Unit 18

1. Palliative Care
Unit 18
HIV Care and ART: A Course
for Pharmacists by Salahadin
M.Ali

2. 2
Introductory Case: Yared
 Yared is a 35 year-old HIV+ gentleman who
returns to clinic complaining of nausea and
diarrhea.
 6 months ago his ART regimen was changed to
Nelfinavir, AZT, and ddI because of immunologic
treatment failure.
 The patient has a history of CNS toxoplasmosis
and pulmonary TB.
 He lost his job and started drinking alcohol daily
since his wife died in a car accident 1 year ago.

3. 3
Introductory Case: Yared (cont.)
 Alert and oriented, but appears fatigued and
chronically ill
 T: 37.7 HR: 110 BP: 90 / 70
 47 kg (7 kg weight loss since last visit)
 Pale conjunctivae
 White plaques on soft palate
 Normal exam otherwise

4. 4
Introductory Case: Yared (cont.)
 Volume depletion
 Nausea & diarrhea
 Clinical treatment failure (new thrush, wt loss)
 Pallor
 Alcohol dependence
 Unemployment
 What are his palliative care needs?

5. 5
Learning Objectives
 Define palliative care and its role in the
management of HIV
 Describe palliative care in the African context
 Assess and manage pain and dyspnea in HIV
 Identify the role of pharmacist in palliative care

6. 6
Principles of Palliative Care
 Interventions that improve the quality of life for
patients and their families
 Prevention and relief of suffering
 pain and other physical problems
 psychosocial and spiritual issues
 An integral part of a comprehensive care and
support framework

7. 7
Principles of Palliative Care
 In the framework of a continuum of care from the
time the incurable disease is diagnosed until the
end of life
 Regards dying as a normal process and affirms
life
 Offers support to help the patient and family
cope during the patient’s illness and in the
bereavement period

8. 8
Pre-HAART Palliative Care Model
Diagnosis Death
Therapies to modify disease
(curative, restorative intent) Hospice
Bereavement
Care
6m

9. 9
The Role of Palliative Care in
HAART Era
Diagnosis Death
Therapies to modify disease
(curative, restorative intent) Actively
Dying
Bereavement
Care
Life
Closure
Palliative Care: interventions intended to
relieve suffering and improve quality of life
6m

10. 10
Palliative Care and ART
 Antiretroviral therapy does not avert the need
for palliative care
 40–50% of patients experience virological failure
 40% of patients have adverse reactions
 HIV-related cancers still occur
 Psychological and spiritual needs persist

11. 11
Role of Palliative Care in HIV
 Treatment of antiretroviral adverse effects
 Management of HIV complications
 Relief of psychosocial challenges
 Improved ART adherence
 Reduction of drug resistance in the individual
and community
 Preparation for end-of-life

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Introductory Case: Yared (cont.)
 Nausea
 Diarrhea
 Fatigue
 Substance dependence
 Unemployment
 Lack of social support

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Return to Case Study
 Yared returns to the clinic 1 month later
 His diarrhea and nausea have improved with
interventions offered at the last visit. He is still
fatigued, however, and continues to use ETOH.
 He is now living with his uncle 500 km away
from clinic.

14. 14
Palliative Care in Africa
 Palliative care models for developed countries
may not work in Africa
 Feasibility ?
 Accessibility ?
 Sustainability ?
 Cultural diversity ?

15. 15
Challenges to Palliative Care in Africa
 Late disease presentation
 Inadequate diagnostic facilities and assessment
skills
 Poor availability of chemotherapy and
radiotherapy
 Absence of opioids
 Regulatory and pricing obstacles
 Ignorance and false beliefs

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Cultural Variation and Preferences
 A “good death” in Africa varies culturally and
historically
 Bearing bad news could be seen as the cause
of a terminal illness
 Labeling patients as “terminally ill” may have
harmful consequences
 Isolation
 Denied access to care
 Traditions need to dictate appropriate models of
care

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Palliative Care Needs in Africa
 Hospice care (home and hospice center)
 Pain and symptom control
 Financial support
 Emotional and spiritual support
 Food and shelter
 Legal help and school fees

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Models in Africa
 Home-based care has been the most common
service model in Africa
 Limitations of home-care models
 Inadequately trained care givers
 Lack access to essential drugs
 Limited access for patients in inaccessible
geographical areas
 Stigma

19. 19
WHO Palliative Care Project
 WHO “community health approach to palliative
care for HIV/AIDS and cancer patients in Africa
project.” 2001
 Botswana, Ethiopia, Uganda, Tanzania, and
Zimbabwe
 Objective
 Improve the quality of life of patients and their families
in African countries
 Develop home based palliative care models

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End of Life Experience in Ethiopia
 86 adults surveyed
 Families members of a person bed-ridden with AIDS
 The most common problems identified:
• Pain associated with the illness (76%)
• Vomiting, diarrhea, and appetite loss (30%)
• Cost of and lack of drugs

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End of Life Experience in Ethiopia (2)
 Patient needs were not met in most cases
 Relief of pain
 Relief of symptoms
 Burden on family
 Education interruption
 Financial constraints
 Emotional (anxiety, fear, sadness)
 Physical

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The Role of Stigma in Ethiopia
 Physician reluctance to pass bad news to
patients on any health matter, especially AIDS
 Fear of discrimination often prevents many
Ethiopians from seeking treatment for AIDS
 Many people with AIDS have been evicted from
their homes by their families and rejected by
their friends and colleagues
 Infected children are often orphaned or
abandoned

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Direction of Palliative Care in Africa
 Understanding of the capacity and needs of the
community
 Innovation within a framework
 Trend towards home-based care (e.g. Ethiopia)
 Integrated approach with strong referral links
 Addresses need at all stages of disease
 Provision of simple protocols
 The WHO Integrated Management of Adolescent
Illness (IMAI) manual
 Advocacy

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Introductory Case: Yared (cont.)
 Yared returns to the clinic 4 months later
 He is very fatigued and has developed burning
lower extremity pain.

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Advanced HIV:
A Spectrum of Symptoms
 Pain
 Diarrhea, nausea, vomiting
 Fever
 Dyspnea, cough
 Fatigue
 Orthopnea, PND
 Skin disorders
 Confusion
 Depression, anxiety, fatigue, fear

26. 26
Pain
 The symptom most feared when patients
contemplate death
 Usually a manifestation of physical distress
 May be exacerbated by anxiety, fear, depression
 Ability to tolerate and cope with pain varies
drastically among patients

27. 27
Pain Syndromes in HIV
 Abdominal pain
 Peripheral neuropathy
 Oropharyngeal pain
 Headache
 Post-herpetic neuralgia
 Musculoskeletal pain

28. 28
Peripheral Neuropathies
 Among the most common causes of pain in HIV
 The neuropathies associated with HIV can be
classified as
 Primary HIV-associated
 Secondary diseases caused by
• Neurotoxic substances
• Opportunistic infections
 Grouped by
 Timing in relation to onset of HIV infection
 Clinical and diagnostic features

29. 29
Distal Symmetrical Sensory
Polyneuropathy (DSSP)
 Most frequent neurological complication
associated with HIV infection
 > 1/3 of HIV-infected patients
 Pathophysiology unclear
 Course: Slowly progressive sensory features
 Location: feet, lower extremity, sometimes
hands; symmetrical distribution

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Clinical feature of DSSP
 Symptoms
 Pain
 Tingling
 Numbness
 Signs
 Depressed or absent ankle reflexes
 Elevated vibration threshold at toes and ankles
 Decreased sensitivity to pain and temperature in a
stocking distribution

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NRTI associated DSSP
 Thought to be secondary to mitochondrial toxicity from
ddI, d4T or ddC (all are called D-drugs, which have
deoxy nucleus)
 Clinically indistinguishable from HIV-related DSSP
 Temporal relationship to NRTI drug use
 Up to 30% of patients affected; after 3-6 months of use
 May be permanent
 Increase risk associated with advanced HIV disease,
alcoholism, diabetes, vitamin B12 or thiamine deficiency,
and neurotoxic drugs (e.g. INH)

32. 32
NRTI associated DSSP (2)
 Early recognition is critical
 NRTI dosing
 May be dose-reduced
 May be stopped and switched to an alternate non-
toxic antiretroviral agent
 Symptomatic relief may begin to be noted
approximately 4 weeks after discontinuation of
the neurotoxic antiretroviral
 In some patients, symptoms may persist, most
likely because of coexistent HIV DSSP

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Assessment of Neuropathic Pain
 History: onset, duration, character, and severity
(scale 1-10)
 Physical examination:
 Pain and temp (diminished sensation in DSSP)
 Ankle reflexes (absent or depressed in DSSP)
 Vibratory (elevated thresholds at the toes in DSSP)
 Proprioception and muscle strength (preserved
except in severe cases of DSSP)

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Pharmacologic Management of
Neuropathic Pain
 Mild pain: Non-opioid analgesics
 Ibuprofen 600-800mg orally three times per day
 Paracetamol (acetaminophen)
 Moderate-to-severe pain: non-opiod and opioid
analgesics combinations
 Paracetamol plus codeine
 Adjuvant analgesics
• TCAs (Amitriptyline)
• Anti-epileptics (Lamotrigine and Gabapentin)
 Severe pain: opioid analgesics
 Morphine

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 Yared returns to clinic 2 weeks later with
continued pain despite
 Dose reduction in ddI (200 bid ->125 bid)
 Stopping ETOH
 Taking Ibuprofen 600mg bid.
 Physical examination is unchanged
Introductory Case: Yared (cont.)

36. 36
WHO 3-step Analgesics Ladder
■ Morphine
■ Hydromorphone
■ Methadone
■ Levorphanol
■ Fentanyl
■ Oxycodone
■ ± Adjuvants
3 severe
2 moderate
■ A/Codeine
■ A/Hydrocodone
■ A/Oxycodone
■ A/Dihydrocodeine
■ ± Adjuvants
1 mild
■ ASA
■ Acetaminophen
■ NSAIDs
■ ± Adjuvants

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 Yared returns 2 months later
 He is tachypneic, cyanotic, delirious, and unable
to stand.
 He says to you “I can’t breath”.
Introductory Case: Yared (cont.)

