Page 32 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 3 of 26 Guideline

TABLE 1: Causes of death at post-mortem examination of 39 HIV-infected patients of the Charlotte Maxeke Johannesburg Academic Hospital, January–December 2009. 9
Causes of death by All deaths (N = 39) Pre-ART deaths (N = 14) Early-ART deaths (N = 15) Late-ART deaths (N = 10)
category and/or organism†
n % n % n % n %
Mycobacterial 27.0 69 8 57 13 87 6 60
Bacterial 13.0 33 5 36 6 40 2 20
Fungal 8.2 21 3 21 4 27 1 10
Viral, not HIV 3.0 8 2 14 0 0 1 10
Neoplasm 10.0 26 3 21 3 20 4 40
Organ dysfunction‡ 10.0 26 1 7 5 33 4 40
IRIS 11.0 28 - - 11 73 - -
Diagnosis unsuspected at death§ 19.0 49 7 50 8 53 4 40
Unexplained 5.0 13 4 29 1 7 0 0
Source: Wong EB, Omar T, Setlhako GJ, et al. Causes of death on antiretroviral therapy: A post-mortem study from South Africa. PLoS One. 2012;7(10):e47542. https://doi.org/10.1371/journal.
pone.0047542
ART, antiretroviral therapy; IRIS, immune reconstitution inflammatory syndrome.
Note: Categorised by the duration of ART at the time of death. Pre-ART deaths occurred in patients who were HIV-positive and eligible for ART but had not yet received it (CD4 cell count < 200 cells/
3
mm ) or those who had received < 7 days of ART. Early ART deaths occurred between 7 and 90 days of ART. Late ART deaths occurred after > 90 days of ART.
†, All causes of death (immediate and contributing) are included and each patient may have ≥ 1 cause of death.
‡, Non-infectious organ dysfunction, that is, pulmonary embolism or end-stage renal disease.
§, At least one cause of death was revealed only through the post-mortem investigation.
TABLE 2: Guidelines for the management of acute pain at the end of life. 38
Type of pain and treatment Initial dosage Comment
Mild-to-moderate pain
Acetaminophen 1000 mg orally or rectally 3–4 times a day Do not exceed 4 g per day. Use with caution in the presence of liver disease, particularly in
(Paracetamol) the elderly and with concomitant alcohol use.
Ibuprofen (NSAIDS) 800 mg orally 3–4 times a day GIT upset and bleeds, ulceration; Avoid in renal failure and use with caution in the presence
of liver disease
Codeine 30 mg with/without 325 mg acetaminophen Do not exceed 360 mg per day. Note that constipation is usual. Provide advice regarding diet,
orally every 3–4 h as needed exercise and the use of laxatives. Codeine can be addictive and thus should be used under
supervision.
Oxycodone 5 mg with or without 325 mg acetaminophen, If analgesia is inadequate with initial treatment, adjust the dosage to 10 mg orally every 3–4
orally every 3–4 h as needed h as needed. As it can be addictive, use under supervision.
Moderate-to-severe pain in patients not already on opioids
Morphine Oral: 2 mg – 4 mg every 30–60 min as needed For both morphine and hydromorphone, if analgesia is inadequate with initial treatment,
IV: 2 mg – 5 mg every 15–30 min as needed increase the bolus dose by 25% – 50% for moderate pain or by 50% – 100% for severe pain.
Morphine can be addictive and thus should be used under supervision.
Hydromorphone Oral: 2 mg – 4 mg every 30 min as needed If the level of analgesia is acceptable, administer continuous infusion (equal to the total daily
IV: 0.4 mg – 0.8 mg every 15–30 min as opioid dose) over 24 h, with a breakthrough dose every hour equivalent to 10% – 20% of the
required total 24 h opioid dose. If the current drug causes unacceptable side effects, administer an
equianalgesic dose of a different opioid. As it can be addictive, use under supervision.
Moderate-to-severe pain in patients already on opioids
Morphine/Hydromorphone Bolus dose, up to 10% – 20% of total opioid If previously satisfactory analgesia becomes inadequate, increase the basal and bolus dose by
taken in the previous 24 h, every 15–60 min as 25% – 50% for moderate pain and by 50% – 100% for severe pain.
needed For daily follow-up, calculate the total 24 h dose received, i.e., basal + breakthrough, and
adjust the basal rate to equal this 24 h opioid amount; Adjust the bolus dose to 10% – 20%
of this 24 h total. If the current drug causes unacceptable side effects, administer an
equianalgesic dose of a different opioid.
Neuropathic pain
Opioids Adjust dose until analgesia has been achieved -
Glucocorticoids For example, 4 mg – 16 mg dexamethasone IV Consider especially for acute neurologic injury such as nerve or spinal cord compression from
daily a tumour.
Transdermal lidocaine patches - Consider especially when allodynia is present.
Short-acting antiepileptic drug, for - If survival of more than a few days is anticipated, consider adding one of these agents
example, gabapentin, pregabalin or immediately.
tricyclic antidepressant
Source: Blinderman CD, Billings JA. Comfort care for patients dying in the hospital. N Eng J Med. 2015;373:2549–2561. https://doi.org/10.1056/NEJMra1411746
NSAIDS, non-steroidal anti-inflammatory drugs.
epidemic are interlinked. Uncontrolled plasma (HIV) viral inconsistent data collection, the huge rural–urban divide,
load increases the risk of malignancy. AIDS-defining empty drug shelves and constant drug stockouts, et cetera.
malignancies were described in the 1980s and 1990s but are This section briefly reviews this subject. Answers to the
still widespread throughout sub-Saharan Africa today. In the palliation of HIV-related cancer include greater access to
era of ART, the risk of non-AIDS defining cancers is also prevention, for example, vaccination against the Human
increasing. Universal Test and Treat (UTT) and the 90-90-90 Papilloma Virus (HPV) and the broader reach of cervical
by 2020 initiatives of the WHO and the UNAIDS, will help to
reduce risk in the long term if successful. health assessments in women, vaccination against Hepatitis
B and the improved early diagnosis of cancer and the rapid
However, at this time, oncology and radiotherapy on the referral to cancer curative treatment services. Closer
African continent face multiple challenges: poor and ageing collaboration between Africa’s oncologists, radiotherapists
infrastructure, insufficient numbers of skilled professionals, and HIV clinicians is needed if any of this is to be achieved.

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