HIVMA Releases New Guideline for Chronic Pain in HIV

October 1, 2017
Kenneth Bender

A new guideline from the Infectious Diseases Society of America addresses management of chronic pain in patients living with HIV.

The first comprehensive clinical practice guideline for the management of chronic pain in patients living with HIV has been released by the HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America (IDSA).

The guideline’s lead author, Douglas Bruce (pictured), MD, the chief of medicine at Cornell Scott-Hill Health Center and an associate clinical professor of medicine at Yale University, described the rationale for the guideline in a statement, citing the struggles of HIV patients.

"Because HIV clinicians typically are not experts in pain management, they should work closely with others, such as pain specialists, psychiatrists, and physical therapists to help alleviate their patients' pain," Bruce said. "These comprehensive guidelines provide the tools and resources HIV specialists need to treat these often-complex patients, many of whom struggle with depression, substance use disorders, and have other health conditions such as diabetes."

Estimates of the prevalence of chronic pain in patients living with human immunodeficiency virus (PLWH) referenced in the guideline range from 39% to 85%, with pain ranked as the second most common symptom presented by PLWH in ambulatory treatment settings. Almost half of pain presentations are found to be neuropathic, from neural damage directly from the viral infection or injury from secondary infection.

The guideline notes that pain symptoms in this population have historically been under-treated, particularly among women, persons with low socioeconomic status, and persons who inject drugs. This pattern can be rectified, however, and the guideline encourages increased attention to pain symptoms, and application of evidence-based interventions.

"Those who treat patients with HIV must be familiar with the evaluation and management of chronic pain," the guideline states. "Although chronic pain management is recognized as a specialty discipline within medicine, many patients lack access to specialized pain management services and must rely on their HIV clinical providers to initially evaluate and address their chronic pain needs."

Treatment recommendations in the guideline are based on data in the literature and are presented with different levels of strength and graded quality of the evidence. The guide qualifies this format, however, as a large limitation in the literature necessitate that some strong recommendations do not correspond to high-quality evidence.

The first recommendation is that all PLWH should receive screening for chronic pain, which can be accomplished with as simple an approach as posing 2 questions: "How much bodily pain have you had during the last week?" and "Do you have bodily pain that has lasted for more than 3 months?"

Subsequent interventions for those screening positive for chronic pain should incorporate biopsychosocial approaches, according to the guideline, with interdisciplinary treatment and monitoring. Nonpharmacologic treatments that are recommended include cognitive behavioral therapy (CBT), as well as a range of other strategies with less available supportive evidence such as yoga and physical and occupational therapy.

Recommended pharmacological interventions include the early initiation of antiretroviral therapy to prevent and treat HIV-associated distal symmetric polyneuropathy. Gabapentin is recommended as the first-line oral pharmacological treatment of chronic HIV-associated neuropathic pain, with the direction to titrate to a minimum of 2400mg per day in divided doses to achieve a therapeutic response. Second-line alternatives include the serotonin-norepinephrine reuptake inhibitor or tricyclic antidepressants, as well as pregabalin (Lyrica, Pfizer).

Topical capsaicin is also strongly recommended for peripheral neuropathic pain, with the guideline indicating that a single 30-minute application of an 8% dermal patch or cream administered at the site of pain has been reported to provide pain relief for several weeks. It suggests that application and removal of 4% lidocaine before the capsaicin can reduce localized erythema and pain associated with the capsaicin.

The guideline address utility of cannabis, which it indicates can be an effective treatment in appropriate patients. It also incorporates much of the current guidance on the conservative use of opioids, agreeing with recommendations that these should not be considered first-line agents.

"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 doses required of the two medications when combined," the guideline recommends.