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

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)

Common sources of pain in HIV/AIDS Cutaneous/Oral Visceral Somatic Neurological/Headache Kaposi’s sarcoma Oral cavity pain Herpes zoster Oral/oesophageal candidiasis Tumours Gastritis Pancreatitis Infection Biliary tract disorders Rheumatological disease Back pain Myopathies HIV-related headaches: encephalitis, meningitis, etc. 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

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)

Peripheral neuropathy Clinical presentation Causes Treatment Burning pain: hands and feet 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 HIV itself (distal sensory neuropathy) Post-herpetic neuralgia ARVs, especially D4T and Efavirenz Other treatments: chemotherapy, Isoniazid, Metronidazole Remove offending agents if possible: change from D4T to Abacavir or from Efavirenz to Ritonavir/Lopinavir Treat herpes zoster early with Acyclovir to limit post-herpetic neuralgia Use WHO analgesic ladder –NSAIDs and opioids Gabapentin in resistant cases Try topical analgesics For localized neuropathies-nerve block Beating Pain, 2nd Ed. APCA (2012)

Abdominal pain Clinical presentation Causes Treatment Presents as acute or chronic pain TB abdomen MAC (mycobacterium avium complex) Pancreatitis Peptic ulcer disease Gastro-oesophageal reflux disease Gall bladder and biliary tract disease Malabsorption syndromes Drug side effects Neuropathic abdominal pain (diagnosis of exclusion) Diagnose and treat underlying cause if possible Start ARVs if indicated Treat pain according to WHO analgesic ladder Beware of ileus/constipation caused by opioids: can make pain worse 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 Beating Pain, 2nd Ed. APCA (2012)

Muscle spasm Clinical presentation Causes Treatment Muscle spasm Caused by HIV itself in the form of HIV encephalopathy with increased tone Secondary to cerebral insults from bacterial or tuberculosis meningitis ARVs 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)

Raised intracranial pressure Clinical presentation Causes Treatment Headache Focal neurological deficits Cryptococcal meningitis Toxoplasmosis Treat pain according to WHO analgesic ladder Morphine and pethidine are contraindicated for raised intracranial pressure Beating Pain, 2nd Ed. APCA (2012)

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

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-in- Africa-Full-Text.pdf Kopf A, Patel N, editors. Guide to Pain Management in Low-Resource Settings [Internet]. 2010. Available from: http://www.iasp- pain.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.