Chemotherapy-Induced Peripheral Neuropathy (CIPN)

Understanding and managing nerve damage from cancer treatment

Incidence

30-40% of patients

Onset

During or after treatment

Duration

Weeks to permanent

Most Affected

Hands and feet

Understanding Peripheral Neuropathy

Chemotherapy-induced peripheral neuropathy (CIPN) is damage to the peripheral nerves caused by certain chemotherapy drugs. These nerves carry messages between the central nervous system and the rest of your body.

Types of Nerves Affected

Sensory nerves: Control sensation (most commonly affected)
- Touch, temperature, pain perception
- Position sense (proprioception)
- Vibration sense
Motor nerves: Control muscle movement
- Muscle strength
- Coordination
- Balance
Autonomic nerves: Control automatic functions
- Blood pressure
- Digestion
- Bladder function

Pattern of CIPN

"Stocking-glove" distribution: Starts in toes/fingers, progresses upward
Symmetrical: Usually affects both sides equally
Length-dependent: Longest nerves affected first (feet before hands)
Dose-dependent: Risk increases with cumulative dose

Signs and Symptoms

Common Symptoms by Type

Sensory Symptoms

Numbness or reduced sensation
Tingling ("pins and needles")
Burning or freezing sensations
Sharp, stabbing pains
Electric shock sensations
Increased sensitivity to touch
Difficulty sensing temperature

Motor Symptoms

Muscle weakness
Difficulty with fine motor tasks
Problems with buttons/zippers
Dropping objects
Difficulty walking
Loss of balance
Muscle cramps

Autonomic Symptoms

Constipation
Urinary retention
Blood pressure changes
Heart rate changes
Sweating abnormalities
Sexual dysfunction

Special Considerations

Acute neuropathy: During infusion (especially oxaliplatin)
- Cold sensitivity
- Throat discomfort
- Jaw spasms
Chronic neuropathy: Develops over time with treatment
Coasting: Symptoms may worsen 2-6 months after stopping treatment

Causes and Risk Factors

High-Risk Chemotherapy Drugs

Drug Class	Specific Drugs	Risk Level	Typical Onset
Platinum compounds	Oxaliplatin, Cisplatin, Carboplatin	High	During treatment
Taxanes	Paclitaxel, Docetaxel, Nab-paclitaxel	High	After several cycles
Vinca alkaloids	Vincristine, Vinblastine, Vinorelbine	Moderate-High	Cumulative
Proteasome inhibitors	Bortezomib, Carfilzomib	Moderate-High	Early in treatment
Immunomodulators	Thalidomide, Lenalidomide	Moderate	Cumulative
Others	Eribulin, Ixabepilone	Moderate	Variable

Risk Factors

Pre-existing conditions:
- Diabetes
- Alcohol use disorder
- Vitamin deficiencies (B12, B6, folate)
- Thyroid disease
- HIV
- Previous neuropathy
Treatment factors:
- Higher cumulative doses
- Combination chemotherapy
- Previous neurotoxic chemotherapy
- Concurrent radiation
Patient factors:
- Older age
- Genetic variations
- Poor nutritional status

Assessment and Grading

NCI-CTCAE Grading Scale

Grade 1

Mild symptoms

Loss of reflexes or paresthesias not interfering with function

Grade 2

Moderate symptoms

Interfering with function but not activities of daily living

Grade 3

Severe symptoms

Interfering with activities of daily living

Grade 4

Life-threatening

Disabling symptoms requiring urgent intervention

Assessment Tools

Patient questionnaires: FACT/GOG-Ntx, EORTC QLQ-CIPN20
Physical examination:
- Vibration sense (tuning fork)
- Light touch (monofilament)
- Temperature discrimination
- Deep tendon reflexes
- Muscle strength testing
- Balance assessment
Functional tests: Timed up and go, 6-minute walk

Prevention Strategies

🛡️ Prevention Approaches

Dose modification: Primary prevention strategy
Cold therapy: For oxaliplatin (hands/feet cooling)
Compression therapy: May help with taxane neuropathy
Nutritional support: Adequate B vitamins, avoid deficiencies
Exercise: May reduce risk and severity

Medications Under Investigation

Currently, no medications are proven to prevent CIPN. The following have been studied:

Calcium/magnesium (mixed results)
Glutathione (limited evidence)
Vitamin E (not recommended)
Glutamine (insufficient evidence)
Antioxidants (may interfere with treatment)

What NOT to Do

Don't take supplements without oncologist approval
Avoid vitamin B6 in high doses (can worsen neuropathy)
Don't ignore early symptoms

Treatment Options

Non-Pharmacological

Physical therapy:
- Balance training
- Strengthening exercises
- Gait training
Occupational therapy:
- Adaptive devices
- Fine motor exercises
- Safety modifications
Exercise programs:
- Tai chi
- Yoga
- Walking program

Complementary Therapies

Acupuncture: May reduce symptoms
Massage therapy: Gentle massage only
Transcutaneous electrical nerve stimulation (TENS)
Mindfulness/meditation: Pain management
Biofeedback: Pain perception
Scrambler therapy: Emerging treatment

