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

8–10 | Clinical Manual for Management of the HIV-Infected Adult/2006
A: Assessment
A partial differential diagnosis includes the following
conditions:
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Allergic reactions
Cardiac insufficiency, congestive heart failure,
myocardial ischemia
Hyperthyroidism
Hypoglycemia
Major depression with superimposed panic attack
Medication effect
Pheochromocytoma medication effect
Phobia (phobia is a specific response to a specific
stimulus, whereas a patient with panic attacks is
unsure when they will recur and what will trigger
them )
Respiratory infection
Pheochromocytoma
Withdrawal from or intoxication with psychoactive
substances (eg, caffeine, amphetamines, cocaine,
hallucinogens, or medications)
P: Plan
Diagnostic Evaluation
Perform the following tests:
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Blood glucose; gamma-glutamyl transpeptidase
(GGT) if symptoms are related to hunger or are
consistent with rebound hypoglycemia
Thyroid studies
Arterial blood gases if the patient has persistent
shortness of breath
Electrocardiogram if chest pain is present
Treatment
Once other diagnoses have been ruled out, consider the
following treatments:
Cognitive-behavioral therapy
Options include individual cognitive-behavioral therapy
(CBT) interventions (refer to community-based
support), a stress management group, relaxation therapy,
visualization, and guided imagery. Emergency referrals
may be needed.
Psychotherapy
Psychotherapy may be indicated if the patient is capable
of forming an ongoing relationship with a therapist. If
possible, refer to an HIV-experienced professional.
Pharmacotherapy
Patients with advanced HIV disease, like geriatric
patients, may become more vulnerable to the central
nervous system (CNS) effects of certain medications.
Medications that affect the CNS should be started
at low doses and should be titrated slowly. Similar
precautions should apply to patients with liver
dysfunction.
Some interactions occur between selective serotonin
reuptake inhibitors (SSRIs), benzodiazepines, and HIV
medications. Consult with an HIV expert or pharmacist
before prescribing.
Treatment should be continued for at least 6 months
beyond the resolution of symptoms.
Options
♦ 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 a dosage of 75-225 mg/d, has been
approved for the treatment of generalized anxiety
disorder. There is a risk of hypertension at the higher
dosages of venlafaxine; monitor blood pressure.
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Tricyclic antidepressants may be used at low doses,
including nortriptyline (Pamelor), 10-75 mg at
bedtime; desipramine (Norpramin), 10-50 mg daily;
amitriptyline (Elavil), 25-75 mg at bedtime; and
imipramine (Tofranil), 25-75 mg at bedtime. Doses
should be titrated slowly. Tricyclic antidepressants
may reach higher blood concentrations when
coadministered with certain protease inhibitors,
including ritonavir (contained in Kaletra); consult
with an HIV expert or pharmacist.
Many patients will require initial short-term
treatment with benzodiazepines, which are titrated
downward as the antidepressant is titrated upward.
Benzodiazepines should be used only for acute,
short-term management, because of the risks of
tolerance and physiologic dependence. These risks
are 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.