Experimental treatments

A study of self-management techniques among 450 people with HIV-related neuropathy in North America found that taking a hot bath was the strategy rated most effective in relieving pain; staying off the feet or avoiding walking were also cited frequently.1

A randomised trial of smoked cannabis found that it relieved neuropathic pain by at least 30% in just over half of those who received it, and in 24% of the placebo group.2

Many people with HIV report that acupuncture helps relieve the pain of neuropathy. However a trial in the United States found that neither a standardized acupuncture regimen nor amitriptyline were effective at reducing pain due to neuropathy3 when compared with a placebo.

There is evidence that mexiletine (Mexitil) 10mg/kg per day does not reduce symptoms of neuropathy despite one uncontrolled trial which suggested that mexiletine had benefit. Topical capsaicin (Axsain / Zacin) has also been reported to help. An experimental drug, oxcarbazapine (Trileptal), is available on a named patient basis.

Anecdotal reports from the United States suggest that a non-steroidal anti-inflammatory cream called diclofenac (Voltaren Emulgel) may relieve HIV-related neuropathy. Sold over the counter in Europe, it is generally used to treat aching joints and muscles. A pilot study of a cream containing the drug lidocaine has found that 75% of 27 participants reported moderate or substantial pain relief. Further clinical trials using lidocaine cream may be conducted.4

Other experimental drugs include gabapentin (Neurontin), which has been studied as a treatment for neuropathy associated with diabetes, and memantine (Ebixa), a drug approved for treating Parkinsons disease. A small placebo-controlled trial of gabapentin has shown modest effects of the drug in reducing pain and increasing sleep quality in patients with HIV-associated sensory neuropathy, but side-effects can include sleepiness.5 Memantine proved ineffective in a placebo-controlled trial.6

A randomised, placebo-controlled study of pregabalin, a close relative of gabapentin, in 300 patients with HIV-related neuropathy showed no difference in the proportion of patients who reported improvement over 12 weeks: over two-thirds in both arms said that symptoms had improved.7  

A skin patch containing capsaicin, the ingredient in chili peppers that causes heat and irritation, has been shown effective in relieving neuropathic pain in a randomised, controlled study in 307 patients with HIV-related neuropathy. One administration of the patch resulted in a pain reduction over more than 30% at week 12 in one-third of recipients.8 The patch works by desensitising pain receptors. The capsaicin patch may receive marketing approval in Europe during 2010 for relief of neuropathic pain in HIV-positive patients.

A drug called flecainide (Tambocor), used to treat cancer-related neuropathic pain, has shown some effectiveness in a trial of HIV-infected people. A trial of a drug called prouridine is being planned in the United States. Researchers are also investigating a drug called nimodipine (Nimotop) for heart-related neurological problems.

Recombinant human nerve growth factor (NGF) has also been used to treat HIV-related and diabetic peripheral neuropathy. One study of 270 people with HIV-associated neuropathy, found that NGF reduced pain and improved sensitivity.9 However, another study found NGF alleviated symptoms of neuropathy but provided no evidence of improvement using neurological measurements.10 Following disappointing results in treating diabetic neuropathy, Genentech have ceased development of NGF.11

Administration of low doses of the hormone erythropoietin has been reported to prevent the nerve damage due to HIV infection and treatment with ddC.12

A final approach which is often more readily available - though not legally -  is medical marijuana. Several studies have reported positive results from using smoked cannabis for neuropathic pain.13 14 For instance, Abrams et al conducted a randomised clinical trial that found that smoked cannabis reduced daily pain by 34%. Greater than 30% reduction in pain was reported by 52% in the cannabis group and by 24% in the placebo group (p = 0.04). The first cannabis cigarette reduced chronic pain by a median of 72% vs 15% with placebo (p < 0.001).15

References

  1. Nicholas PK et al. Symptom management and self-care for peripheral neuropathy in HIV/AIDS. 19(2):179-89, 2007
  2. Abrams DI et al. Cannabis in painful HIV-associated sensory neuropathy: a randomized placebo-controlled trial. Neurology 68(7):515-21, 2007
  3. Shlay JC et al. Acupuncture and amitriptyline for pain due to HIV-related peripheral neuropathy: a randomised controlled trial. Journal of the American Medical Association 280: 1590-1595, 1998
  4. Dorfman D et al. Treatment of painful distal sensory polyneuropathy in HIV-infected patients with a topical agent: results of an open-label trial of 5% lidocaine gel. AIDS 13: 1589-1591, 1999
  5. Hahn K et al. A placebo-controlled trial of gabapentin for painful HIV-associated sensory neuropathies. J Neurol 251: 1260-1266, 2004
  6. Schiffito G et al. A placebo-controlled study of memantine for the treatment of human immunodeficiency virus-associated sensory neuropathy. J Neurovirol 12(4):328-31, 2006
  7. Simpson DM et al. A randomized, double-blind, placebo-controlled, multicenter trial of pregabalin vs placebo in the treatment of neuropathic pain associated with HIV neuropathy. XVII International AIDS Conference, Mexico City, abstract THAB0301, 2008
  8. Simpson DM et al. Controlled trial of high-concentration capsaicin patch for treatment of painful HIV neuropathy. Neurology; 70(24):2305-13, 2008
  9. McArthur J et al. A phase II trial of recombinant nerve growth factor for sensory neuropathy associated with HIV infection. Neurology 54: 1080-1088, 2000
  10. Schifitto G et al. Long-term treatment with recombinant nerve growth factor for HIV-associated sensory neuropathy. Neurology 57(7): 1313-1316, 2001
  11. Apfel SC et al. Nerve growth factor for the treatment of diabetic neuropathy: what went wrong, what went right, and what does the future hold? Int Rev Neurobiol 50: 393-413, 2002
  12. Keswani SC et al. Erythropoietin is neuroprotective in models of HIV sensory neuropathy. Neurosci Lett 371: 102-105, 2004
  13. Wilsey B et al. A randomized, placebo-controlled, crossover trial of cannabis cigarettes in neuropathic pain. J Pain. 9(6):506-21, 2008
  14. Martín FM Role of cannabinoids in the management of neuropathic pain. CNS Drugs.;22(8):645-53, 2008
  15. Abrams DI et al. Cannabis in painful HIV-associated sensory neuropathy: a randomized placebo-controlled trial. Neurology 68(7):515-21, 2007
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