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8–14 | Clinical Manual for Management of the HIV-Infected Adult/2006 ♦ ♦ ♦ Wake up at the same time each day regardless of total hours of sleep. Have a dark, quiet, comfortable environment conducive to sleep. If unable to fall sleep after 15-20 minutes, the patient should get up, go into another room for nonstimulating activity in dim light (such as reading), and not go back to bed until sleepy. The patient should discontinue use of caffeine, central nervous system stimulants, alcohol, and tobacco, with tapering if necessary to avoid withdrawal symptoms. Teach or refer the patient for relaxation techniques. Pharmacotherapy The following options are available: ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ Antihistamines, such as diphenhydramine or hydroxyzine 25-50 mg at bedtime (be aware of anticholinergic adverse effects). Sedating antidepressants such as trazodone 25- 50 mg at bedtime, or amitriptyline 10-50 mg at bedtime. Check for drug interactions with antiretroviral agents and other medications. Mirtazapine (Remeron) is a newer antidepressant with fewer drug interactions that may be used at low dosages (7.5-15 mg) for insomnia. Sedative hypnotics, such as triazolam (Halcion) 0.125-0.25 mg at bedtime as needed; temazepam (Restoril), 15 mg at bedtime; and newer agents such as zolpidem (Ambien), eszopiclone (Lunesta), zaleplon (Sonata). Because of addictive potential and problems such as amnesia and confusion, these should be used only for short-term management (5-7 days). 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 central nervous system depressants should be avoided. Consult with a clinical pharmacist before prescribing. Midazolam (Versed) and triazolam (Halcion) are contraindicated with all protease inhibitors and delavirdine and efavirenz. Consult with a skilled mental health clinician if problems persist or depression is suspected. Patient Education ♦ ♦ Behavioral interventions can help to reduce insomnia. Patients should report new or worsening symptoms to their health care provider. References ♦ ♦ ♦ ♦ ♦ Darko DF, McCutchan JA, Kripke DF, et al. Fatigue, sleep disturbance, disability, and indices of progression of HIV infection. Am J Psychiatry. 1992 Apr;149(4):514-20. Lee KA. An overview of sleep and common sleep problems. ANNA J. 1997 Dec;24(6):614-23, 677; quiz 624-5. Norman SE, Chediak AD, Kiel M, et al. Sleep disturbances in HIV-infected homosexual men. AIDS. 1990 Aug;4(8):775-81. Uphold CR, Graham MV. Clinical Guidelines in Adult Health. 2nd ed. Gainesville, FL: Barmarrae Books; 1999:95-99. Weiss RE. Neuropsychiatric Complications of HIV Infection. In: Buckley RM, Gluckman SJ, eds. HIV Infection in Primary Care. Philadelphia: Saunders; 2002:192.
Suicidal Ideation Background Transient suicidal thoughts are common in some people throughout the course of HIV disease and do not usually indicate significant risk of suicide. However, persistent suicidal thoughts with associated feelings of hopelessness and intent to die are very serious and must be assessed promptly and carefully. The risk of suicide is especially high for patients who are depressed and for those at pivotal points in the course of HIV infection. Many events may trigger suicidal thoughts among persons with HIV. Such events may include learning about their positive HIV status, disclosing to family and friends, starting antiretroviral therapy, noticing the first symptoms, having a decrease in CD4 counts, undergoing a major illness or hospitalization, receiving an AIDS diagnosis, losing a job, experiencing major changes in lifestyle, requiring evaluation for dementia, and losing of a significant relationship. A suicide assessment must always be included in the psychiatric evaluation. Risk factors for suicide attempts include the following: ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ Abandonment by, or isolation from family, friends, or significant others Age, especially teen years or >45 years of age Recent or current illness Any acute change in health status Fear of HIV-associated dementia Financial difficulty Hopelessness Multiple losses or recent stressors Pain Perception of poor prognosis Perception of poor social support Previous suicide attempts Substance abuse, especially alcohol Relapse into drug use after significant recovery Severe anxiety, depression, or other mental health disorder Social isolation (eg, being single, divorced, or alone, or experiencing the death of a spouse) ♦ Section 8—Neuropsychiatric Disorders | 8–15 Stigmatization due to illness, sexual orientation, substance use history, or other factors S: Subjective The patient expresses or exhibits, or a personal care giver discloses the following: ♦ ♦ ♦ Active suicidal ideation with intent and plan, such as giving away significant personal belongings, saying goodbye, gathering the means (eg, gun, pills), writing a suicide note Passive withdrawal from therapy or medical care or decreased adherence (eg, stopping medications, missing appointments) A desire for HIV disease to progress more rapidly History Inquire about the following during the history: ♦ ♦ ♦ ♦ ♦ Previous suicide attempt(s) Friend or family member who has committed suicide Personal or family history of depression Previous episode of psychosis Presence of risk factors described above Probe for other depressive symptoms and the immediacy of potential suicidal intent. Sample questions may include the following: ♦ ♦ ♦ ♦ ♦ “It sounds as if you're in great pain. Have you ever thought life is not worth living?” “Do you often think of death?” “Do you think about hurting yourself?” “How might you do that?” “Is this something you feel you might do?” O: Objective ♦ ♦ Perform a mental status examination and suicide assessment. Look for signs of self-inflicted injuries such as wrist lacerations or neck burns.
