Managing HIV peripheral neuropathy

Abstract

Peripheral nerve disorders are frequent complications of HIV disease. Distal symmetrical polyneuropathy (DSP) is the most common peripheral nerve disorder associated with HIV and occurs in over one third of infected patients but may occur in up to 67% if asymptomatic patients are included. Risk factors for DSP include increased age, advanced HIV disease, and history of "d-drugs" or other neurotoxic drugs. The primary manifestations of polyneuropathy are slowly progressive numbness and paresthesias, with burning sensations in the feet usually in a symmetrical pattern. The etiology of HIV-associated DSP is unknown, although neurotoxic effects of cytokines, toxicity of HIV proteins, and mitochondrial damage have been implicated. The current treatment for HIV-associated DSP is symptomatic, with pain modifying medications, including anti-inflammatory agents, opioids, antidepressants, antiepileptics, topical anesthetics, and capsaicin. Sustained virologic control may improve DSP. Novel therapies such as -acetyl-l-carnitine or neurotrophic factors are being studied for treatment of DSP.

Pain in Selected Neurologic Disorders

“…6 Allodynia may be experienced during ambulation and can be debilitating. In addition to the neuropathies associated with primary HIV infection, antiretroviral agents may be neurotoxic.…”

Initiating antiretrovirals during tuberculosis treatment: a drug safety review

“…Almost half (43%) of the 842 single-stavudine substitutions in this analysis were attributed to peripheral neuropathy and these patients were more likely to be on TB treatment at ART initiation or during follow-up (relative risk (RR) 1.53, 95% CI 1.33–1.75). Isoniazid is the TB drug most likely to be associated with peripheral neuropathy [101] as are the ARVs stavudine [102] and didanosine [103]. …”

Acu/Moxa for Distal Sensory Peripheral Neuropathy in HIV: A Randomized Control Pilot Study

“…Distal sensory peripheral neuropathy (DSP) continues to be a prevalent complication associated with HIV (Ellis et al, 2010; Evans et al, 2011; Gonzalez-Duarte, Cikurel, & Simpson, 2007; Nicholas et al, 2010), despite medications effective in suppressing viral replication (Ances & Ellis, 2007; Evans et al, 2011; McArthur, Brew, & Nath, 2005). The pathogenesis of DSP in HIV is uncertain, but proposed mechanisms include cytokine dysregulation, viral protein-produced neurotoxicity, and mitochondrial dysfunction associated with antiretroviral medications (Cornblath & Hoke, 2006; Gonzalez-Duarte et al, 2007; Simpson, Estanislao, Brown, & Sampson, 2008).…”

“…The pathogenesis of DSP in HIV is uncertain, but proposed mechanisms include cytokine dysregulation, viral protein-produced neurotoxicity, and mitochondrial dysfunction associated with antiretroviral medications (Cornblath & Hoke, 2006; Gonzalez-Duarte et al, 2007; Simpson, Estanislao, Brown, & Sampson, 2008). DSP occurs in an estimated 30% to 35% of persons with HIV, causing painful dysesthesias, numbness, and “pins and needles” sensations, predominantly in the feet (Centers for Disease Control and Prevention, 1993; Ferrari et al, 2006; Nicholas et al 2002; Schifitto et al, 2002; Verma, Estanislao, & Simpson, 2005).…”

“…Studies of treatments to manage the neuropathic pain have largely focused on pharmacologic therapy such as nonsteroidal anti-inflammatory drugs (NSAIDs), tricyclic antidepressants, opioids, anticonvulsants, and topical analgesics (Dworkin et al, 2010; Gonzalez-Duarte et al, 2007; Keswani, Pardoa, Cherry, Hokea, & McArthur, 2002). Placebo-controlled trials have found these agents to be limited in efficacy and inconsistent in benefit for the symptoms of DSP (Silver, Blum, Grainger, Hammer, & Quessy, 2007; Simpson et al, 2010).…”