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Neuropathy (motor or sensory nerve impairment or damage)
[/vc_column_text][vc_column_text]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
[/vc_column_text][/vc_tab][/vc_tabs][/vc_column][/vc_row][vc_row][vc_column][vc_separator css=”.vc_custom_1508960503215{margin-top: 20px !important;margin-bottom: 20px !important;}”][vc_column_text]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
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
- 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
RED FLAGS:
- Guillain–Barré syndrome
- Myasthenia gravis