're not going to want to miss this!
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Welcome!
Peripheral Neuropathy: Will it ever go away? Problems, Causes, Solutions
Part of Fight Colorectal Cancer’s Monthly Patient Webinar Series
Our webinar will begin shortly
www.FightColorectalCancer.org877-427-2111
Fight Colorectal Cancer
1. Tonight’s speaker: Cindy Tofthagen, PhD, ARNP, AOCNP, FAANP
2. Archived webinars: FightColorectalCancer.org/Webinars
3. Follow up survey to come via email. Get a free Blue Star of Hope pin when you tell us how we did tonight.
4. Ask a question in the panel on the right side of your screen and look for hyperlinks during throughout the presentation.
5. Or call the Fight Colorectal Cancer Answer Line at 877-427-2111
Fight Colorectal CancerDisclaimer
The information and services provided by Fight Colorectal Cancer are for general informational purposes only.
The information and services are not intended to be substitutes for professional medical advice, diagnosis, or treatment.
If you are ill, or suspect that you are ill, see a doctor immediately. In an emergency, call 911 or go to the nearest emergency room.
Fight Colorectal Cancer never recommends or endorses any specific physicians, products or treatments for any condition.
www.FightColorectalCancer.org877-427-2111
Fight Colorectal Cancer
Up coming webinar
Advances in Surgical Treatments for Colon and Rectal Cancer Patients
November 20, 20138 - 9:30pm EDT
Fight Colorectal Cancer
www.FightColorectalCancer.org877-427-2111
Cindy Tofthagen, PhD, ARNP, AOCNP, FAANPUniversity of South Florida
College of Nursing
Chemotherapy Related Neuropathy: Managing this Nerve Wracking ProblemCindy Tofthagen, PhD, ARNP, AOCNP, FAANPUniversity of South FloridaCollege of Nursing
Topics of Discussion
• What is chemotherapy induced peripheral neuropathy (CIPN)?
• What are the risk factors?
• What can we do about it?
What is CIPN?
A group of neuromuscular symptoms that result from nerve damage caused by drug therapies used in the treatment of cancer.
Affects 30-100% of patients getting specific neurotoxic chemotherapy drugs.
The most commonly used classes of drugs causing peripheral neuropathy are taxanes (Taxol and Taxotere) and platinum based drugs (cisplatin and oxaliplatin).
(Ocean & Vahdat, 2004; Visovsky, 2003)
•Sensory, motor, or autonomic
•Vary from person to person based on type of treatment and individual differences
•Numbness, tingling, and discomfort in the upper or lower extremities are the hallmarks of peripheral neuropathy
Symptoms
Problem
CIPN can last for months to years after chemotherapy and sometimes is permanent.
It can interfere with the ability to perform usual activities.
Risk Factors• Increasing dose• Pretreatment or concurrent treatment with other
neurotoxic chemotherapies• Diabetes• Hypothyroidism• HIV infection• Charcot-Marie-Tooth disease• Autoimmune disorders• Vitamin B12 deficiency• Chronic alcohol abuse• Shingles
Sue’s Story
Supposedly chemotherapy increased my chances of living 5years by 8%. I don’t want to live for another 5 years like this.My hands and fingers are numb. My feet are numb. My legs arenumb from my knees to the bottom of my feet. I have pain,gnawing, burning, and cramping most of the time. My legsache and feel stiff and heavy all the time. Driving is a problem,walking is a problem, Being on my feet is a problem. My handsdon’t work. I feel collapsed, dizzy, and weak all day, everyday, all the time. I have disabling fatigue. I feel like I have beenpoisoned.-written in 2008 by Sue, colorectal cancer survivor.
(Tofthagen, 2010)
FunctionalDisability
Loss of Sensation
Peripheral Neuropathy
Exaggerated Sensation
Walking
Driving
Hobbies
Picking up
things
Relation-
ships
Chores
WorkWritingExercise
Sleep
Sexual
Activity
4 Approaches to CIPN
1) Prevent it
2) Recognize it early
3) Control the pain
4) Minimize effects on quality of life
Prevent it
A variety of preventative strategies have been evaluated thus far with varying degrees of success, including:
Calcium/Magnesium InfusionsAlpha-lipoic acidB VitaminsGlutamine/glutathioneVitamin E
Calcium/Magnesium Infusions • Numerous clinical trials supporting its use
• One trial was closed because of safety concerns
• Recent meta-analysis confirmed safety and efficacy of Calcium and Magnesium infusions for prevention of neuropathy caused by oxaliplatin only
• Reduces the incidence of grade 2 but not grade 1 neuropathy
(Grothey et al., 2011; Hochster, Grothey, & Childs, 2007; Ishibashi, Okada, Miyazaki, Sano, & Ishida, 2010; Wen et al., 2012)
Genetics• Neurotoxicity may be directly related to
individual variations in neurotoxic drug metabolism, distribution, and elimination.
• Genetic polymorphisms associated with CIPN may lead to genetic tests to help identify individuals likely to develop severe neuropathy
Bergmann, et al., 2011; Sissung, et al., 2006; Renbarger, et. al., 2008; Hertz, et al., 2012; Kroetz, et al., 2010; Schneider, et al., 2011.
Recognize it Early
• Early recognition is key because dose adjustments may be required that may lesson severity and minimize long-term nerve damage.
