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Bortezomib Neuropathy — RACP Adult Medicine MCQ

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ModerateHaematologyBortezomib NeuropathyRACP Adult Medicine

A 60-year-old man with multiple myeloma on bortezomib develops tingling and burning pain in his feet (glove-and-stocking distribution) with impaired vibration sense. NCS shows sensory axonal polyneuropathy. His symptoms started 3 months after commencing bortezomib. What is the most appropriate management?

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Correct answer: E — Dose-reduce bortezomib and switch to subcutaneous route

Bortezomib-induced peripheral neuropathy (BIPN) is the most common dose-limiting toxicity of bortezomib. Management: dose reduction (from 1.3 to 1.0 mg/m²) AND switch from IV to subcutaneous administration (subcutaneous route has significantly less neurotoxicity per PETHEMA trial). If Grade 3 neuropathy (interfering with ADLs) or neuropathic pain: withhold bortezomib and consider switching to carfilzomib or ixazomib (less neurotoxic proteasome inhibitors). Symptomatic treatment: duloxetine, pregabalin, or amitriptyline for neuropathic pain.

Reference: IMWG – 2024 – Bortezomib Neuropathy; PETHEMA Trial; ALLG