Neurologic
May 18, 2025Peripheral neuropathy Guillain Barré Syndrome
May 24, 2025Neurologic - Peripheral neurological toxicity
Uncomplicated Peripheral neuropathy
Mild
- No interference with function
- Symptoms not concerning to patient
- Any mild cranial nerve problem should be managed as ‘moderate’
Management escalation pathway
- Low threshold to withhold ICPI
- Close monitoring for any progression
Assessment and Investigations
- Comprehensive neurological examination
- Autoimmune anamnesis alcohol history, medication – diabetic screen – B12/folate – HIV – TSH – autoimmune serology – alcohol stigmata
- MRI brain or spine (exclude CVA, structural cause)
- Lumbar puncture to exclude tumor invasion (after brain CT scan)
- Contact neurologist.
Moderate
- Some interference with activities of daily living, symptoms concerning to patient
- Cranial nerve involvement
Management escalation pathway
- Withhold ICPI
- Initial observation reasonable vs direct iniation of prednisolone 0.5 to 1 mg/kg (if progressing, e.g. from mild)
- Pregabalin or duloxetine might be introduced for pain
- If no clinical improvement after 48h, manage as severe
- Consider Myasthenia Gravis, GBS or CIDP
- Only consider resuming ICPI after multidisciplinary discussion
Advice on steroid wean:
- Conversion from i.v. to oral steroids at clinician discretion once improvement is noted
- Suggested oral prednisolone taper for 4-8 weeks
- Consider PJP prophylaxis, vitamin D if > 4-weeks duration
Assessment and Investigations
- Consider EMG for lower moter neuron and/or sensory change
- Neurological consult
- Perform imagery to exclude local compression due to cancer progression
Severe
- Limits self-care and aid warranted
- Life threatening (e.g. respiratory problems)
Management escalation pathway
- Withhold ICPI and admit patient Initiate (methyl) prednisolone 2mg/kg i.v.
- Involve neurologist in care
- Respiratory function should be checked 6 x pd
- Daily or more frequent neurological review according to severity
Multidisciplinary team involvement:
- Physiotherapy, occupational therapy and speech therapy as appropriate, opthalmology review for ocular/cranial nerve issues
- Orthopedic devices (e.g. for foot drop) should be considered
Assessment and Investigations
- MRI brain/spine advised
- EMG
- Lumbar puncture
- Consider pulmonary function or diafragmatic function tests
- Neurological consult