What to tell your healthcare team
1. What symptoms are you having?
2. Are the symptoms on one or both sides?
3. How much of the extremity is involved?
4. How severe and distressing is each symptom?
5. Are symptoms constant or do they come and go?
6. How are your activities and lifestyle being affected?
Controlling the Pain
Controlling Neuropathic Pain
Neuropathic pain is severe, difficult to treat, and may not respond well to narcotic analgesics.
Image retrieved from http://www.topnews.in/health/files/chronic-pain.jpg
Describing Your Pain•Onset •Location •Duration •Characteristics •Aggravating Factors •Relieving Factors •Treatments tried
Duloxetine
•Based on primary results (n=220) Duloxetine 60mg daily:•Diminishes CIPN pain in the majority• Improves function & QOL•One of the few drugs recommended that has data to support its use for painful CIPN
Treatment of Neuropathic Pain
First LineTricyclic Antidepressants Gapapentin or Pregabalin
Second LineSerotonin-norepinephrine reuptake inhibitors Lidocaine Patch
Third LineTramadol or Controlled Release Opioid
Fourth LineCannabinoids, methadone, lamotrigine, topiramate,
valproic acid
Moulin, et al., 2007
Drug /Class Starting Dose Titration Maximum Dose
Trial Duration
Nortriptyline/TCA
25mg at bedtime
Increase by 25mg every 3-7 days as tol
150mg/day 6-8 weeks
Desipramine/TCA
25mg at bedtime
Increase by 25mg every 3-7 days as tol
150mg/day 6-8 weeks
Duloxetine/SSNRI
30mg/day Increase to 60mg/day in 7 days
60mg /BID 4 weeks
Venlafaxine/SSNRI
37.7mg once or twice a day
Increase by 75 mg/week
225mg/day 4-6 weeks
Gabapentin 100-300mg TID 100-300mg TID every 1-7 days as tolerated
3600 mg/d (1200 mg 3 times daily)
3-8 wk forTitration and 2 weeks at max dose
Pregabalin 50mg TID or 75mg BID
Increase to 300mg/day after 3-7 days, then by 150mg/d every 3-7 days
600mg/d 4 weeks
Dworkin, et al., 2010
Minimizing Neuropathy’s Effects on Quality of Life
Cycle Number Perceived Loss of Balance
Fall Risk
FALL PREDICTORS
Treatment of Foot NeuropathyPatients with numbness in the feet should:
• wear comfortable, properly fitting shoes• avoid sandals, open toed or open heeled shoes• inspect feet daily for injury • avoid walking barefoot or in socks alone• always check for foreign objects in shoes before putting them on• change shoes in the middle of the day to avoid continued pressure in the
same locations
(Plummer & Albert, 2008).
Home Safety
• Water temperature for bathing should be carefully assesses and the thermostat on the water heater should be adjusted to a maximum of 100 degrees Fahrenheit
• Run cold water first
• Use protective gloves when washing dishes
• Always use pot holders (Armstrong, Almadrones, & Gilbert, 2005; Hot Water Burns Like Fire Campaign, 2006).
Home Safety
• Living areas should be kept well lit
• Keep walkways clear
• Nightlights should be kept on in hallways, bathrooms and bedrooms, nonskid mats in the shower or bathtub
(Armstrong, Almadrones, & Gilbert, 2005; Visovsky, Collins, Abbott,Aschenbrenner, & Hart, 2007).
Home Safety• Store frequently used items in easy-to-reach locations• Remove throw rugs and mats• Use sturdy chairs with arm rests• Use a long handled reacher to pick up items from the floor • Remove clutter around the house• Install hand rails in the tub and beside the toilet• Use a shower chair and a hand held shower• Use hand railing when climbing stairs,• Add a strip of brightly colored tape to the steps so that the outline
ofeach step is clearly visible,
• Keep walkways and stairs in good repair and free of clutter and debris
Self-Care Techniques• A study of self-reported self care techniques used by patients with
related neuropathy (n=450) indicate techniques that patients found helpful in relieving symptoms include:
• warm baths (66%)• walking (60%) • massage (41%) • rubbing cream on the feet (47%)• elevating feet (57%)• staying off the feet (59%)• acupuncture (12%) • meditation (20
(Nicholas et al., 2007)
Exercise• Compared to healthy people, persons with neuropathy
have reduced proprioception, lower extremity sensation, and reduced ankle strength predisposing them to falls
• Strength and balance training results in fewer falls
• Safe for people with peripheral neuropathy
• Tai Chi, a low impact form of Chinese martial art, may help reduce falls and improve balance
(Gillespie et al., 2009; Morrison, Colberg, Mariano, Parson, & Vinik, 2010; Allet, et al., 2010; Kruse et al., 2010).
Referrals• Neurologist to establish/confirm diagnosis
• Pain management
• Physiatrist-physician who specialize in cancer rehabilitation, locate one at http://www.cancer.net/survivorship/rehabilitation
• Physical therapist -specific exercises designed to help improve muscle strength and balance
• Occupational therapists -maintain your independence, adjust to physical limitations
• Support groups and mental health professionals
• Podiatrists –recommend footwear, and fit for orthotics(Tofthagen, 2012)
Community Resources
Summary
• Neuropathy is an uncomfortable and distressing symptom that can interfere with your ability to do the activities you want and need to do on a daily basis.
• Scientists are looking for ways to prevent neuropathy caused by chemotherapy.
• Patients can get better control of neuropathy symptoms and their effects on quality of life by being aware of treatment options, communicating with their healthcare team and seeking out resources within their community.
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Alexandria, VA 22314(703) 548-1225
Toll-Free Answer Line: 1-877-427-2111www.FightColorectalCancer.org
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