eMedicine Specialties > Neurology > Neurological Infections
HIV-1 Associated Distal Painful Sensorimotor Polyneuropathy: Treatment & Medication
Updated: Feb 23, 2007
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
Treatment options fall into 2 groups: causal and symptomatic.
- Causal treatment
- Avoid neurotoxic medications, if possible.
- Correct vitamin B-12 and folate deficiency.
- Consider thiamine replacement if malnourished.
- Symptomatic treatment of painful dysesthesias is discussed in the Medication section.
Diet
A well-balanced diet is recommended to prevent vitamin deficiency.
Medication
Some antidepressants, anticonvulsants, and antiarrhythmics control neuropathic pain.
Tricyclic antidepressants
TCAs are effective in painful paresthesias. While dosages are similar, drugs in this category vary in their sedative properties. Amitriptyline can be used if the patient suffers from insomnia, while nortriptyline and desipramine are better choices when sedation becomes a problem.
Amitriptyline (Elavil)
Increases synaptic concentration of serotonin and norepinephrine by reuptake inhibition at presynaptic neuronal membrane; dose may be increased slowly, until pain relief or intolerable side effects occur; doses >125 mg qhs rarely are helpful; if no response, a different TCA may be tried, but drugs from a different category such as anticonvulsants are usually preferable.
Adult
Starting dose: 10-25 mg PO qhs; increase prn, as tolerated, in 3-7-d intervals and 25-mg steps up to 125 mg PO qhs; >75 mg obtain ECG before each further dose increase to rule out AV block
Pediatric
Children: 0.1 mg/kg PO qhs; increase, as tolerated, over 2-3 wk to 0.5-2 mg/kg PO qhs
Adolescents: Starting dose of 25 mg PO qhs; increase gradually to 100 mg qhs
Metabolized by the P 450 2D6 system; drugs that inhibit this enzyme system (eg, cimetidine, quinidine) may increase tricyclic levels; phenobarbital may increase metabolism of amitriptyline and decrease efficacy; blocks uptake of guanethidine and prevents its hypotensive actions; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram
Documented hypersensitivity; in patients with AV block or who have taken MAOIs or fluoxetine in the past 14 d
Pregnancy
D - Unsafe in pregnancy
Precautions
Caution in patients with seizures, renal or hepatic impairment, cardiac disease, conduction disturbances, cognitive impairment, urinary retention, hyperthyroidism, or who receive thyroid hormones; particular caution in older patients; less sedative drugs may be tolerated better
Nortriptyline (Aventyl HCl, Pamelor)
Demonstrated effectiveness in neuropathic pain; increases synaptic concentration of serotonin and norepinephrine by reuptake inhibition at presynaptic neuronal membrane; additional pharmacodynamic effects such as desensitization of adenyl cyclase and downregulation of beta-adrenergic and serotonin receptors appear to be involved.
Adult
Starting dose: 10-25 mg PO qhs; increase prn, as tolerated, in 3-7 d intervals and in 25-mg steps to about 125 mg qhs; >75 mg obtain ECG before each further dose increase to rule out AV block
Pediatric
25-35 kg: 10-20 mg PO qhs
35-54 kg: 25-35 mg PO qhs
Cimetidine may increase levels when used concurrently; may increase PT in patients on warfarin
Documented hypersensitivity; in patients with AV block or who have taken MAOIs or fluoxetine in the past 14 d
Pregnancy
D - Unsafe in pregnancy
Precautions
Caution in patients with seizures, renal or hepatic impairment, cardiac disease, conduction disturbances, cognitive impairment, urinary retention, hyperthyroidism, or who receive thyroid hormones; particular caution in older patients; less sedative drugs may be tolerated better
Desipramine (Norpramin)
Useful for neuropathic pain; may increase synaptic concentration of norepinephrine by reuptake inhibition at presynaptic neuronal membrane; may desensitize adenyl cyclase and downregulate beta-adrenergic and serotonin receptors.
