A Guide to Primary Care of People with HIV/AIDS - Canadian Public ...

A Guide to Primary Care of People with HIV/AIDS
Chapter 8: Symptom Management
8
FATIGUE
What are the common causes of chronic fatigue
in patients with HIV?
Fatigue can have a large impact on the quality of a
patient’s life. Common descriptors of fatigue include
tiredness, weakness, lack of energy, sleepiness, and
exhaustion. Of the many possible causes of chronic
fatigue in patients with HIV, the most common
is depression. Other psychosocial causes include
stress, anxiety, use of recreational substances, sleep
disturbances, domestic abuse, and lack of exercise.
ODs must be considered as a possible cause of fatigue
in patients with low CD4 cell counts. Other disease
states such as anemia, hypothyroidism, hypogonadism,
adrenal insufficiency, influenza and other nonopportunistic
infections, diabetes, liver disease, and
malnutrition can also present as fatigue. Fatigue can be
a side effect of ART and other medications commonly
taken by patients with HIV. HIV-associated fatigue is a
diagnosis of exclusion.
How do you determine the cause of a patient’s
fatigue?
Ask if the patient is having other symptoms of
depression: change in sleep or appetite patterns,
depressed mood, anhedonia, agitation or retardation,
difficulties with concentration, decreased self-esteem,
and suicidal ideation. Take a thorough social history
and determine if multiple life stressors are present.
Inquire as to how many hours of sleep the patient is
getting per night and the number of middle-of-thenight
awakenings; ask if the patient feels rested in
the morning. Important history questions that help
differentiate a physical from a psychological etiology
for fatigue are in Table 8-3. Identify any barriers to
effective sleep. Ask about the patient’s diet and exercise
habits, and determine if the patient drinks alcohol or
uses recreational drugs, including caffeine. Thoroughly
review the patient’s medication list and identify any
medications, such as certain antiretroviral drugs, betablockers,
antihistamines, etc., that can be associated
with fatigue. Do a complete review of systems and
physical exam to elicit other symptoms or signs that
may suggest an OD or other disease state. Simple
laboratory tests, such as alanine aminotransferase (ALT),
blood glucose, thyroid stimulating hormone (TSH),
and hematocrit, can help to rule out common diseases
that can cause fatigue. Electrolyte abnormalities can
suggest adrenal insufficiency. Order other laboratory or
diagnostic tests as symptoms and signs direct.
Table 8-3. History Questions to
Differentiate Physical from Psychological
Causes of Fatigue
Onset
Psychological
cause
Often follows
problem or conflict
Physical
cause
Related to onset of
physical ailments
Duration Chronic Of recent onset
Progression Fluctuates Increases as
disease advances
Effect of sleep
Diurnal
Unaffected by
sleep
Present in
morning, may
improve
NEUROPATHIC PAIN
Relieved by sleep
Increases as the
day progresses
What is the most common cause of neuropathic
pain and paresthesias in patients with HIV?
Distal symmetrical polyneuropathy (DSP) is most
commonly caused by antiretroviral drugs. The drugs
didanosine (ddI), zalcitabine (ddC), stavudine (d4T)
can all cause DSP at high doses. Studies have shown
zalcitabine to be the most likely to cause neuropathy
at standard doses; concurrent alcohol use or vitamin
B12 deficiency may increase risk. HIV-related DSP is
less common than drug-induced DSP. The two types of
neuropathies present similarly, although onset may be
more acute in drug-induced DSP. HIV-related DSP does
not appear to respond to viral suppression with ART.
How do you diagnose and treat DSP?
Diagnose drug-related DSP by linking the onset of the
symptoms with the initiation of drug therapy. Treat
by drug removal; symptoms may worsen temporarily
but should regress within several weeks. Residual
painful symptoms of DSP may be treated with tricyclic
antidepressants, narcotic analgesics, or gabapentin.
The topical medication capsacin may be helpful if the
neuropathy is limited to a small surface area.
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U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau