Transcript Palliative Issues in HIV/AIDS

Palliative Care in HIV/AIDS
http://hivmanagement.org/palliative.html
James A Zachary MD
LSU Health Sciences Center
Delta AETC
December 13, 2004
• Identify palliative care issues
involved with HIV/AID
• Discuss tools of palliation
• Hospice: purpose, goals, methods,
identifcation of barriers &
overcoming them
• Case presentations
• The Hospice Rx
HIV/AIDS Palliative Care Issues
• Dermatomal herpes zoster
– 15x higher incidence than uninfected
• Post herpetic neuralgia
– Approx 20% incidence without HIV
– Increased incidence with HIV
• Distal sensory polyneuropathy 1040%
– HIV, drugs, infection (e.g. CMV)
HIV/AIDS Palliative Care Issues
• Miscellaneous pain
– Chronic musculoskeletal
pain especially spinal pain
– Chronic headaches
– Trauma-related injuries
– Chronic post-operative
pain
Pain Control Basics
• Believe the patient!
• Thoroughly evaluate pain
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History and physical
Blood testing
Imaging
Consultants
• Always treat the cause if possible
• Pain control during work-up and until resolved
• Close follow-up!!!!
WHO Analgesic Ladder
Acute Pain
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Apply analgesic ladder principle
Short acting analgesics
Adjuvant therapy with gabapentin
Avoid constipation
Examples: acute herpes zoster,
acute headache
Acute Pain
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NSAIDs
Buprenorphene IM
Tramodol
Merperidine
Codeine/acetaminophen
Hydrocodone/acetaminophen or
ibuprofen
Oxycodone/acetaminophen or aspirin
Oxycodone
Hydromorphone
Immediate release morphine sulfate
Chronic Pain
Pain >48 hours
• Begin with adequate supply of short acting
analgesic: avoid acetaminophen
combination drugs
– Oxycodone tablets or suspension
– Morphine sulfate immediate release
liquid or tablets
• Allow patient to re-administer (and
slowly escalate) every 2-4 hours
• At the end of 24-48 hours, begin a longacting opiate based on the previous 24 hour
dosage of short-acting analgesic and
continue short-acting
Chronic Pain
Pain >48 hours
• Extended release morphine
– MS Contin, Oramorph, generics: q8-12 hours
– Avinza, Kadian: q24 hour
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Extended release oxycodone: OxyContin
Transdermal fentanyl
Methadone
Buprenorphene sublingual*
Neuropathic Pain
• Description: lancinating, numbness,
burning, itching
• Palliative options
– Nerve blocks – not too practical
– Topical lidocaine (Lidoderm)
– Gabapentin (or levacetram) up to
5600 mg per day or more
– Opiates
Opiates
• Use a consistent approach to your pain
assessment such as asking the patient to
use the 1-10 scale
• Document clearly that you are doing your
best to diagnose and treat the pain
• Don’t prescribe on the first visit with a
new patient unless source of pain is very
clear
• Addiction seldom occurs when used for
pain control.
Pain In Addicts
• Higher incidence of pain in addiction
• Same principles apply as in nonaddicted
patients
• Consider a pain contract
• Consider urine toxicology testing if
suboptimal results are achieved
– Look for prescribed substances
primarily
– Evaluate and treat for nonprescribed
substances as you would normally
Pain In Addicts
Pain In Addicts
• Higher incidence of pain in addiction
• Same principles apply as in nonaddicted
patients
• Consider a pain contract
• Consider urine toxicology testing if
suboptimal results are achieved
– Look for prescribed substances
primarily
– Evaluate and treat for nonprescribed
substances as you would normally
Pain In Addicts
• Boundary issues are extremely
important!
• Consider a Pain Management
referral
• Consider a Mental Health
referral
Opiates
• Avoid constipation!
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Senna + stool softener = Senokot
Lactulose
Go-lytely or Miralax
Sorbitol
• To control possible nausea provide
an antiemetic such as promethazine
or metoclopropamide and
administer it on a schedule
HIV/AIDS Palliative Care Issues
• Nausea
– Drugs
– CNS processes: meningitis, abscess,
tumor, increased intracranial pressure,
motion sickness
– Metabolic processes: hepatitis, adrenal
insufficiency
– GI: pancreatitis, gastritis, PUD, KS,
microsporidiosis, cryptococcosis,
CMV, DMAC
Nausea Control
• Be aggressive in approach!
• Diagnose and treat underlying cause if
possible
• Prevent nausea: much easier than
suppressing it once started!
Nausea Control
• Phenothiazines: promethazine (Phenergan),
prochlorperazine (Compazine), etc.
• Metoclopropamide (Reglan)
• Ondansetron (Zofran), granisetron (Kytril)
• Dranabinol (Marinol)
• Lorazepam
• Haloperidol (Haldol)
• Dexamethasone (Decadron)
Conclusions
• Palliate aggressively even during active care
• Close follow-up is probably helpful to patient and
provider
• The approach and treatment of the addicted patient
is fundamentally no different from that of any
other patient.
• The use of opiates can be simple and safe.
• Adjuvant drugs such as gabapentin should be
frequently considered.