Chemotherapy Induced Neuropathy Treatment

Unfortunately neuropathy associated with chemotherapy is often inadequately treated.  In my practice, as a cancer rehabilitation physician who specializes in treating cancer related muscle, joint, and nerve side effects, I often see patients who have been inadequately treated for neuropathy for a year or more.  The main reason for this is that the patients' oncologists will try to manage the symptoms.  Most of the oncologists that I interact with are only comfortable using a few different medications for neuropathy, and not always the most appropriate ones.   I do NOT want to badmouth the oncologists in any way.  They do an incredible job treating cancer, and without their life-saving treatments, I wouldn't be seeing these patients in the first place.  However, I do believe there are other specialists, such as myself, that would probably have more success treating these symptoms.  Here's my breakdown of neuropathy treatments:

1) Be sure that neuropathy is not affecting your balance.  If this is the case, this needs to be addressed first.  If I put a patient on a medication for pain and tingling, and they fall and hurt themselves due to impaired balance, I have not done my job.

2) Physical therapy can help with neuropathy symptoms.  Physical therapists can help work on balance but also perform desensitization techniques that decrease the discomfort.

3) Another non-medication remedy is electrical stimulation, or TENS.  These electrical units can be put on the painful area to decrease pain signals to the brain.  It has essentially no side effects and is usually covered by insurance.  You can ask your doctor for a prescription for this treatment.

4) OK, let's finally get to medications.  Gabapentin, or neurontin, is the tried and true option, that's been around forever.  It is a good drug that generally works but can have some side effects.  The "newer" version is called Lyrica (I'm sure you have seen it on TV).  It can also have side effects but works quicker and probably better than gabapentin.  Another "newer" drug for neuropathy is Cymbalta (I'm  DEFINITELY sure you have seen it on TV).  It can work well and a new study in a major medical journal recently demonstrated its effectiveness for chemotherapy induced neuropathy.  It is generally well tolerated and usually only needs to be taken once or twice a day (instead of 2 or 3 times a day for gabapentin and Lyrica).  It's important to note that Cymbalta cannot be combined with tamoxifen.   There are some other meds out there as well that work, but the three I discussed above, are what I typically use.  Tricyclic anti-depressants (TCAs) are old drugs that do work, but can have side effects.

Many oncologists will opioids or narcotics (percocet, vicodin, oxycodone, etc).  These drugs can work but are not very specific for neuropathic pain.  In addition, they can have serious side effects like addiction, overdose, and constipation, so I tend to avoid them.

5) Topical medications: You may not know this, but any medication that has a generic version can be made into a cream.  I do this very regularly in my practice.  I will take medications that are typically prescribed orally and turn them into a compound cream.  I have found this to be a tremendously effective treatment with essentially no side effects.  My patients love it!

6) Natural stuff: OK, so everybody always wants to know about "natural" supplements.  B vitamins have been mentioned today on twitter.  For some reason, most of the oncologists I work with recommend it to their patients.  I really don't know where this comes from.  There is very little evidence basis to this treatment.  It is very rare that I see a patient that tells me that it helps.  At this time, there is really nothing in this "natural" category that I can convincingly tell patients that works.  Vitamin E, L-acetyl-carnitine, and glutamate have been studied, with mixed outcomes.  Some of these treatments, may work, I just can't say it convincingly at this point.  I hope we find out more about this in the future, and there are currently ongoing studies that should give us more information.

7) Autonomic symptoms: This is what I categorize as the "weird" symptoms of neuropathy.  These can include dizziness, feeling hot all the time, and bowel and bladder problems.  There usually are potential solutions to all of these symptoms.  One of my favorite patient stories was a woman I saw who always felt intolerably hot when working out or outside in hot weather.  I figured out that this was a neuropathy.  I put her on a low dose of Lyrica and her symptoms resolved.

As you can see, neuropathy can be complicated and there are a number of different possible treatments. The key is to see a specialist (such as a cancer rehab doc like me) that can get to the bottom of the symptoms and find a treatment that works for you.

Opioid Overuse Even in Cancer Patients

My job as a physician is to help cancer patients feel better during and after treatment.  An obvious part of this is managing pain. The mantra for cancer patients has always been, "don't be afraid to treat pain".  This means that we shouldn't hesitate to give strong pain medications like percocet, oxycodone, and morphine to cancer patients since they are truly suffering.  While the suffering of these patients is absolutely correct, that does not necessarily mean that an opioid pain medication is always the right choice.

The real issue from my perspective is that as cancer treatments are improving, more people are surviving cancer.  The number of cancer survivors is rising exponentially (over 13 million in the U.S. today).  Therefore, in many cases, when we treat cancer patients, we are treating patients that will be around for a long, long time.  As opioid pain medications can be addictive and have many side effects, they may not be the right choice for these patients.  For patients that don't have metastatic cancer, I prefer to avoid opioids for pain, except for immediately after surgery.  After that, pain can typically be managed in other ways, including non-pharmacological treatments like physical therapy.  By physicians overprescribing opioid pain medications to cancer patients, these patients may end up on these medications for life.  This is often unnecessary and may be doing patients a great disservice.

http://www.nytimes.com/2013/06/23/sunday-review/profiting-from-pain.html?_r=0