Adult
Starting dose: 10-25 mg PO qhs; increase prn, as tolerated, in 3-7 d intervals and in 25-mg steps to about 125 mg PO qhs; >75 mg obtain ECG before each further dose increase to rule out AV block
Pediatric
<12 years: Not established
>12 years: Initially 25 mg PO qhs; gradually increase to 100 mg PO qhs
Decreases antihypertensive effects of clonidine but increases effects of sympathomimetics and benzodiazepines; phenytoin, carbamazepine, and barbiturates decrease effects
Documented hypersensitivity; in patients that have taken MAOIs or fluoxetine in the past 14 d
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Caution in patients with seizures, renal or hepatic impairment, cardiac disease, conduction disturbances, cognitive impairment, urinary retention, hyperthyroidism, or who receive thyroid hormones; particular caution in older patients
Anticonvulsants
Gabapentin alleviates painful dysesthesias and spasms. It is well tolerated with a wide dose range. Drug levels are not available, indicated, or meaningful. Lamotrigine has been shown to be effective in distal painful sensorimotor polyneuropathy but not ATN.
Gabapentin (Neurontin)
Shares pharmacologic properties with other anticonvulsants; exact mechanism of action is unknown; structurally related to GABA but does not interact with GABA receptors.
Adult
Start at low dose as described to minimize side effects:
Day 1-3: 300 mg PO qd
Day 4-6: 300 mg PO bid
Day 7-9: 300 mg PO tid
Day 10-12: 600 mg PO qam, 300 mg PO qpm, 300 mg PO qhs
Day 13-15: 600 mg PO qam, 300 mg PO qpm, 600 mg PO qhs
Day >16: 600 mg PO tid
Following this regimen, increase prn, as tolerated, not to exceed 1200 mg PO tid; younger, otherwise fairly healthy individuals often tolerate faster dose increase; dose needs to be adjusted for renal impairment
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Antacids may reduce bioavailability of gabapentin by about 20%; administer at least 2 h after antacid administration; cimetidine may reduce gabapentin clearance but this may not be of clinical significance; may increase norethindrone levels by 13%
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Caution in patients with severe renal disease; may cause sedation, although less commonly than with tricyclic antidepressants; occasionally efficacy decreases after several weeks; may necessitate further dose increase
Carbamazepine (Tegretol, Carbatrol, Epitol)
Has antineuralgic effects; may depress activity of the nucleus ventralis of the thalamus or decrease synaptic transmission or summation of temporal stimulation by limiting influx of sodium ions across cell membrane or by other unknown mechanisms.
Adult
Initial dose: 200 mg PO bid; increase gradually prn over 2-wk interval to 200 mg PO tid; target blood serum concentrations are 4-12 mg/L
Sustained release dosing: Therapeutic dose bid
Pediatric
<6 years: Initially 10-20 mg/kg/d PO; titrate dose prn
6-12 years: Initially 100 mg PO bid; titrate dose prn
>12 years: Initially 200 mg PO bid; titrate dose prn
May interact with many drugs including cyclosporine, oral contraceptives, TCAs, warfarin, phenytoin, doxycycline, neuroleptics, fentanyl, calcium channel blockers, macrolide antibiotics, isoniazid, cimetidine, lamotrigine, and propoxyphene
Documented hypersensitivity; bone marrow suppression; MAOIs
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Discontinue MAOIs for a minimum of 14 d before carbamazepine is begun; caution in patients with history of cardiac damage or hepatic disease; blood cell abnormalities have been reported following treatment with this medication; check CBC once or twice a year; may worsen seizures in persons with primary generalized epilepsy and atypical absence seizures; 0.5-1% risk of spina bifida in children born to mothers who take carbamazepine during pregnancy
Lamotrigine (Lamictal)
Triazine derivative useful in treatment of neuralgia. Inhibits release of glutamate and inhibits voltage-sensitive sodium channels, which stabilizes neuronal membrane. Follow manufacturer's recommendation for dose adjustments.
