50
Treatment
Table 7. Nervous System Toxicities
7.3 Peripheral Neuropathy
Workup/Evaluation
G1:
• Consider neurolog y consultation to guide neuropathy phenotype determination and
workup.
• Serum testing for reversible neuropathy causes: HbA1c, vitamin B12, TSH, vitamin
B6, folate, serum protein electrophoresis, immunofixation and CPK.
• Consider additional testing guided by neuropathy phenotype: ANA, ESR, CRP,
ANCA, anti-Smooth muscle, SSa/SSb, RNP, anti-dsDNA, ganglioside ab, anti-
MAG, anti-Hu (ANNA-1 ab), thiamine, Lyme, hepatitis B/C, HIV.
• Consider MRI spine with and without contrast.
G2— In addition to the above:
• MRI spine advised, MRI brain if cranial nerve involvement, MRI plexus if concern
for plexus involvement.
• Consider lumbar puncture: CSF analysis for cell count and differential, cytolog y for
malignant cells, protein, glucose and viral/bacterial cultures. Consider EMG/NCS.
G3–4: go to GBS algorithm.
Grading Management
G1: Mild: no interference with
function and symptoms not
concerning to patient.
Note: any cranial nerve problem
should be managed as moderate.
• Low threshold to hold ICPi and monitor
symptoms for a week. If to continue, monitor
very closely for any symptom progression.
G2: Moderate: some interference
with ADLs, symptoms
concerning to patient (i.e.,
pain but no weakness or gait
limitation).
• Hold ICPi and resume once return to ≤G1.
• Initial observation OR initiate prednisone 0.5–1
mg/kg/day (if progressing from mild).
• Gabapentin, pregabalin, or duloxetine for pain.
G3–4: Severe: limiting self-care
and aids warranted, weakness
limiting walking or respiratory
problems (i.e., leg weakness, foot
drop, rapidly ascending sensory
changes). Severe may be GBS and
should be managed as such.
• Permanently discontinue ICPi.
• Admit patient.
• Neurolog y consultation.
• Initiate IV methylprednisolone 2–4 mg/kg/day
and proceed as per GBS management.
(cont'd)
