The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

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A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 4: PainOptimal management of pain in AIDS is multimodal and requires pharmacologic, psychotherapeutic,cognitive-behavioral, anesthetic, neurosurgical and rehabilitative approaches. A multidimensionalmodel of AIDS pain that recognizes the interaction of cognitive, emotional, socioenvironmentaland nociceptive26 picasaspects of pain suggests a model for multimodal intervention.PHARMACOLOGIC INTERVENTIONS FOR PAIN■ The World Health Organization has devised guidelines for analgesic management of cancer painwhich the AHCPR has endorsed for the management of pain related to cancer or AIDS. 58, 59 Theseguidelines, also known widely as the WHO Analgesic Ladder (Figure 4-1), have been well validated. 65This approach advocates selection of analgesics based on the severity of pain as well as the type ofpain (i.e., neuropathic vs. non-neuropathic pain). For pain that is mild to moderate in severity,non-opioid analgesics such as NSAIDs (non-steroidal anti-inflammatory drugs) and acetaminophenare recommended. For pain that is persistent and moderate to severe in intensity, opioid analgesicsof increasing potency (such as morphine) should be utilized.Adjuvant agents, such as laxatives and psychostimulants, are useful in preventing as well as treatingopioid side effects such as constipation or sedation respectively. Adjuvant analgesic drugs, such asthe antidepressant analgesics, are suggested for considered use, along with opioids and NSAIDs, inall stages of the analgesic ladder (mild, moderate or severe pain), but have their most importantclinical application in the management of neuropathic pain.The WHO approach, while not yet validated in AIDS, has been recommended by the AHCPR andclinical authorities in the fields of pain management and AIDS. 8, 10, 12, 17, 29, 58, 66 In addition, clinicalreports have appeared in recent literature describing successful application of the WHO Analgesic9, 17,Ladder principles to pain management in AIDS, with particular emphasis on the use of opioids.67, 68, 69, 70, 71Non-Opioid AnalgesicsThe non-opioid analgesics are prescribed principally for mild-to-moderate pain or to augment theanalgesic effects of opioid analgesics in the treatment of severe pain (see Table 4-6). The use of NSAIDsin patients with AIDS must be accompanied by heightened awareness of toxicity and adverse effects.NSAIDs are highly protein-bound, and the free fraction of available drug is increased in AIDS patientswho are cachectic, wasted and hypoalbuminic, often resulting in toxicities and adverse effects. Patientswith AIDS are frequently hypovolemic, on concurrent nephrotoxic drugs, and experiencing HIVnephropathy, and so are at increased risk for renal toxicity related to NSAIDs. The antipyretic effectsof the NSAIDs may also interfere with early detection of infection in patients with AIDS.Major adverse effects associated with NSAIDs include the following:• Gastric ulceration• Renal failure• Hepatic dysfunction• BleedingThe nonacetylated salicylates, such as salsalate, sodium salicylate, and choline magnesium salicylate,theoretically have fewer gastrointestinal (GI) side effects and might be considered in caseswhere GI distress is an issue. Prophylaxis for NSAID-associated GI symptoms includes H2 antagonistdrugs (cimetidine 300 mg tid-qid or ranitidine 150mg bid); misoprostal 200 mg qid.; omeprazole 20 mgqd; or an antacid.104U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau
A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 4: PainTable 4-6: Oral Analgesics for Mild to Moderate Pain in HIV/AIDSAnalgesic Starting Duration Plasma(by class) Dose (MG) (HRS) Half-Life (HRS) COMMENTSAcetaminophen 650 4-6 4-6 May be hepatotoxic if exceeds recommended doses26 picasNonsteroidal (NSAIDs)Aspirin 650 4-6 4-6 Standard of comparison among non-opioidanalgesics.Ibuprofen 400-600 — — Like aspirin, can inhibit platelet function.Choline magnesium trisalicylate 700-1500 — — Essentially no hematologic or gastrointestinalside effects.Weaker opioidsCodeine 32-65 3-4 — Metabolized to morphine, often used to suppresscough in patients at risk of pulmonary bleed.Oxycodone 5-10 3-4 — Available as a single agent and in combinationwith aspirin or acetominophen.Propoxyphene 65-130 4-6 — Toxic metabolite norpropoxy accumulates withrepeated dosing.IVU.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 105
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DedicationA Clinical Guide to Suppo
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Lynn A Jansen, RN, PhDAssistant Res
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TABLE OF CONTENTSPart IChapter 1Cha
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IChapter 1.26 picasHIV and Palliati
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IA Clinical Guide to Supportive and
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IIIChapter 3.Assessment of Physical
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Chapter 8.26 picasOral ProblemsDavi
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Chapter 9.26 picasDermatologic Prob
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Chapter 11.26 picas Substance Use P
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Chapter 14.26 picasCulture and Care
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Chapter 15.26 picasSpecial Populati
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Chapter 17.26 picasEthical IssuesLy
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Chapter 18.26 picasLegal and Financ
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Chapter 19.Palliative 26 picas Care
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Chapter 26.26 picasResourcesMagda B
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DRUGS AND THERAPIES INDEXNOTES: Ent
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