Transcript Treatment in HIV/AIDS

Treatment in HIV/AIDS
Disclaimer: This presentation contains information on the general principles of pain management. This presentation cannot account for
individual variation among patients and cannot be considered inclusive of all proper methods of care or exclusive of other treatments. It
is the responsibility of the treating physician, or health care provider, to determine the best course of treatment for the patient. Treat the
Pain and its partners assume no responsibility for any injury or damage to persons or property arising out of or related to any use of
these materials, or for any errors or omissions.
Objectives
• Discuss common sources of pain for patients with HIV/AIDS
• Review the clinical presentation, causes, and treatment for
specific HIV/AIDS-related pain
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Pain in HIV/AIDS
• Pain in HIV is common, has various presentations, and can
result from multiple sources at the same time
• Pain may be related to HIV infection, immunosuppression, or
HIV therapy
• Many people with HIV/AIDS also have cancer
Beating Pain, 2nd Ed. APCA (2012)
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Common sources of pain in HIV/AIDS
Cutaneous/Oral
Visceral
Somatic
Neurological/Heada
che
• Kaposi’s sarcoma
• Tumours
• Rheumatological disease
• Oral cavity pain
• Gastritis
• Back pain
• Herpes zoster
• Pancreatitis
• Myopathies
• HIV-related headaches:
encephalitis, meningitis,
etc.
• Oral/oesophageal
candidiasis
• Infection
• Biliary tract disorders
• HIV-unrelated
headaches: tension,
migraine, etc.
• Iatrogenic (AZT)
• Peripheral neuropathy
• Herpes neuritis
• Neuropathies associated
with DDI, D4T toxicities
• Alcohol, nutritional
deficiencies
Beating Pain, 2nd Ed. APCA (2012), adapted from Carr DB
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Treatment of pain in HIV/AIDS
• Follow the World Health Organization (WHO) analgesic ladder
– Use NSAIDs with caution in those with low platelets or
those with a history of gastrointestinal disease such as
peptic ulcer disease
• Adjuvants (co-analgesia) can be very useful
• Some antiretroviral medications interact with analgesics, so
check interactions or consult with an expert
– Main interactions involve adjuvants: phenytoin,
carbamazepine, dexamethasone, and amitriptyline
Beating Pain, 2nd Ed. APCA (2012)
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Peripheral neuropathy
Clinical presentation
Causes
Treatment
• Burning pain: hands and feet
• HIV itself (distal sensory
neuropathy)
• Post-herpetic neuralgia
• Remove offending agents if possible:
change from D4T to Abacavir or from
Efavirenz to Ritonavir/Lopinavir
• ARVs, especially D4T and
Efavirenz
• Treat herpes zoster early with Acyclovir
to limit post-herpetic neuralgia
• Other treatments:
chemotherapy, Isoniazid,
Metronidazole
• Use WHO analgesic ladder –NSAIDs and
opioids
• Pins and needles
• Allodynia (the experience of
pain from a stimulus that
would not usually cause pain
in a normal individual)
• Pain relieved by local pressure
• Gabapentin in resistant cases
• Try topical analgesics
• For localized neuropathies-nerve block
Beating Pain, 2nd Ed. APCA (2012)
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Abdominal pain
Clinical
presentation
Causes
Treatment
• Presents as acute or
chronic pain
• TB abdomen
• Diagnose and treat underlying cause if possible
• MAC (mycobacterium avium complex)
• Start ARVs if indicated
• Pancreatitis
• Treat pain according to WHO analgesic ladder
• Peptic ulcer disease
• Beware of ileus/constipation caused by opioids:
can make pain worse
• Gastro-oesophageal reflux disease
• Gall bladder and biliary tract disease
• Malabsorption syndromes
• Drug side effects
• Neuropathic abdominal pain (diagnosis of
exclusion)
Beating Pain, 2nd Ed. APCA (2012)
• Remember morphine causes contraction of
sphincter of Oddi, so pethidine is a better choice
in pancreatitis
• For MAC immune reconstitution inflammatory
syndrome (IRIS), try low dose steroids
• Beware of NSAIDs and gastritis
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Muscle spasm
Clinical presentation
Causes
Treatment
• Muscle spasm
• Caused by HIV itself in the form
of HIV encephalopathy with
increased tone
• ARVs
• Secondary to cerebral insults
from bacterial or tuberculosis
meningitis
• Levodopa (extrapyramidal dysfunction)
• Analgesics (Step 2: non-opioid + weak
opioid)
• NSAIDs may help for musculoskeletal
pain
• Baclofen (for muscle spasm, can cause
seizures)
• Adjuvants, especially Rivotril
Beating Pain, 2nd Ed. APCA (2012)
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Raised intracranial pressure
Clinical presentation
Causes
Treatment
• Headache
• Cryptococcal meningitis
• Focal neurological deficits
• Toxoplasmosis
• Treat pain according to WHO
analgesic ladder
• Morphine and pethidine are
contraindicated for raised
intracranial pressure
Beating Pain, 2nd Ed. APCA (2012)
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Take home message
• ARVs may not relieve all causes of pain for people
people with HIV/AIDS and patients may need
additional pain treatment
• Cancer is common in people living HIV/AIDS
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References
•
African Palliative Care Association. Beating Pain: a pocketguide for pain
management in Africa, 2nd Ed. [Internet]. 2012. Available from:
http://www.africanpalliativecare.org/images/stories/pdf/beating_pain.pdf
•
African Palliative Care Association. Using opioids to manage pain: a pocket guide
for health professionals in Africa [Internet]. 2010. Available from:
http://www.africanpalliativecare.org/images/stories/pdf/using_opiods.pdf
•
Amery J, editor. Children’s Palliative Care in Africa [Internet]. 2009. Available from:
http://www.icpcn.org/wp-content/uploads/2013/08/Childrens-Palliative-Care-inAfrica-Full-Text.pdf
•
Kopf A, Patel N, editors. Guide to Pain Management in Low-Resource Settings
[Internet]. 2010. Available from: http://www.iasppain.org/files/Content/ContentFolders/Publications2/FreeBooks/Guide_to_Pain_
Management_in_Low-Resource_Settings.pdf
•
The Palliative Care Association of Uganda and the Uganda Ministry of Health.
Introductory Palliative Care Course for Healthcare Professionals. 2013.
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