Supportive Measures

Proper footwear (cushioned, non-slip)
Orthotic devices
Assistive devices (canes, walkers)
Temperature regulation
Skin care
Fall prevention strategies

Medications for CIPN

First-Line Medications

Duloxetine (Cymbalta):
- Only FDA-approved for CIPN
- 30-60 mg daily
- SNRI antidepressant

Other Commonly Used Medications

Gabapentin (Neurontin): 300-3600 mg/day in divided doses
Pregabalin (Lyrica): 75-300 mg twice daily
Tricyclic antidepressants:
- Amitriptyline 10-75 mg at bedtime
- Nortriptyline 10-75 mg at bedtime
Venlafaxine (Effexor): 37.5-225 mg daily

Topical Treatments

Capsaicin cream 0.025-0.075%
Lidocaine patches or gel 5%
Menthol-containing creams
Compounded creams (ketamine/amitriptyline/baclofen)

For Specific Symptoms

Muscle cramps: Baclofen, magnesium
Shooting pains: Carbamazepine, oxcarbazepine
Severe pain: Tramadol, opioids (last resort)

Safety Measures

🦺 Home Safety Modifications

Bathroom:
- Install grab bars in shower/tub
- Use non-slip mats
- Consider shower chair
- Adjust water heater to <120°F
Stairs:
- Install handrails on both sides
- Ensure good lighting
- Mark edges with contrasting tape
- Remove loose carpeting
General home:
- Remove throw rugs
- Clear walkways
- Improve lighting
- Secure electrical cords

Temperature Precautions

Test water temperature with unaffected body part
Use thermometer for bath water
Wear gloves when handling frozen items
Avoid extreme temperatures
Be cautious with heating pads

Injury Prevention

Check feet daily for cuts/sores
Wear protective footwear at all times
Use gloves for household tasks
Be extra careful with sharp objects
Trim nails carefully (consider podiatrist)

Daily Living Adaptations

Kitchen and Eating

Use lightweight, non-breakable dishes
Built-up handles on utensils
Non-slip placemats
Electric can openers
Rocker knives for cutting
Cups with lids and straws

Dressing and Grooming

Velcro fasteners instead of buttons
Elastic shoelaces
Long-handled shoehorn
Button hooks
Electric toothbrush/razor
Shower brush with long handle

Work and Hobbies

Ergonomic keyboard and mouse
Voice recognition software
Pencil grips
Book stands
Magnifying glass with light
Modified tools for hobbies

Mobility

Well-fitting, supportive shoes
Orthotic inserts
Walking stick or cane
Consider handicap parking permit
Plan rest breaks during activities

When to Contact Your Healthcare Team

🚨 Contact Immediately If:

Sudden worsening of symptoms
Falls or injuries
Signs of infection in numb areas
Severe pain not controlled by medication
Loss of bowel or bladder control
Sudden weakness or paralysis
Chest pain or breathing problems

Schedule Appointment For:

New or worsening symptoms
Symptoms interfering with daily activities
Need for assistive devices
Medication side effects
Questions about dose modifications
Referrals to specialists

Document and Report

Keep symptom diary
Rate pain/numbness daily (0-10)
Note activities affected
Track medication effectiveness
Record any falls or injuries

Recovery and Prognosis

📈 Recovery Timeline

During treatment: Symptoms may stabilize or progress
0-6 months after: May worsen before improving ("coasting")
6-12 months: Gradual improvement common
1-2 years: Continued slow improvement
Long-term: Some may have permanent symptoms

Factors Affecting Recovery

Favorable:
- Younger age
- Good overall health
- Early recognition and management
- Lower cumulative doses
- Prompt dose modification
Less favorable:
- Pre-existing neuropathy
- Diabetes or other risk factors
- High cumulative doses
- Severe symptoms (Grade 3-4)

Long-term Outlook

30-40% completely recover
30-40% have partial improvement
20-30% have persistent symptoms
Recovery can continue for years
Adaptation improves function over time

Resources and Support

Healthcare Team

Oncologist: Dose modifications, overall management
Neurologist: Specialized neuropathy care
Physiatrist: Rehabilitation medicine
Physical therapist: Mobility and balance
Occupational therapist: Daily living skills
Pain specialist: Complex pain management
Podiatrist: Foot care

Support Services

Neuropathy support groups
Online communities
Patient education programs
Vocational rehabilitation
Home health services

Financial Resources

Disability benefits information
Equipment loan programs
Prescription assistance programs
Transportation services

References

ASCO Guidelines. Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy. J Clin Oncol. 2025.
Loprinzi CL, et al. Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers. ASCO Guideline Update. 2025.
National Cancer Institute. Peripheral Neuropathy (PDQ) - Health Professional Version. 2026.
Seretny M, et al. Incidence, prevalence, and predictors of chemotherapy-induced peripheral neuropathy. Pain. 2025.
NCCN Guidelines. Survivorship: Neuropathy. Version 1.2026.

Last reviewed: January 24, 2026 | Medical Review: Dr. Patricia Kumar, MD