Peripheral neuropathy occurs when nerve fibers outside the brain and spinal cord are disrupted. Often, it is described as nerve pain throughout the limbs, most commonly in the hands and feet. Symptoms include numbness, tingling, pain, and loss of sensation. Today, we will discuss drug-induced peripheral neuropathy (DIPN) and the top five medication classes associated with it.
Chemotherapy Agents
The most common category of medications associated with DIPN is chemotherapy agents, specifically in the category of vinca alkaloids which includes vincristine.2 It is more common than not for patients who receive vincristine to experience DIPN, this often limits treatment regimens.3 Another class highly associated with DIPN is platinums which includes medications oxaliplatin and cisplatin. The incidence of DIPN to occur with platinums is around 30-40%, especially when the doses are higher.2 There is also a phenomenon that is called “coasting” where even when agents are stopped after high dosing, the symptoms of neuropathy continue to worsen months after the treatment.2
Cardiac Medications
The next area to discuss is cardiovascular medications, specifically an antiarrhythmic medication called amiodarone. Amiodarone is used to treat irregular heartbeats either by controlling the rate or the rhythm. It already comes with a long list of possible adverse effects and DIPN is one of them. The risk of DIPN increases with higher doses of amiodarone but is not as common as chemotherapy agents.
Antibiotics
There are many different antibiotic classes that can be associated with peripheral neuropathy, however, the regimen for tuberculosis includes three medications that could be associated with DIPN. The most common medication is isoniazid due to its interaction with vitamin B6 synthesis.2 The risk of neuropathy can be reduced with supplementation of pyridoxine. Quinolones, metronidazole, and nitrofurantoin are other antibiotics that have been associated with causing drug-induced peripheral neuropathy. These are always good examples that may show up on your board exams!
TNF-alpha Blockers
Within the category of immunosuppressants, there are a variety of classes that have been slightly associated with DIPN. The most prominent ones include the TNF-α inhibitors which are the medications infliximab, adalimumab, and etanercept. Neuropathy is rare and typically reversible with cessation of these agents.
HIV Therapy
The final category to be discussed is therapy options that target HIV. The class associated with the most incidence are nucleoside reverse transcriptase inhibitors (NRTIs) which include the medications zalcitabine, didanosine, stavudine, and lamivudine. The incidence of DIPN is most prevalent with zalcitabine.2,3
Overall, there are many different medications that can lead to drug-induced peripheral neuropathy. The classes noted above have been the ones most commonly associated however, the incidence can differ by patient and their current state. This brief overview brings up awareness of the possibility of drug-induced peripheral neuropathy and some common medications you should look out for. Have you seen any other medications cause drug-induced peripheral neuropathy in your practice?
This article was written by McKayla Narveson, PharmD Candidate in collaboration with Eric Christianson, PharmD, BCPS, BCGP
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References:
- Hammi C, Yeung B. Neuropathy. [Updated 2022 Oct 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK542220/
- Jones MR, Urits I, Wolf J, Corrigan D, Colburn L, Peterson E, Williamson A, Viswanath O. Drug-Induced Peripheral Neuropathy: A Narrative Review. Curr Clin Pharmacol. 2020;15(1):38-48. doi: 10.2174/1574884714666190121154813. PMID: 30666914; PMCID: PMC7365998.
- Author(s): Kim Dan Do Barker, & 2, O. published: S. (2022, December 1). Peripheral neuropathies associated with drugs and toxins. PM&R KnowledgeNow. https://now.aapmr.org/peripheral-neuropathies-associated-with-drugs-and-toxins/
May I add statins? Blocking synthesis of cholesterol for the myelin sheath which also leads to peripheral neuropathy.