Table 1. Pharmacologic Interventions
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|Discontinuation of offending drug (eg, switching from dNRTIs, avoiding combinations with additive neurotoxicity)|
- Differentiate DSP and ARV toxic neuropathy by timing of symptom onset.
- Prompt discontinuation of a neurotoxic medication may prevent progression of symptoms, and may allow reversal of symptoms.
- Before discontinuing an offending drug, carefully weigh risks and potential benefits.
- Consider dosage reduction of d4T, if discontinuation is not possible.
- With ARV toxic neuropathy caused by a dNRTI, symptoms often improve within 3 months (though they may be permanent).
|Initiation of ART|
- Initiation of ART can improve non-ARV-associated DSP for patients with advanced HIV who have uncontrolled viremia and low CD4 counts.
(for dosages and additional information, see Pain Medications)
- Use as first-line therapy for mild symptoms.
- Can use in combination with tricyclic antidepressants (TCAs), anticonvulsants, and topical adjuncts.
- Avoid use or limit dosages for patients with underlying liver or renal disease.
- Gabapentin: considered first-line for its tolerability.
- Pregabalin: sometimes better tolerated than gabapentin. Little evidence of efficacy for HIV-SN.
- Lamotrigine: has shown the greatest efficacy in clinical trials for HIV-SN.
- Data for other anticonvulsants, such as topiramate, are lacking; may be useful for selected patients with close monitoring.
- To discontinue these agents, taper slowly over course of ≥7 days.
|Antidepressants: TCAs and SNRIs|
- TCAs: amitriptyline and nortriptyline
- SNRIs: venlafaxine and duloxetine; these are inadequately studied in people with HIV infection
- Consider SNRIs for patients with comorbid depression.
- Small studies have shown limited or negative results with TCAs.
- TCAs may cause sedation.
- Monitor serum TCA levels and EKG to avoid cardiotoxicity at higher dosage levels.
Potential ARV Interactions
- Drug interactions: RTV and other PIs may increase the level of TCAs; start at low dosage, increase slowly.
- Capsaicin patch or cream
- Lidocaine patch
- A single capsaicin patch application can provide some degree of pain relief for up to 12 weeks.
- Topical lidocaine has not shown significant benefit over placebo, and is expensive. Consider brief trial for patients with incomplete pain relief on other therapies.
- Long-acting narcotics preferred:
- Transdermal fentanyl
- Long-acting morphine
- Long-acting oxycodone
- For moderate to severe HIV-SN with an inadequate response to the therapies listed above.
- Titrate carefully. (For more information, see Pain Medications.)
- Methadone: acts on NMDA receptors; may give adjunctive benefit. Caution: start at low dosage and titrate slowly because of its long half-life; consult with pharmacist.
- Transdermal fentanyl is appropriate only for patients already on stable dosage of other opiates: start at equianalgesic (or lower) dosage.
From Peripheral Neuropathy
Primary Care of Veterans with HIV
Office of Clinical Public Health Programs
Veterans Health Administration, 2009