HIV Related Peripheral Neuropathy

Peripheral neuropathy is a painful condition that is caused by damage to the nerves in the peripheral nervous system, which includes the nerves that run from the brain and the spinal cord to the arms, hands, legs, and feet. The damaged nerves alter sensations and feelings such as pain, temperature, and touch. Peripheral neuropathy occurs frequently with HIV disease and can result in a great deal of pain. It greatly impacts the quality of life of an HIV positive person, often leading to isolation and depression. It is reported in approximately 1/3 of patients who are AIDS diagnosed, but it can occur at any stage of HIV disease including the acute seroconversion stage and the latent (asymptomatic) period.

Causes of peripheral neuropathy:
Peripheral neuropathy is often a side effect of the medications used to treat HIV, but can also be caused by HIV infection itself. Neuropathy can also be caused by vitamin deficiencies (vitamin B12, folate), diabetes, or thyroid abnormalities. Alcohol abuse, older age (greater than 50), and low CD4+cell counts are also assosiated with an increased incidence of peripheral neuropathy.

Drugs that cause peripheral neuropathy:

• Videx (didanisone, ddi), antiretroviral medication used to treat HIV
  
• Zerit (stavudine, d4t), antiretroviral medication used to treat HIV
• Dapsone, used to treat or prevent PCP pneumonia
• Metronidazole (flagyl), antibiotic
• Isoniazid (INH), antibiotic used to treat tuberculosis
  
• Pyridoxine (vitamin B6)
• Ethambutol (used to treat MAC infection)
• Vincristine (chemotherapy to treat Kaposi's sarcoma)
• Hydroxyurea
  
• ALCOHOL
  

Symptoms of peripheral neuropathy:
The earliest symptoms of peripheral neuropathy are pain, numbness, and tingling in the hands and feet in the classic "sock and glove" distribution. The pain is often described as burning, shooting, electric-shock like, throbbing, or aching. Some people describe an altered sensation when picking up objects, as if their fingers are "made of plastic", or feelings of their hands and feet falling asleep. The patient may complain of their feet throbbing or cramping at night or of stumbling when they try to walk. The symptoms are generally symmetric (occur on both sides of the body), although they may be more severe on one side. If the neuropathy is severe, touching the affected extremity can feel like an open wound is being touched. In the most severe cases, severe pain and dysfunction of the nerves can result in difficulty walking and disability.

Diagnosis of peripheral neuropathy:
The diagnosis of peripheral neuropathy can generally be made by a healthcare provider who is experienced in the treatment of HIV disease based on a history of the symptoms and a comprehensive physical examination which includes testing of the reflexes and evaluation of the sense of vibration,touch, pressure, and pain in the extremities. Bloodwork will be done to check CD4+ cell count, HIV viral load, blood glucose (sugar), thyroid function, Vitamin B1, B6, and B12 levels, folate levels, Vitamin E levels, and Magnesium levels. The HIV specialist may refer the patient to a neurologist for an evaluation and treatment recommendations, and nerve-conduction studies (electromyography, or EMG) may be scheduled.

Treatment of peripheral neuropathy:
Unfortunately, there iss no cure for peripheral neuropathy. They key to treatment is to remove the underlying cause and to control the pain.

• If a vitamin deficiency is the cause of the neuropathy, restoring the nutritional balance with vitamin supplementation will often reverse the process.
• In cases of medication-induced neuropathy, reducing the dosage of the offending drug or discontinuing it will oftentimes reverse the neuropathy, although this may take 2-4 months.
• If heavy alcohol consumption has been determined to be a contributing factor, all use of alcohol must be stopped. Substance abuse counselling services may be needed.
  
• Metabolic conditions such as diabetes and thyroid disorders need to be stabilized.
• HIV needs to be well-controlled, with an undetectable HIV viral load.

Medications used to treat peripheral neuropathy:

• Certain anticonvulsants (Tegretol, Lamictal, Neurontin, or Dilantin) have been used with some success in treating HIV related peripheral neuropathy. These medications can change the levels of HIV medications in your body, so be sure to tell your HIV specialist if another healthcare provider prescribes these for you.
• Antidepressants (Elavil, Cymbalta) have shown to have some effect on decreasing the pain associated with neuropathy.
• Topical anesthetics such as lidocaine cream patches or Capsaicin cream may provide some pain relief.
• If Tylenol or Motrin do not provide pain relief, you may need narcotic (opiate-based) pain medications in addition to some of the other medications listed. Narcotics are started at a low dose and are increased gradually until the pain is controlled, as long as there are no side effects.

Other things to try:

• Be sure to keep your healthcare provider informed about how your symptoms are, especially if they are worsening. Report any medication side effects.
• Inspect your feet carefully every morning and every night, including between the toes and the bottoms of the feet. You may hurt your foot and have an infection, but may fail to feel pain due to the neuropathy. Always were socks and properly fitted shoes; do not go barefoot.
• Massaging your hands and feet or soaking them in cold water may provide temporary pain relief.
• Keep your hands and feet cool; many people report feeling more comfortable sleeping without sheets or blankets on their feet.
• Some people report good pain relief with accupuncture. Many AIDS Service Organizations offer accupuncture to patients free of charge.
• Get up and walk around!