Adult
Monotherapy: 50-100 mg/d PO divided bid initial dose; 100-400 mg/d PO qd or divided bid maintenance; not to exceed 500 mg/d
Adjunct therapy with valproic acid: 25 mg PO qod initial dose; 50-200 mg/d PO qd or divided bid maintenance; not to exceed 200 mg/d
Pediatric
2-12 years:
Monotherapy
Weeks 1-2: 0.6 mg/kg/d PO divided bid, rounded down to nearest 5 mg
Weeks 3-4: 1.2 mg/kg/d PO divided bid, rounded down to nearest 5 mg
Maintenance: 5-15 mg/kg/d PO; not to exceed 400 mg/d divided bid; to achieve usual maintenance dose, increase subsequent doses q1-2wk as follows: calculate 1.2 mg/kg/d and round down to nearest 5 mg; add this amount to previously administered daily dose
Concomitant therapy with valproic acid
Weeks 1-2: 0.15 mg/kg/d PO qd or divided bid, rounded down to nearest 5 mg; if initial calculated daily dose is 2.5-5 mg, then take 5 mg on alternate days for first 2 wk
Weeks 3-4: 0.3 mg/kg/d PO qd or divided bid, rounded down to nearest 5 mg
Maintenance: 1-5 mg/kg/d PO; not to exceed 200 mg/d PO qd or divided bid; to achieve usual maintenance dose, increase subsequent doses q1-2wk as follows: calculate 0.3 mg/kg/d and round down to nearest 5 mg; add this amount to previously administered qd dose
>12 years:
Monotherapy
Weeks 1-2: 50 mg/d PO
Weeks 3-4: 100 mg/d PO divided bid
Maintenance: 300-500 mg/d PO divided bid; to achieve maintenance, increase by 100 mg/d q1-2wk
Concomitant therapy with valproic acid Weeks 1-2: 25 mg PO qod
Weeks 3-4: 25 mg PO qd
Maintenance: 100-400 mg/d PO qd or divided bid; to achieve maintenance, increase by 25-50 mg/d PO q1-2wk
Acetaminophen increases renal clearance of medication, decreasing effects; similarly, phenobarbital and phenytoin increase lamotrigine metabolism, causing a decrease in lamotrigine levels; administration of valproic acid with lamotrigine increases half-life; succinimide anticonvulsants (eg, methsuximide, phensuximide) decrease lamotrigine levels
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Use appropriate dosing if used concurrently with valproic acid; caution in impaired renal or hepatic function; need to warn patients of potential rash (Stevens-Johnson syndrome)
Topical anesthetics
These agents are used to induce localized analgesia.
Lidocaine (Lidoderm 5% patch)
Several recent studies have advocated topical administration of lidocaine as treatment of PHN. In placebo-controlled study, lidocaine gel (5%) showed significant relief in 23 patients. By contrast, The Lidoderm-HIV Neuropathy Group showed that lidocaine 5% gel was ineffective in the treatment of pain associated with HIV distal painful sensorimotor polyneuropathy.
Adult
Apply to affected area prn
Leave on for 12 h, then remove patch for 12 h between applications
Pediatric
Not established
Coadministration with cimetidine or beta-blockers, increases toxicity of lidocaine; coadministration with procainamide and tocainide may result in additive cardiodepressant action; may increase effects of succinylcholine
Documented hypersensitivity to amide-type local anesthetics; avoid in Adams-Stokes syndrome and Wolf-Parkinson-White syndrome; avoid in severe sinoatrial, atrioventricular (AV), or intraventricular block, if artificial pacemaker not in place
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Use a solution without preservatives; caution in heart failure, hepatic disease, hypoxia, hypovolemia or shock, respiratory-depression and bradycardia; may increase risk of CNS and cardiac side effects in elderly persons; high plasma concentrations can cause seizures, heart block, and AV conduction abnormalities
Capsaicin (Dolorac, Zostrix)
Natural chemical derived from plants of Solanaceae family. Penetrates deep for temporary relief of minor aches and pains of muscles and joints associated in inflammatory reactions. May render skin and joints insensitive to pain by depleting substance P in peripheral sensory neurons. Has demonstrated effectiveness in several studies of diabetic neuropathic pain and in other types of neuropathic pain.
Adult
Apply to affected area tid/qid for 3-4 consecutive wk and evaluate efficacy; not to exceed 4 applications/d; wash hands with soap and water after applying
Pediatric
Not established
None reported
Documented hypersensitivity; broken or irritated skin
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
For external use only; avoid contact with eyes; do not use tight bandage; discontinue use if condition worsens or symptoms persist for 14-28 d
More on HIV-1 Associated Distal Painful Sensorimotor Polyneuropathy |
| Overview: HIV-1 Associated Distal Painful Sensorimotor Polyneuropathy |
| Differential Diagnoses & Workup: HIV-1 Associated Distal Painful Sensorimotor Polyneuropathy |
 Treatment & Medication: HIV-1 Associated Distal Painful Sensorimotor Polyneuropathy |
| Follow-up: HIV-1 Associated Distal Painful Sensorimotor Polyneuropathy |
| References |
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References
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Further Reading
Keywords
acquired immunodeficiency syndrome, AIDS, HIV-1 associated peripheral neuropathy, HIV infection, neurotoxic drugs, vitamin deficiencies, nutritional deficiencies, drug toxicity, didanosine, stavudine, zalcitabine, lamivudine
