Clinical Manual for Management of the HIV-Infected ... - myCME.com

8–2 | Clinical Manual for Management of the HIV-Infected Adult/2006
P: Plan
Laboratory and Diagnostic Evaluation
Perform the following tests:
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Electrocardiogram (EKG)
Thyroid studies
Blood glucose
Arterial blood gases (if frank difficulty
breathing is not self-limited)
Other tests as indicated based on symptoms and
physical examination
Treatment
Once other diagnoses have been ruled out and the
diagnosis of anxiety disorder is established, several
options are available:
Cognitive-behavioral interventions
Options include individual cognitive-behavioral
therapy, a stress-management group, relaxation therapy,
visualization, and guided imagery. Refer the patient to
available community-based support.
Psychotherapy
Psychotherapy may be indicated if experienced
professionals are available and the patient is capable of
forming an ongoing relationship. If possible, refer to an
HIV-experienced therapist.
Pharmacotherapy
Patients with advanced HIV disease, like geriatric
patients, may become more vulnerable to the CNS
effects of certain medications. Medications that affect
the CNS should be started at low dosage and titrated
slowly. Similar precautions should apply to patients with
liver dysfunction.
Interactions may occur between selective serotonin
reuptake inhibitors (SSRIs), benzodiazepines, and HIV
medications. Consult with an HIV expert or pharmacist
before prescribing.
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SSRI-type antidepressants, including fluoxetine
(Prozac), paroxetine (Paxil), sertraline (Zoloft),
citalopram (Celexa), and escitalopram (Lexapro) may
be effective. Venlafaxine timed-release formulation
(Effexor XR), at dosages of 75-225 mg/d, has been
approved for the treatment of generalized anxiety
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disorder. Note: There is a risk of hypertension at
the higher dosages of venlafaxine; monitor blood
pressure.
Buspirone (BuSpar) is a nonaddictive anxiolytic.
Start at 5 mg orally 3 times per day. If symptoms
persist, the dosage can be increased by 5 mg per
dose each week to a maximum of 10-15 mg orally
3 times per day (for a total daily dosage of 30-45
mg). It will take several weeks for patients to notice
a decrease in anxiety; low-dose benzodiazepines may
be used during this interval. The major potential
adverse effects of buspirone are dizziness and
lightheadedness.
Treatment may include intermediate half-life
benzodiazepines such as oxazepam (Serax) 10 mg
orally every 6 hours or lorazepam (Ativan) 0.5 mg
orally every 8 hours, if buspirone is not tolerated
or to alleviate anxiety symptoms until buspirone
takes effect. Longer-acting benzodiazepines such
as clonazepam (Klonopin) also may be useful at
dosages of 0.25-0.5 mg orally twice a day.
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Benzodiazepines should be used only for acute,
short-term management because of the risk of
tolerance and physiologic dependence. These
risks are even more problematic in patients with
a history of addiction.
Note that protease inhibitors and nonnucleoside
reverse transcriptase inhibitors may raise blood
concentrations of many benzodiazepines. If
benzodiazepines are used, they should be started
at low dosages, and other CNS depressants
should be avoided. Consult with a clinical
pharmacist before prescribing.
Midazolam (Versed) and triazolam (Halcion)
are contraindicated with all protease inhibitors
and with delavirdine and efavirenz.
Some sedating antidepressants are effective,
nonaddictive anxiolytic agents. These include
trazodone (Desyrel) 25-100 mg at bedtime or
imipramine (Tofranil) 25 mg at bedtime. Note that
imipramine is contraindicated with ritonavir or in
advanced HIV disease. Neurontin 200-400 mg 2
times daily or 4 times daily can also be used.