What prescription and treatment approach is recommended for a patient with leg pain, sleeplessness, and low energy, who is also HIV (Human Immunodeficiency Virus) positive?

Treatment Approach for HIV-Positive Patient with Leg Pain, Sleeplessness, and Low Energy

A multimodal treatment approach is strongly recommended for HIV-positive patients with leg pain, sleeplessness, and low energy, with gabapentin as first-line pharmacological treatment for neuropathic pain, combined with non-pharmacological interventions including cognitive behavioral therapy and physical therapy. 1

Initial Assessment

• A comprehensive pain assessment should include evaluation of pain onset, duration, intensity, character, exacerbating/alleviating factors, past treatments, and effect on physical and psychological function 1
• Use the PEG (Pain intensity, Enjoyment of life, General activity) assessment tool to evaluate pain in busy HIV clinical settings 1
• Screen for depression using the two-question approach: feeling down/depressed/hopeless and little interest/pleasure in activities 1
• Assess for HIV-associated neurocognitive disorder, which may contribute to low energy and cognitive complaints 2

Pharmacological Management for Leg Pain

For Neuropathic Pain (if suspected):

• Gabapentin is recommended as first-line treatment for HIV-associated neuropathic pain 1

  • Titrate to 2400 mg per day in divided doses
  • Has additional benefit of improving sleep scores (reported in 80% of patients) 1

• If inadequate response to gabapentin:

  • Consider serotonin-norepinephrine reuptake inhibitors 1
  • Consider tricyclic antidepressants 1
  • Consider pregabalin for post-herpetic neuralgia 1, 3
  • Consider alpha lipoic acid (ALA) 1

• Topical treatments:

  • Capsaicin 8% dermal patch or cream for peripheral neuropathic pain 1
  • Apply 4% lidocaine for 60 minutes before capsaicin to reduce application pain 1

For Musculoskeletal Pain (if suspected):

• Acetaminophen and NSAIDs are recommended as first-line agents 1

  • Use lower acetaminophen dosing for patients with liver disease
  • Consider cardiovascular risk with COX-2 NSAIDs

• If inadequate response to first-line agents:

  • Tramadol may be considered for osteoarthritis (37.5-400 mg in divided doses) 1

Non-Pharmacological Interventions

• Cognitive behavioral therapy (CBT) is strongly recommended for chronic pain management 1

  • Promotes patient acceptance of responsibility and development of adaptive behaviors

• Physical therapy is recommended for chronic pain 1

  • Focuses on restoring function and improving quality of life

• Yoga is recommended for chronic neck/back pain, headache, and general musculoskeletal pain 1

• Consider hypnosis for neuropathic pain 1

• Consider acupuncture as a trial for chronic pain 1

Management of Sleep Disturbances

• Gabapentin can address both pain and sleep disturbances 1

• Ensure proper sleep hygiene practices 1

• Address any pain that may be disrupting sleep 1

Management of Low Energy

• Evaluate for depression, which may contribute to low energy 1

  • Use PHQ-9 for diagnosis if positive on initial screening
  • Consider psychiatric follow-up for PHQ-9 score ≥10

• Assess medication regimen complexity, as complex regimens may contribute to fatigue and reduced adherence 4

• Ensure optimal HIV treatment with early initiation of antiretroviral therapy 1

Special Considerations

• Involve an interdisciplinary team for complex chronic pain management, especially with co-occurring substance use or psychiatric disorders 1

• Assess for risk of opioid misuse before prescribing opioid analgesics 1

  • Opioids should not be first-line for chronic neuropathic pain in HIV patients 1
  • Consider time-limited trials only for moderate-to-severe pain that doesn't respond to first-line therapies

• Regular reassessment of pain, function, and treatment efficacy is essential 1

Cautions and Pitfalls

• Avoid lamotrigine for HIV-associated neuropathic pain 1

• Be aware that HIV patients may have higher medication regimen complexity, which can affect adherence 4

• Screen for neurocognitive disorders before and during long-term opioid therapy 1

• New pain symptoms in patients with controlled chronic pain should be thoroughly investigated, as they may indicate new pathology or medication adverse effects 1

• Consider potential drug interactions between pain medications and antiretroviral therapy 1