IDSA GUIDELINES Bundle (free trial)

Treatment ➤ Clinicians might consider a trial of acupuncture for chronic pain (W-M). Values and preferences: This recommendation places a relatively high value on the reduction of symptoms and few undesirable effects. Remark: Evidence to date is available only for acupuncture in the absence of amitriptyline and among PLWH with poorer health in the pre-HAART era. Pharmacological Treatments For Neuropathic Pain Non-Opioids ➤ Early initiation of anti-retroviral therapy (ART) is recommended for the prevention and treatment of HIV-associated distal symmetric polyneuropathy (S-L). ➤ Gabapentin is recommended as a first line oral pharmacological treatment of chronic HIV-associated neuropathic pain (S-M). Remark: A typical adult regimen will titrate to 2,400 mg per day in divided doses. Evidence also supports that gabapentin improves sleep scores — somnolence was reported by 80% of subjects receiving gabapentin (S-L). a. If patients have an inadequate response to gabapentin, clinicians might consider a trial of serotonin-noradrenaline reuptake inhibitors (SNRIs) based on their effectiveness in the general population (W-M). b. If patients have an inadequate response to gabapentin, clinicians might consider a trial of tricyclic antidepressants (W-M). c. If patients have an inadequate response to gabapentin, clinicians might consider a trial of pregabalin for patients with post-herpetic neuralgia (W-M). ➤ Capsaicin is recommended as a topical treatment for the management of chronic HIV-associated peripheral neuropathic pain (S-H). Remark: A single 30-minute application of an 8% dermal patch or cream administered at the site of pain can provide pain relief for at least 12 weeks. Erythema and pain are common side effects for which a 60-minute application of 4% lidocaine can be applied and wiped off before applying capsaicin (S-H). ➤ Medical cannabis may be an effective treatment in appropriate patients (W-M). Values and preferences: This recommendation places a relatively high value on the reduction of symptoms and a relatively low value on the legal implication of medical cannabis possession. Remark: Current evidence suggests medical cannabis may be more effective for patients with a history of prior cannabis use, and the potential benefits of a trial of cannabis need to be balanced against the potential risks of neuropsychiatric adverse effects at higher doses, the harmful effects of smoked forms of cannabis in patients with pre-existing severe lung disease, and addiction risk to patients with cannabis use disorder. ➤ The IDSA recommends alpha lipoic acid (ALA) for the management of chronic HIV-associated peripheral neuropathic pain (S-L). Values and preferences: This recommendation places a high value on providing tolerable medications which may be of some benefit in patients with difficult-to-treat neuropathic pain. Remark: Studies in patients with HIV are lacking. However, there is a growing body of literature of the benefits of ALA in patients with diabetic neuropathy.

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