Table 3

Medications associated with peripheral neuropathy

Drug/classTypical pattern of neuropathyNotes/additional features
Tumour necrosis factor inhibitorsAcute or subacute polyradiculoneuropathy (axonal or demyelinating)Some of the conditions being treated with these drugs are also associated with a neuropathy
Calcineurin inhibitors (tacrolimus, ciclosporin)Acute or subacute polyradiculoneuropathy (axonal or demyelinating)Almost exclusively reported in post-transplant patients
Interferon-alphaAcute, subacute or chronic demyelinating polyradiculoneuropathyInitial course of immunomodulation usually needed; however, most recover after single course
LeflunomideLength-dependent sensory or sensorimotor axonal
LinezolidPainful predominantly sensory axonalDose dependent—mainly with prolonged courses. May also cause optic neuropathy
MetronidazolePainful length-dependent sensory axonalDose dependent—mainly with prolonged courses (≥4 weeks). May coexist with ataxia or encephalopathy
NitrofurantoinLength-dependent sensorimotor axonal, often rapid onset with clinical weakness
DapsoneMotor-predominant axonalDose dependent—mainly with prolonged courses
Fluoroquinolones (eg, ciprofloxacin, norfloxacin)Sensory symptoms, however, detailed clinical features not well documentedLikely to be extremely rare with short courses
Antituberculous drugs
IsoniazidSensory predominant axonalPrevented with pyridoxine (B6) supplementation. Occasionally causes optic neuropathy
EthambutolSensory predominant axonal (uncommon)Optic neuropathy
Some triazoles (itraconazole, voriconazole, posaconazole)Sensory predominant axonalMay also increase risk of neuropathy with vinca alkaloids and calcineurin inhibitors due to CYP3A4 inhibition
Some nucleoside reverse transcriptase inhibitors (stavudine, didanosine, zalcitabine)Sensory predominant axonalHave largely been superseded by non-neurotoxic agents
Cardiac drugs
AmiodaroneDistal predominant sensorimotor, often with both sensory ataxia and distal weakness. Nerve conduction studies may show demyelinating or axonal changes.Tremor, cerebellar ataxia, optic neuropathy, myopathy may develop
PerhexilineSevere, demyelinating polyradiculoneuropathyVery common. No longer available in the UK
Other drugs
PhenytoinMild axonal or demyelinating sensory or sensorimotor. Commonly asymptomatic signs or nerve conduction abnormalitiesOccasional cases of more significant neuropathy associated with high doses/phenytoin concentrations, often without cerebellar signs. Folate supplementation should be given
Levodopa–carbidopa intestinal gelSensory predominant axonal neuropathyDue to impaired absorption/metabolism of pyridoxine and other B vitamins
ColchicineMild sensory predominant axonalMyopathy usually more prominent
ChloroquineMild sensory predominant axonalMyopathy usually more prominent
DisulfiramSensorimotor axonal, often with clinical muscle weakness
Nitrous oxideUsually length-dependent sensorimotor. Can also cause a pure motor/motor-predominant neuropathyMyelopathy often more prominent
Pyridoxine (vitamin B6)Sensory ganglionopathy with prominent large fibre loss and ataxiaPyridoxine deficiency can also lead to a sensory predominant neuropathy. Mild elevation in plasma concentration (2–3 times upper limit of normal) common with multivitamin supplementation