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

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 5: Constitutional Symptomsafternoon or evening. The dosage can be increased daily as tolerated to effect or to a maximumdaily dose of 60 mg.While generally26 picaswell-tolerated, methylphenidate should be used with caution in patients withanxiety, delirium, agitation, or tachyarrhythmias. Any jitteriness, mild anxiety, or hyperactivitythat develop during treatment often can be managed with a dose reduction.Dextroamphetamine has indications and properties very similar to those of methylphenidate. 43The recommended dosage is the same.Pemoline, which is chemically unrelated to amphetamine and has milder sympathomimeticeffects, also may be effective against fatigue and depression in advanced medical illness includingHIV disease. 45 In the only randomized controlled trial of psychostimulants for fatigue in HIVpositivepeople, methylphenidate (7.5 mg twice daily) and pemoline (18.75 mg/day) were significantlybetter than placebo at improving not only fatigue but also depression, psychologicaldistress, and overall quality of life. 46 The starting dosage of pemoline is 18.75 mg orally at 8 a.m.or twice per day at 8 a.m. and noon. The dosage can be increased as tolerated to effect or to amaximum daily dose of 112.5 mg. However, due to its potential for severe hepatotoxicity, pemolineshould be used with caution and should not be used in patients with liver disease.VCorticosteroidsCorticosteroids have been shown to temporarily improve fatigue in cancer patients. 28 It ispossible that many HIV/AIDS patients may experience similar benefits in the palliative caresetting. Information on the use of corticosteroids for fatigue and other indications in generalpalliative care can be found in this chapter, in the section on HIV wasting above.There is direct evidence that corticosteroids improve fatigue in one sub-population of HIV/AIDSpatients: those with disseminated mycobacterium avium complex (MAC) with progressive diseasedespite combination antimycobacterial therapy. Low-dose dexamethasone (4-6 mg/day)led to a rapid decrease in fatigue, fever and night sweats within one week of initiating treatmentin a series of 12 patients. In similar studies of (low-dose) corticosteroids in small numbers of47, 48patients, weight gain, fever reduction, and improved sense of well-being were documented.While randomized controlled trials have not been done, corticosteroids appear to be useful inthe palliative care of patients with end-stage AIDS and MAC refractory to antimycobacterialtherapy. 49FEVERS AND SWEATS■ Fevers, sweats, or both are frequent causes of suffering and poor quality of life in AIDS patients.Fever increases metabolic rate, and persistent fever is associated with anorexia, weightloss and wasting. 6 Etiologies of fever include infections, HIV-associated malignancies, side effectsof drugs (e.g., trimethoprim-sulfamethoxazole and other sulfa drugs, abacavir and otherantiretrovirals, amphotericin B), hormonal dysfunction, and auto-immune disorders.While any source of fever can cause sweats, sweats without fever may occur in the setting ofsome infections, malignancies, endocrinopathies and medications. For example, both opioidsand withdrawal from opioids may cause sweats in the absence of fever. If possible and appropriate,efforts should be made to identify and treat the underlying etiology of fevers or sweats.Medications used to treat fever and sweats of many etiologies include antipyretics, corticosteroidsand anticholinergics.U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 129