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

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 7: Gastrointestinal SymptomsCannabinoids such as dronabinol (Marinol) exert their effects via the central nervous systemand have been found to have antiemetic activity both when used alone and in combination withother medications. Marinol is FDA-approved only for use as an appetite stimulant in AIDS patients26(itpicasis approved as an antiemetic for cancer patients receiving chemotherapy) though ithas frequently been used “off-label” for management of nausea and vomiting in patients withHIV/AIDS.The use of adjunctive medications such as glucocorticoids (dexamethasone), benzodiazepines,antihistamines (diphenhydramine, hydroxyzine) or anticholinergics may enhance the effectivenessof antiemetics. Antihistamines and anticholinergics are primarily useful in controllingnausea and vomiting resulting from motion sickness or other inner ear disturbances. They donot act on the chemoreceptor trigger zone and are of little value in other causes of vomiting. 10Antihistamines may be a particularly useful adjunct for patients on phenothiazines or otherantidopaminergic medications since they will usually prevent dystonic reactions. H2-receptorantagonists or proton pump inhibitors can be used to control gastritis and gastroesophagealreflux disease, which can also be a cause of nausea or vomiting.Other interventions that can be tried include changing the patient’s diet or giving the patientsmaller, more frequent meals until symptoms are under adequate control. If the vomiting is sosevere that the patient is unable to take oral medications, the antiemetics should be administeredparenterally or by suppository. For patients with chronic nausea, around-the-clock administrationof antiemetics should be considered. Finally, appropriate precautions must always betaken to minimize the patient’s risk of aspiration.Table 7-3 presents dosage information for many of the antiemetic agents.DYSPHAGIA AND ODYNOPHAGIA■ Prior to the advent of HAART, approximately one-third of AIDS patients at some point developedopportunistic infections involving the esophagus. 12 In fact, esophageal symptoms rank secondonly to diarrhea in frequency of gastrointestinal complaints among patients with AIDS. 13Additionally, since opportunistic disorders of the esophagus usually present only after the CD4count has dropped to below 100/mm 3, 14 they are problems that will frequently be seen in patientswho have advanced AIDS.AssessmentThe most common symptoms of esophageal disorders in persons with AIDS are dysphagia andodynophagia. Less common symptoms are retrosternal chest pain, coughing, and hiccups, whichmay occur secondary to acid reflux or esophagitis. Those processes may, in turn, lead to aspirationand/or the development of esophageal ulcers that can then heal and leave esophageal scarring. 15Infections are the most common cause of esophageal disorders. The most common infectiousetiologies are candida and the herpes viruses herpes simplex (relatively rare) and cytomegalovirus(more common). Mycobacterium tuberculosis and mycobacterium avium complex areinfectious causes of esophageal disease that are seen less frequently. Additional etiologies includeidiopathic ulcers, apthous ulcers, Kaposi’s sarcoma, gastroesophageal reflux disease andpill-induced esophagitis. 15162U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau