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Mohamed H. Dahir (Chairman Pharmaceutical Association of Somaliland)
HIV AIDS (cont’d)
Management Of Terminally Ill Aids Patients
Terminal stage, if AIDS overlaps the advanced stage of AIDS. Severe fatigue, severe debility, neuralgia, renal failure or dementia may be present in advanced stage of AIDS. Infections may be worsening. Response to therapy may be poor, particularly to the antiretroviral drugs. Incidence of drug allergy is high. Some physicians hold the view that "fewer is better". Yet, ARV naïve patients in advanced stage of AIDS may still have a chance to recover with appropriate antiretroviral therapy.
In the terminal stage the antiretroviral options may have been exhausted for the antiretroviral experienced patients. Still the prophylaxis of opportunistic infections must be considered. The impact of prophylactic drugs on patient’s quality of life and versus risk of disease must be weighed. Even prophylaxis may become limited by adverse effects. Antifungal prophylaxis, pneumocystis carinii pneumonia prophylaxis may be necessary to maintain quality of life. Similarly patients who suffered recurrent attacks of herpes may also be protected, for it affects quality of life. Prophylaxis of mycobacterium avium complex or cytomegalovirus may be a little more difficult to choose readily.
Palliative therapy for the symptoms would be the major concern of the physician caring for the terminally ill AIDS patient. Quality of life is important at this stage. Fever and accompany nightsweats complicate terminal stage AIDS. Infection or neoplastic diseases may be the cause induced and treating the disease process may be the best way to give palliation but sometimes no clear-cut cause may emerge. Fever and adrenocortical insufficiency may also be explored.
Nausea and vomiting in the late stage of AIDS is common, caused by AIDS cholangiopathy, CMV disease, lymphomas or CNS leisons. All drugs in the therapy should be re-evaluated their ability to cause GI complications and pared down. The goal of therapy in the term9nal stages is patient comfort.
Diarrhea and dehydration and electrolite imbalance may be life threatening in the advanced state of AIDS. Drugs, infections and neoplasms may cause diarrhea. Some are treatable but diarrhea may also be due to untreatable organism or it may be idiopathic.
Anorekia and weight loss is a usual complication in the late stage AIDS. Chronic disseminated infection, diarrhea along with malabsorption and GI complications due to medication usually lead to wasting. Inadequacy of calories intake leads to wasting. Appetite stimulants are not useful in the terminally ill patients but total parenteral nutrition may help but it is initiated only after careful evaluation.
Progressive physical deterioration, loss of friends and isolation consequent to AIDS, impoverishment, all combine to cause severe depression in many terminally ill and it should be aggressively treated.
Pain is a complication in half of the advanced stage AIDS cases. Peripheral neuropathy, chronic abdominal pain and pain from skin leisons and pain from immobilization are usual. Pain can be expected as the HIV disease advances and it is comparable to cancer pain in the advanced stages. It is paramount to treat pain in the terminally ill.
To be continued next week.
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