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Table of Contents Clinical Manual f
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Preface—About this Manual | Clini
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Previous Editions Atlanta Contribut
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♦ ♦ ♦ ♦ ♦ | Clinical Manu
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1-2 | Clinical Manual for Managemen
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Initial Physical Examination Backgr
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Genitals/Rectum • Inspect the gen
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Initial and Interim Laboratory and
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Section 1—Testing and Assessment
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Patient Education ♦ ♦ ♦ ♦ D
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Section 2—Health Maintenance and
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References ♦ ♦ ♦ ♦ ♦ ♦
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Occupational Postexposure Prophylax
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P: Plan Laboratory Testing Provide
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For hepatitis C, no recommended pro
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as hepatitis C or another sexually
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for treatment is appropriate, and b
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contact with the patient. Patients
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tablet daily of trimethoprim-sulfam
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Opportunistic Infection Prophylaxis
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Discontinuing Primary Prophylaxis P
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Latent Tuberculosis Background Late
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INH may cause liver toxicity and it
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Patient Education ♦ ♦ ♦ ♦
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Reducing Maternal-Infant HIV Transm
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Some states require written informe
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contraindicated during pregnancy be
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Section 3—Antiretroviral Therapy
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Nelfinavir (Viracept) Adequate drug
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Section 4—Complications of Antire
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♦ ♦ ♦ Toronto General Hospita
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Adverse Reactions to HIV Medication
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♦ ♦ ♦ ♦ ♦ Vital signs: No
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egimen, symptoms of fatigue could i
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Recreational Drugs and Antiretrovir
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Section 4—Complications of Antire
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LSD, Mescaline, Psilocin, and Methy
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Immune Reconstitution Syndrome Back
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A: Assessment In the appropriate cl
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♦ ♦ ♦ ♦ ♦ Navas E, Martin
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Eye Problems Background The immunos
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of
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Fever Background Although fever may
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Headache Background Headache may ha
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Lymphadenopathy Background Lymphade
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Treatment Treatment will depend on
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Neurologic Symptoms Background The
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Pulmonary Symptoms Background Short
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Treatment Once the diagnosis is mad
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Candidiasis, Oral and Esophageal Ba
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Maintenance therapy Use caution whe
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Cervical Dysplasia Background Cervi
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Patient Education ♦ ♦ ♦ ♦ P
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Cryptosporidiosis Background Crypto
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Gonorrhea and Chlamydia Background
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Treatment of Gonorrhea Treatment op
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Hepatitis B Infection Background He
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Hepatitis C Infection Background He
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pregnancy. Ribavirin is teratogenic
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Herpes Simplex, Mucocutaneous Backg
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References ♦ ♦ ♦ ♦ ♦ Cent
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Kaposi Sarcoma Background Kaposi sa
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Treatment Treatment of KS is not co
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Molluscum Contagiosum Background Mo
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Mycobacterium avium Complex Backgro
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Table 1. Interactions between Rifab
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Mycobacterium tuberculosis: Treatme
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P: Plan Diagnostic Evaluation Durin
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Table 1. Regimens for Treatment of
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Rifabutin may be substituted for ri
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Non-Hodgkin Lymphoma Background Non
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Patient Education ♦ ♦ ♦ ♦ S
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Page 338 and 339: Toxoplasmosis Background Toxoplasma
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