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

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 10: Psychiatric ProblemsTable 10-19: Common Psychiatric Medications (continued)Anxiety disorders (also PTSD)See also SSRIs above26 picasInsomniaAlcohol dependenceAlcohol withdrawalClonazepam (Klonopin): 1 to 4mg in divided doses*Lorazepam (Ativan): 1 to 6mg in divided dosesBuspirone (BusPar): 15 to 45mg in divided dosesVenlafaxine (Effexor XR ): 37.5 to 225mgZolpidem (Ambien): 5 to 10mgZaleplon (Sonota): 5 to 10mgTemezepam (Restoril): 15 to 30mgTrazadone (Desyrel): 25 to 300mgLorazepam (Ativan): 0.5 to 2mg at hsClonazepam (Klonopin): 0.5 to 2mg at hsDisulfiram (Antabuse): 250 to 500mgClorazepate (Tranxene): 15 to 40mg q 2 to 6 hoursOpiate dependence Methadone: 60 to 120+mg qd ***Opiate withdrawalMethadone: 5 to 20mg in divided doses,tapered by 5mg/day***Clonidine: 0.3mg in three divided doses;increase to 2 mg/day in divided dosesXAbbreviations: SSRI-selective serotonin reuptake inhibitors; PTSD-post-traumatic stress disorder* Must be used with caution in patients on protease inhibitors.** Use with caution in later-stage illness.*** Some anti-HIV medications increase levels of methadone, others decrease (see chart on medication interactions).**** Concerns about pemoline-induced liver failure necessitate frequent blood tests to evaluate liver function. Should not be used inpatients with co-morbid HIV and hepatitis C.Adapted from Kobayashi J, Psychiatric issues. In Anderson, JR, ed. Guide to Clinical Care of Women with HIV, Rockville, Maryland:U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau, 2001.Table 10-19 provides information about antidepressants commonly used in the treatment ofdepression. Older antidepressants such as tricyclics may be effective and tolerated in early HIV;however, they may exacerbate both cognitive impairment and gastrointestinal disturbances as aresult of their anticholinergic activity. Selective Serotonin Reuptake Inhibitors (SSRIs) are effectiveantidepressants but are often problematic because of sexual side effects. Newer antidepressantssuch as buproprion and venlafaxine are very effective, with few drug-drug interactions.Bupropion (more activating) and nefazodone (more sedating) are tolerated well.Nefazodone must be used cautiously with patients on protease inhibitors (particularly ritonovir),which may raise blood levels 4 to 8 times. Mirtazapine is a sedating antidepressant compatiblewith antiretroviral medications, and may also stimulate appetite and weight gain. A more recentlyapproved SSRI, Escitalopram, is reported to have fewer side of effects, minimal interactionwith other drugs metabolized by the P450 cytochrome enzymes, and may have a faster onsetof action. So far there are no studies of its use in people with HIV.Antidepressants should be started at low doses and gradually increased. It is important to usesufficient doses of medication to achieve a therapeutic level. Raising doses too quickly, however,U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 229