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 SymptomsIn the palliative management of fever in patients with HIV/AIDS, it is important to maintainbody temperature within a comfortable range. Usually patients are most comfortable at normalor near-normal body temperature, but not all fevers cause discomfort. The most common antipyretic26usedpicasis acetaminophen, given in a dosage of 650 to 1000 mg orally or rectally every 6hours as needed or around the clock. Non-steroidal anti-inflammatory drugs (NSAIDs) are particularlyhelpful in patients with fevers related to neoplasms and/or when an additional antiinflammatoryeffect is desired. The gastrointestinal toxicity of NSAIDs can be reduced by usingcholine magnesium trisalicylate (500 to 1000 mg orally twice-thrice daily), using a selectivecyclooxygenase-2 inhibitor such as rofecoxib (12.5 to 50 mg orally every day), and/or adding acytoprotective agent such as an H2 antagonist, proton pump inhibitor, or misoprostol (100 to 200µg orally twice to four times per day).For severe, unremitting fever, acetaminophen and an NSAID both can be given every 6 hours ina staggered fashion with the patient receiving one or the other every 3 hours. Corticosteroidsprovide an alternative that can cut down on the number and frequency of medications, and maybe equally effective in some situations. As described above in the section on fatigue, low-dosedexamethasone (4 to 6 mg/day) led to a rapid decrease in fever, night sweats and fatigue withinone week of initiating treatment in a series of 12 patients with disseminated MAC refractory toantimycobacterial therapy. 47-49Keeping the patient warm and dry will help to prevent chills and shivering. 6 If fluid and electrolyteloss from fever and sweats is considerable, the clinician must weigh the benefits and burdensof aggressive hydration to restore and maintain fluid balance in light of the patient’s goals,values, and prognosis.Sweats associated with fever are treated as above. If sweats are unrelated to fever, NSAIDs asdescribed above still may prove helpful. Anticholinergics also may be tried, such as scopolamine(0.2-0.6 mg subcutaneously or intravenously every 1-4 hours, or by 1.5 mg transdermal patch, 3-5 patches every 72 hours) or hyoscyamine (0.125-0.25 mg orally every 1-4 hours). An anticholinergicwith minimal central nervous system effects is glycopyrrolate (1-2 mg orally once daily atbedtime or up to thrice daily or 0.1-0.2 mg subcutaneously or intravenously once daily at bedtimeor up to every 6 hours). In addition, the use of the H2 antagonist cimetidine (400-800 mg28, 50orally twice daily) may provide symptomatic relief.CONCLUSIONS■ In people with HIV/AIDS, constitutional symptoms such as wasting, fatigue, fever and sweatsoften severely compromise quality of life and overall sense of well-being. Careful management ofthese symptoms throughout the course of the illness is an important component in overall HIV/AIDS care. As with any intervention, clinicians should weigh the potential benefits and burdensof treatments for constitutional symptoms for each individual patient in each clinical situation.When a patient’s life expectancy is short and maximizing his or her quality of life is an importantgoal, possible long-term side effects of a treatment become less relevant if the treatment islikely to improve short-term quality of life.130U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau