➤ The IDSA recommends against using lamotrigine to relieve HIV-associated
neuropathic pain (S-M).
Values and preferences: This recommendation places a relatively high value on the
discontinuation of neurotoxic agents and minimizing the incidence of lamotrigine-associated
rash and places a relatively low value on the reduction in pain symptoms found in an earlier
RCT by the same authors.
Remark: A benefit was seen only in patients currently receiving neurotoxic ART, and the
IDSA recommends discontinuing all neurotoxic ART.
Opioids
➤ For persons living with HIV, opioid analgesics should NOT be prescribed
as a first line agent for the long-term management of chronic neuropathic
pain (S-M).
Values and preferences: This recommendation places a relatively high value on potential
risk of pronociception through the up-regulation of specific chemokine receptors, cognitive
impairment, respiratory depression, endocrine and immunological changes, and misuse and
addiction.
➤ Clinicians may consider a time-limited trial of opioid analgesics for
patients who do not respond to first line therapies and who report
moderate to severe pain. As a second or third line treatment for chronic
neuropathic pain, a typical adult regimen should start with the smallest
effective dose and combine short- and long-acting opioids (W-L).
Remark: When opioids are appropriate, a combination regimen of morphine and gabapentin
should be considered in patients with neuropathic pain for their possible additive effects and
lower individual doses required of the two medications when combined.
Pharmacological Treatments For Non-Neuropathic Pain
Non-Opioids
➤ Acetaminophen and NSAIDS are recommended as first-line agents for the
treatment of musculoskeletal pain (S-H).
Remark: Acetaminophen has fewer side effects than NSAIDS. Studies typically used 4 grams/
day dosing of acetaminophen. Lower dosing is recommended for patients with liver disease.
Compared to traditional NSAIDS, COX-2 NSAIDs are associated with decreased risk of
gastrointestinal side effects but increased cardiovascular risk.
Opioids
➤ Patients who do not respond to first line therapies and who report
moderate to severe pain and functional impairment can be considered for
a time limited trial of opioid analgesics (W-L).
Values and preferences: This recommendation places a relatively high value on safer opioid
prescribing. The potential benefits of opioid analgesics need to be balanced with the potential
risks of adverse events, misuse, diversion, and addiction.
Remark: As a second or third line treatment for chronic non-neuropathic pain, a typical adult
regimen should start with the smallest effective dose, combining short- and long-acting opioids.
