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Neuropathy (motor or sensory nerve impairment or damage)

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Grading

[/vc_column_text][vc_tabs][vc_tab title=”Grade 1 (Mild)” tab_id=”1508881210-1-100″][vc_column_text css=”.vc_custom_1509136001840{margin-top: 5px !important;margin-right: 5px !important;margin-bottom: 5px !important;margin-left: 5px !important;border-top-width: 3px !important;border-right-width: 3px !important;border-bottom-width: 3px !important;border-left-width: 3px !important;padding-top: 0px !important;padding-right: 10px !important;padding-bottom: 10px !important;padding-left: 10px !important;border-left-color: #fbbdbd !important;border-left-style: dashed !important;border-right-color: #fbbdbd !important;border-right-style: dashed !important;border-top-color: #fbbdbd !important;border-top-style: dashed !important;border-bottom-color: #fbbdbd !important;border-bottom-style: dashed !important;border-radius: 3px !important;}”]Peripheral Motor:

• Asymptomatic; clinical or diagnostic observations only
• No intervention indicated

Peripheral Sensory:

Asymptomatic; loss of deep tendon reflexes or paresthesia[/vc_column_text][/vc_tab][vc_tab title=”Grade 2 (Moderate)” tab_id=”1508881210-2-6″][vc_column_text css=”.vc_custom_1509136018277{margin-top: 5px !important;margin-right: 5px !important;margin-bottom: 5px !important;margin-left: 5px !important;border-top-width: 3px !important;border-right-width: 3px !important;border-bottom-width: 3px !important;border-left-width: 3px !important;padding-top: 0px !important;padding-right: 10px !important;padding-bottom: 10px !important;padding-left: 10px !important;border-left-color: #ed8585 !important;border-left-style: dashed !important;border-right-color: #ed8585 !important;border-right-style: dashed !important;border-top-color: #ed8585 !important;border-top-style: dashed !important;border-bottom-color: #ed8585 !important;border-bottom-style: dashed !important;border-radius: 3px !important;}”]Peripheral Motor:

Moderate symptoms; limiting ADLs

Peripheral Sensory:

Moderate symptoms; limiting ADLs[/vc_column_text][/vc_tab][vc_tab title=”Grade 3 (Severe)” tab_id=”1508882017189-2-2″][vc_column_text css=”.vc_custom_1509136032643{margin-top: 5px !important;margin-right: 5px !important;margin-bottom: 5px !important;margin-left: 5px !important;border-top-width: 3px !important;border-right-width: 3px !important;border-bottom-width: 3px !important;border-left-width: 3px !important;padding-top: 0px !important;padding-right: 10px !important;padding-bottom: 10px !important;padding-left: 10px !important;border-left-color: #e04f4f !important;border-left-style: dashed !important;border-right-color: #e04f4f !important;border-right-style: dashed !important;border-top-color: #e04f4f !important;border-top-style: dashed !important;border-bottom-color: #e04f4f !important;border-bottom-style: dashed !important;border-radius: 3px !important;}”]Peripheral Motor:

Severe symptoms; limiting self-care ADLs; requires assistive devices

Peripheral Sensory:

Severe symptoms; limiting self-care ADLs[/vc_column_text][/vc_tab][vc_tab title=”Grade 4 (Potentially Life-Threatening)” tab_id=”1508882044418-3-5″][vc_column_text css=”.vc_custom_1509136055578{margin-top: 5px !important;margin-right: 5px !important;margin-bottom: 5px !important;margin-left: 5px !important;border-top-width: 3px !important;border-right-width: 3px !important;border-bottom-width: 3px !important;border-left-width: 3px !important;padding-top: 0px !important;padding-right: 10px !important;padding-bottom: 10px !important;padding-left: 10px !important;border-left-color: #d31e1e !important;border-left-style: dashed !important;border-right-color: #d31e1e !important;border-right-style: dashed !important;border-top-color: #d31e1e !important;border-top-style: dashed !important;border-bottom-color: #d31e1e !important;border-bottom-style: dashed !important;border-radius: 3px !important;}”]Peripheral Motor:

Life-threatening; urgent intervention indicated

Peripheral Sensory:

Life-threatening; urgent intervention indicated

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Management

Overall Strategy:

• Rule out infectious, non-infectious, disease-related etiologies
• High-dose steroids (1–2 mg/kg/day prednisone or equivalent) to be used
• Ipilimumab to be withheld for Grade 2 event, nivolumab for first occurrence of Grade 3 event, and pembrolizumab based on disease severity; ipilimumab to be discontinued for Grade 2 events persisting ≥6 weeks or inability to reduce steroid dose to ≤7.5 mg prednisone or equivalent per day; pembrolizumab or nivolumab to be discontinued for Grade 3/4 events that recur, persist ≥12 weeks, or inability to reduce steroid dose to ≤10 mg prednisone or equivalent per day
• Neurology consult
  • Consideration of electromyelogram and nerve conduction tests
  • Immune globulin infusions
  • Plasmapheresis
• Taper steroids slowly over at least 4 weeks once symptoms improve
• If needed, obtain physical therapy or occupational therapy consult (for both functional assessment and evaluate safety of patient at home)
• Supportive medications for symptomatic management

[/vc_column_text][vc_separator css=”.vc_custom_1508960503215{margin-top: 20px !important;margin-bottom: 20px !important;}”][vc_column_text css=”.vc_custom_1509136178683{border-top-width: 1px !important;border-right-width: 1px !important;border-bottom-width: 1px !important;border-left-width: 1px !important;padding-top: 10px !important;padding-right: 10px !important;padding-bottom: 10px !important;padding-left: 10px !important;background-color: #6fac46 !important;border-left-color: #000000 !important;border-left-style: solid !important;border-right-color: #000000 !important;border-right-style: solid !important;border-top-color: #000000 !important;border-top-style: solid !important;border-bottom-color: #000000 !important;border-bottom-style: solid !important;border-radius: 10px !important;}”]

Nursing Implementation:

• Compare baseline assessment; grade & document neuropathy and etiology (diabetic, medication, vascular, chemotherapy)
• Early identification and evaluation of patient symptoms
• Early intervention with lab work and office visit if neuropathy symptoms suspected

[/vc_column_text][vc_separator css=”.vc_custom_1508960503215{margin-top: 20px !important;margin-bottom: 20px !important;}”][vc_column_text css=”.vc_custom_1509136191927{border-top-width: 1px !important;border-right-width: 1px !important;border-bottom-width: 1px !important;border-left-width: 1px !important;padding-top: 10px !important;padding-right: 10px !important;padding-bottom: 10px !important;padding-left: 10px !important;background-color: #4471c4 !important;border-left-color: #000000 !important;border-left-style: solid !important;border-right-color: #000000 !important;border-right-style: solid !important;border-top-color: #000000 !important;border-top-style: solid !important;border-bottom-color: #000000 !important;border-bottom-style: solid !important;}” el_class=”steroid”]*Steroid taper instructions/calendar as a guide but not an absolute

• Taper should consider patient’s current symptom profile
• Close follow-up in person or by phone, based on individual need & symptomatology
• Anti-acid therapy daily as gastric ulcer prevention while on steroids
• Review steroid medication side effects: mood changes (anger, reactive, hyperaware, euphoric, mania), increased appetite, interrupted sleep, oral thrush, fluid retention
• Be alert to recurring symptoms as steroids taper down & report them (taper may need to be adjusted)

Long-term high-dose steroids:

• Consider antimicrobial prophylaxis (sulfamethoxazole/trimethoprim double dose M/W/F; single dose if used daily) or alternative if sulfa-allergic (e.g., atovaquone [Mepron^®] 1500 mg po daily)
• Consider additional antiviral and antifungal coverage
• Avoid alcohol/acetaminophen or other hepatoxins

[/vc_column_text][vc_separator css=”.vc_custom_1508960503215{margin-top: 20px !important;margin-bottom: 20px !important;}”][vc_column_text css=”.vc_custom_1509136205640{border-top-width: 2px !important;border-right-width: 2px !important;border-bottom-width: 2px !important;border-left-width: 2px !important;padding-top: 10px !important;padding-right: 10px !important;padding-bottom: 10px !important;padding-left: 10px !important;background-color: #f2f2f2 !important;border-left-color: #c00000 !important;border-left-style: double !important;border-right-color: #c00000 !important;border-right-style: double !important;border-top-color: #c00000 !important;border-top-style: double !important;border-bottom-color: #c00000 !important;border-bottom-style: double !important;}”]

RED FLAGS:

• Guillain–Barré syndrome
• Myasthenia gravis

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