HIV / AIDS
It is estimated that nearly one-third of people with HIV/AIDS experience some peripheral nerve damage. While neuropathy is very common in patients with advanced HIV/AIDS, certain forms of neuropathy like Guillain-Barre Syndrome (GBS) and chronic inflammatory demyelinating polyneuropathy (CIDP) may affect patients in the earlier stages of the disease. For patients with HIV/AIDS, peripheral neuropathy can by caused by the virus itself, by certain drugs used in the treatment of HIV/AIDS or other complications, or as a result of opportunistic infections (e.g., cytomegalovirus [CMV], hepatitis C virus, varicella zoster virus (VZV), syphilis and tuberculosis). Neuropathy could also result from other associated causes, such as autoimmunity, heavy ethanol consumption and vitamin deficiencies (i.e. B12, B1, B6).
Peripheral neuropathy is a potential side effect of certain medications used to treat HIV/AIDS. Nucleoside reverse transcriptase inhibitors (NRTIs), or "d-drugs", are most frequently associated with peripheral neuropathy. This group of drugs includes:
| ddI: |
Didanosine, Videx® |
| ddC: |
Zalcitabine, Hivid® |
| d4T: |
Stavudine, Zerit® |
Other forms of NRTIs (3TC [Epivir®, AZT [Retrovir®], and abacavir [Ziagen®], along with non-nucleoside reverse transcriptase inhibitors (NNRTIs) and protease inhibitors, are not generally associated with peripheral neuropathy.
Other drugs used in the treatment of HIV-related disorders that can increase the chance of developing peripheral neuropathy include:
- Dapsone, used for pneumocystis pneumonia (PCP)
- Isoniazid, (INH, Nydrazid®), used to treat tuberculosis. This medication often results in B6 deficiency.
- Metronidazole (Flagyl®), used to treat amoebic dysentery and microsporidiosis
- Vincristine (Oncovin®), used for Kaposi's sarcoma (KS) and non-Hodgkin's lymphoma Thalidomide, used to treat cancers, wasting syndrome and severe mouth ulcers
- Hydroxyurea (Droxia®, Hydrea®), a drug used to treat cancer that may also help certain anti-HIV drugs work better, appears to increase the risk of peripheral neuropathy.
Peripheral neuropathy caused by these medications can often be treated by reducing the dosage or withdrawing the drug. Although it can take several months for the nerves to completely heal after discontinuing these treatments, the patient may start to feel better within a few weeks. In some cases, the nerve damage may be permanent.
SYMPTOMS
The symptoms of peripheral neuropathy that HIV/AIDS patients usually experience include burning, stiffness, prickling, tingling, and numbness or a loss of feeling in the toes and soles of the feet. Sometimes the nerves in the fingers, hands, and wrists are also affected. Although relatively uncommon, pain above the ankles could indicate more severe nerve damage.
Less commonly, neuropathy presents with progressive weakness. Other symptoms may include dizziness and loss of blabber and bowel control.
EVALUATION AND TESTS
(Not all evaluation and tests may be necessary.)
For peripheral neuropathy:
- Neurological exam
- Nerve conduction study
- Electromyography
- MRI study of appropriate section of the spinal cord
- Blood testing (including assessment for CD4 count, HIV viral load, hepatitis C and CMV antibodies, B12, B1, B6, etc.)
- Spinal fluid examination
TREATMENT AND THERAPY
(Not all treatments and therapies may be indicated.)
- Discontinue drugs that cause peripheral neuropathy
- Institute non-drug treatments to reduce pain, such as:
- Avoiding extended periods of standing or walking
- Wearing looser shoes
- Soaking feet in ice water
- Maintain adequate nutrition
- Take safety measures to compensate for loss of sensation
- Ask your doctor about special therapeutic shoes (which may be covered by Medicare and other insurance)
- Pain medications: painful neuropathy associated with HIV/AIDS is often refractory to treatment and multiple medications are sometimes needed to control the pain.
- Anticonvulsants: gabapentin, pregabalin, lamotrigine.
- Antidepressants: duloxetine, amitryptiline
- Topicals: lidoderm patch, high dose capsaicin
- Analgesics and narcotics: tramadol, morphine, oxycodone, methadone, etc.
- Other medications:
- Intravenous immunoglobin and plasmaphresis are often used in the treatment of GBS and CIDP.
- Treatment for HIV infection (HAART)
- Appropriate treatment for superimposed infections like VZV, CMV.
- Vitamin supplements
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