Standard treatment

There are a number of treatments which have some effectiveness against neuropathy.

If the neuropathy is caused by a drug such as ddI, the symptoms usually occur after a few weeks on the drug. Depending on the severity of the neuropathy and other treatments available, a person experiencing neuropathy may be advised to stop or to reduce the dosage of the offending drug immediately. If a person continues on the drug, nerve damage may worsen and become irreversible. Symptoms may continue for a few weeks even after the treatment has been discontinued, and then gradually abate. People who stop taking drug therapies because of neuropathy often find that they can later resume treatment at a lower dose without problems.

In settings where d4T remains the predominant treatment, an immediate switch to AZT is preferable to an interruption of treatment.

The main purpose of treating neuropathy is to relieve symptoms. In mild cases where the symptoms are not affecting daily life, standard painkillers such as ibuprofen may be all that is necessary.

If the symptoms are starting to be disruptive, tricyclic antidepressants such as amitriptyline, nortriptyline (Allegron), doxepin (Sinequan) and desipramine may be used, starting at low doses. These drugs can take a couple of weeks to show any effects, and may cause side-effects of dry mouth, difficulty urinating, high blood pressure and drowsiness. However the evidence supporting their use is weak.

Two randomised studies have shown little evidence of effect in HIV neuropathy, although it is possible the studies did not last long enough or recruit enough patients to come up with a clear answer.^{1 2} In these studies, which compared amitryptiline with acupuncture and with mexiletine or placebo respectively, there was modest improvement in all groups, but no significant differences between treatments.

People with severe symptoms may require stronger pain killers such as methadone or injections of fentanyl (Actiq / Durogesic).

The anti-convulsants phenytoin (Epinutin) and carbamazepine (Tegretol) used to treat epilepsy can be useful, especially if the pain is coming in brief bursts. A small placebo controlled trial of an anti-convulsant called lamotrigine (Lamictal) commonly used for epilepsy showed no reduction in pain when given as an adjunct to non-opiod painkillers or gabapentin.³ However these drugs reduce blood levels of efavirenz, nevirapine and protease inhibitors, so they may not be appropriate for use in HIV neuropathy.