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 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
A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 5: Constitutional Symptoms26 picasREFERENCESV1. Fantoni M, Ricci F, Del Borgo C, et al. Symptom profile in terminally ill AIDS patients. AIDS Patient CareSTDs 10:171-3, 1996.2. Vogl D, Rosenfeld B, Breitbart W, et al. Symptom prevalence, characteristics, and distress in AIDSoutpatients. J Pain Symptom Manage 18:253-62, 1999.3. Lorenz K, Shapiro M, Asch S, et al. Associations of symptoms and health-related quality of life: findings froma national study of persons with HIV infection. Ann Intern Med 134:854-6, 2001.4. Bartlett JG. The Johns Hopkins Hospital 2002 Guide to Medical Care of Patients with HIV Infection, 10thed. Philadelphia: Lippincott Williams & Wilkins, 2001.5. Grinspoon S, Corcoran C, Miller K, et al. Body composition and endocrine function in women with acquiredimmunodeficiency syndrome wasting. J Clin Endocrinol Metab 87:1332-7, 1997.6. Ropka M, Williams A. HIV Nursing and Symptom Management. Sudbury, Mass.: Jones & Bartlett Publishers,1998.7. Corcoran C, Grinspoon S. Treatments for wasting in patients with the acquired immunodeficiency syndrome.N Engl J Med 340:1740-50, 1999.8. Nemechek P, Polsky B, Gottlieb M. Treatment guidelines for HIV-associated wasting. Mayo ClinicProceedings 75:386-94, 2000.9. Coodley GO, Loveless MO, Nelson HD, Coodley MK. Endocrine function in the HIV wasting syndrome.J Acquir Immune Defic Syndr 7:46-51, 1994.10. Grinspoon S, Corcoran C, Lee K, et al. Loss of lean body and muscle mass correlated with androgen levels inhypogonadal men with acquired immunodeficiency syndrome and wasting. J Clin Endocrinol Metab 81:4051-8, 1996.11. Raghavan S, Grant LB, Barisch G, et al. Change in log HIV RNA & protease inhibitor use associated withweight change in HIV+ men in a national clinical trial. Presented at 12th World AIDS Conference Geneva,June 28-July 3, 1998.12. Schwenk A, Beijenherz A, Kremer G, et al. Impact of protease inhibitor treatment on body composition andprevalence of malnutrition in HIV positive outpatients. Presented at 12th World AIDS Conference Geneva,June 28-July 3, 1998.13. Gilbert CL, Muuraheinen N, Collins G, et al. Body composition in HIV-infected men and women in 1996-1997.Presented at 12th World AIDS Conference Geneva, June 28-July 3, 1998.14. Wanke CA, Silva M, Knox TA, et al. Weight loss and wasting remain common complications in individualsinfected with human immunodeficiency virus in the era of highly active antiretroviral therapy. Clin Infect Dis31:803-5, 2000.15. Berger D, Cimoch P, Nemechek P, et al. Measurement of body weight and body cell mass in patients receivinghighly active antiretroviral therapy (HAART). In program and abstracts of the 37th annual meeting of theInterscience Conference on Antimicrobial Agents and Chemotherapy, Toronto, Ontario, September 28-October 1, 1997.16. Moore RD, Chaisson RE. Natural history of HIV infection in the era of combination antiretroviral therapy.AIDS 13:1933-42, 1999.U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 131
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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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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 26.26 picasResourcesMagda B
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DRUGS AND THERAPIES INDEXNOTES: Ent
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