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Dyspnea
 A subjective awareness of difficulty or distress
associated with breathing
 Mechanisms are not well understood
 Often ignored by health professionals
 The patient's report is the best indicator of dyspnea
 Note respiratory rate and oxygenation status
 Often takes a chronic course of respiratory decline
 Punctuated by episodes of acute shortness of breath
and increased anxiety

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Causes of Dyspnea in HIV
 Opportunistic infections
 Pulmonary malignancies
 Pneumothorax
 Asthma
 Bronchiectasis
 Pulmonary embolism
 Severe anemia
 Congestive heart failure
 Debilitation / severe wasting

40. 40
Assessment of Dyspnea
 History
 Onset, duration, PCP-prophylaxis
 Physical exam
 Vitals, Pulmonary, Cardiac, Extremities, etc
 Diagnostic testing
 CXR, CBC, Chemistry
 Prompt diagnosis
 Ensure best chance of curative treatment

41. 41
 Onset of dyspnea was gradual, and associated
with dry cough and fever. He stopped taking
Cotrimoxazole one month ago
 T 38.5 HR 110 BP 98 / 70 RR 35
 Pale, cyanotic, fatigued
 Cardiac and lung exam were normal
 No lower extremity edema
 Laboratory:
 Hgb 5 gm/dl, MCV 104, Creatinine 1.1.
Introductory Case: Yared (cont.)

42. 42
Introductory Case: Yared (cont.)
© Slice of Life and Suzanne S. Stensaas

43. 43
Introductory Case: Yared (cont.)
 Yared was admitted to the hospital and started
on high dose Co-trimoxazole plus steroids for
treatment of PCP
 He was also provided a blood transfusion.

44. 44
Non-pharmacologic
Treatment of Dyspnea
 Position patient for comfort
 Prop patient forward using pillows
 May allow better lung expansion / gas exchange
 Provide cool circulating air
 Encourage presence of family and caregivers
 Consider pursed-lip breathing
 Promote soothing activities, such as prayer or
listening to relaxing music

45. 45
Oxygen Therapy
 Titrated to comfort is recommended for
terminally-ill, hypoxemic, and dyspneic patients
 Role in treating patients who are not hypoxemic
is less clear
 Many patients and families believe that oxygen
can alleviate shortness of breath
 If it does no harm, oxygen administration may
confer a psychological benefit

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Pharmacologic
Management of Dyspnea
 Opioids - the primary modality
 Mechanism of action is not clearly understood
 Start low dose (5 to 10 mg PO morphine or 2 to 4 mg
IV or SC morphine)
 Start early in course of dyspnea
• help reduce the effects of respiratory depression
• allows for rapid titration to levels that can comfort the
patient and reduce anxiety

47. 47
Pharmacological
Management of Dyspnea
 Anxiolytics
 Should be considered as a second-line intervention
 Used when a "true” anxiety (psychological rather than
physiologic in origin) is perceived
 Disease specific treatment
 Bronchodilators
 Diuretics
 Steroid
 Antibiotics

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Cough
 Violent expiration of air through the glottis
 Thought to result from irritation and inflammation
of sensory receptors in the tracheobronchial tree
 Usually related to
 Increased mucus production
 Aspiration of mucus
 Gastric contents

49. 49
Cause of Cough in HIV
 Inflammatory processes caused by infections
 Tuberculosis
 Bacterial / fungal pneumonia
 Bronchial lesions
 Lung parenchymal disease

50. 50
Management of Cough
 Avoid stimuli that may induce coughing
 smoke, cold air, exercise
 Elevate head of bed (reduce gastroesophageal
reflux)
 Bronchodilators
 Corticosteroids
 Cough suppressant (when no therapeutic
reason to stimulate cough)
 Opioid based medicine

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Delirium
 An acute confusional state
 Disturbances of level of consciousness
 Attention
 Thinking
 Perception
 Memory
 Psychomotor behavior
 Progresses rapidly over hours or days
 Early symptoms are often nonspecific
 irritability
 disturbances in the sleep-wake cycle

52. 52
Cause of Delirium in HIV
 Infection
 Metabolic
 Drugs
 Endocrine
 Inflammation
 Vascular
 Malignancy

53. 53
Management of Delirium
 Assess and treat underlying cause
 Create quiet, familiar, comfortable environment
 If persistent
 Antipsychotics (Haloperidol)
 Anxiolytics (Diazepam) – use with caution; may
worsen confusion

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Key Points
 Palliative care
 is integral to HIV care from the time of diagnosis
 Palliative care faces unique challenges in Africa and
must be culturally sensitive
 Management of pain and dyspnea includes both
pharmacological and non-pharmacological methods
 Pain is common in HIV and can be managed
according to WHO pain ladder
 Delivering bad news and talking about death is part of
effective palliative care

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Key Points (2)
 Pharmacist as a member of health care team
has a role especially in the supply and
procurement of essential drugs for palliative
care.