2017 Guidelines for Chronic Pain Management in Patients with HIV

Patients with HIV should be assessed for chronic pain and offered pain management options, according to recently-published guidelines released by the HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America (IDSA).

The guidelines, which provide comprehensive recommendations on HIV and chronic pain, suggest that patients who screen positive should be offered a variety of pain management options, starting with nondrug treatment such as cognitive behavioral therapy, yoga, and physical therapy. A patient who screens positive should also undergo comprehensive evaluation, including a physical exam, psychosocial evaluation, and diagnostic testing, according to the guidelines.

The recommendations suggest that health care providers screen all patients with HIV for chronic pain by asking the questions:

• How much bodily pain have you had during the week?
• Do you have bodily pain that has lasted more than 3 months?

Although non-pharmacological therapies are recommended as the first treatment option, the guidelines suggest starting with a treatment other than opioids is preferred if medication is needed. The recommended pharmacological treatments include:

• Early initiation of antiretroviral therapy (strong, low).
• Gabapentin as a first-line oral pharmacological treatment of chronic HIV-associated neuropathic pain (strong, low).
• Capsaicin as a topical treatment for the management of chronic HIV-associated peripheral neuropathic pain (strong, high).
• Medical cannabis (weak, moderate).
• Alpha lipoic acid for the management of chronic HIV-associated peripheral neuropathic pain (strong, low).

Additionally, the guidelines advise against using lamotrigine to relieve HIV-associated neuropathic pain.

If patients have an inadequate response to gabapentin, health care providers can consider:

• Serotonin-norepinephrine reuptake inhibitors based on their effectiveness in the general population (weak, moderate).
• Tricyclic antidepressants (weak, moderate).
• Pregabalin for patients with post-herpetic neuralgia (weak, moderate).

For the treatment of musculoskeletal pain in patients with HIV:

• Acetaminophen and nonsteroidal anti-inflammatory drugs are recommended as first-line agents (strong, high).

If patients do not respond to first-line therapies, the guidelines note that tramadol taken for up to 3 months may decrease pain and improve stiffness, function, and overall well-being in patients with osteoarthritis (weak, moderate). The range of dosing studied is 37.5 mg (combined with 325 mg of acetaminophen) once daily to 400 mg in divided doses.

According to the guidelines, HIV health care providers should participate in interdisciplinary care teams to help manage and treat patients with chronic pain, especially for patients with co-occurring substance use or psychiatric disorders. The authors concluded that additional studies are needed to confirm the optimal nonpharmacological and pharmacologic treatment for HIV-associated chronic pain.

The comprehensive online version of the guidelines can be found here.

Reference

Bruce RD, Merlin J, Lum PJ, et al. 2017 HIVMA of IDSA clinica practice guideline for the management of chronic pain in patients living with HIV. Clin Infect Dis. 2017. https://doi.org/10.1093/cid/cix636