Nerve Pain From Chemotherapy

Along with the constellation of things that may accompany some forms of chemotherapy is an unfortunate and often long-lasting condition known as' peripheral neuropathy,' or nerve pain with no discernable pathology.  With some forms of chemotherapy this can occur in 20 to 40% of people, and since nerves, as Rick and I have opined so often on PodMed, can be decidedly cranky once irritated, this pain can persist for months or even years. Clearly such a condition has a negative impact on quality of life, so good news then in this week's Journal of the American Medical Association on the use of duloxetine to manage peripheral neuropathy.

Previous research suggested that duloxetine, which inhibits the reuptake of both serotonin and norepinephrine, neurotransmitters known to be involved in pain pathways, was helpful for people with neuropathy related to diabetes.  Based on this data, researchers conducted a randomized phase 3 trial in 231 patients 25 years of age or older with chemotherapy induced neuropathy  The study employed a crossover design, where subjects were started with an initial 30 mg dose of duloxetine once per day for one week, followed by 30 mg twice daily for four weeks, then five weeks of placebo, or the opposite. Pain severity during the study was assessed using the Brief Pain Inventory Short Form.

Patients treated with duloxetine initially were more likely to report a greater decrease in pain, but reductions in pain were greater with duloxetine in general than placebo. The effect of duloxetine was also related to which form of chemotherapy the patient had been on, with a greater impact in those who were on platinum-based agents rather than taxanes, suggesting a different mechanism for pain development and a potential need for chemotherapy-specific interventions.

Secondary measures of the effect of duloxetine were also assessed: how much pain interfered with daily function and quality of life, both of which were improved with the medication.  Side effects were similar in placebo and duloxetine arms, and included fatigue, insomnia and nausea in 5-7% of the active drug arm and fatigue, sleepiness and insomnia in 5-8% of the controls. In summary then, it appears that duloxetine is effective at reducing peripheral neuropathy secondary to chemotherapy and is well-tolerated by most patients.  About time, I say.  I am reminded of studies on suicidality among people with chronic pain syndromes and think that especially among people who've survived chemotherapy and other forms of cancer treatment, preserving quality of life must be primary among treatment goals.  As we continue to see many forms of cancer morph into chronic conditions rather than acute illnesses resulting in death, we must learn to effectively manage sequelae, especially pain.

Other topics this week include factors related to discontinuation of statin therapy in Annals of Internal Medicine, a look at levels of omega-3 fatty acids and their ability to predict mortality in the same journal, and the costs of dementia in NEJM.  Until next week, y'all live well.

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