Page 42 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 13 of 26 Guideline

Management: Address the cause. Inner-ear or motion sickness dietary fibre (bran) including vegetables and fruit. The
requires antihistamines, for example, dimenhydrinate, following medicines can be tried: lactulose, psyllium,
cyclizine; if drug-related – antidopaminergic, for example, bisacodyl and fleet enemas. Management must be expectant
prochlorperazine; if chemotherapy-related – 5-HT antagonist, and preventive.
3
for example, ondansetron, granisetron; if intestinal and gastro-
related – 5-TH agonist, for example, cisapride, metoclopramide Suggested end-of-life care:
4
and somatostatin analogues, for example, octreotide. • Senna 2–4 tabs (8.6 mg sennosides per tab) or 1–2 tabs as
Chemotherapy-induced N&V may result in ‘anticipatory’ a single daily dose or in two divided doses per day. Do
N&V viz. CNS-arousal and anxiety, and may require treatment not exceed 100 mg per day.
with a benzodiazepine (e.g. lorazepam), glucocorticoids (e.g. • Bisacodyl suppository: 10 mg given rectally per day as
methylprednisone), dexamethasone or with cannabinoids needed.
(e.g. tetrahydrocannabinol) (see Section 7).

Suggested end-of-life treatment: Fever
• Bowel obstruction: Octreotide 100–200 µg subcutaneous Fever in someone with HIV infection usually suggests an
injection 3 times a day or 100–600 µg per day in an IV infectious complication. The constellation of fever, cough,
infusion. Should a nasogastric tube (NGT) be placed? weight loss and night sweats in an HIV-infected person in
Where the likelihood is that this will provide little or no Africa indicates a heightened suspicion of tuberculosis.
improvement and where the expectation is that death is However, TB must be confirmed as it is a treatable,
within hours or a few days, it is more humane to withhold transmissible disease and its presence puts others at risk.
NGT and maximise alternative forms of symptomatic Even at the end of life, TB must be diagnosed, treated and
relief. controlled and it is particularly important to check whether
• Dexamethasone 4 mg po/IV–8 mg po/IV daily: maximum the disease is drug-resistant or not (Gene Xpert analysis gives
16 mg daily. information about rifampicin sensitivity or resistance). Even
• Gastroparesis: in the context of palliative care, patient isolation and infection
• Metoclopramide 10 mg po/IV–20 mg po/IV every 4–6 h: control measures must be implemented.
maximum 100 mg per day.
• Elevated intracranial pressure: If fever is part of an end-of-life infection, such as an
• Dexamethasone 4 mg po/IV–8 mg po/IV daily: maximum aspiration pneumonia, the patient and his or her family
16 mg daily. may resist the idea of prolonging the inevitable with
• Unspecified cause but including chemotherapy: antibiotics and active interventions. The task of the
ß Metoclopramide 10 mg po/IV–20 mg po/IV every palliative care team is to assist the patient to face the
4–6 h: maximum 100 mg per day. inevitability of death yet at the same time the team must
ß Haloperidol Oral: 1.5 mg–5 mg 2–3X per day IV: 0.5 agree to do all that it can to minimise suffering, that is, to
mg–2 mg every 8 h. support the patient. This is where the palliative care
ß Ondansetron 8 mg po 8 h as needed. physician and team provide what is frequently missing
ß Dexamethasone 4 mg po/IV–8 mg po/IV daily: from the wards of our South African hospitals as death
maximum 16 mg daily. Usually combined with other should be about healing even when the latter is not
anti-emetics. 52,53 delivered by way of pills, lines and procedures.

Constipation Management: Treat the cause when a fever is indicated.
Paracetamol, aspirin, NSAIDS and sometimes steroids may
This is defined as infrequent emptying of bowel or rectum
often with a sensation of incomplete evacuation. It is seldom assist in controlling it, while tepid sponging, a fan and oral
secondary to a significant medical problem. fluids may help to alleviate the patient’s distress. Avoid
paracetamol in patients with liver disease. Antimicrobial
• Acute or recent onset: Local problem (viz. tumour, therapy that is not directed at a particular pathogen
stricture, trauma or analgesics including opioids, or a likely diagnosis is unlikely to be helpful at the
inactivity, not eating). end-of-life. Prophylactic trimethoprim sulfamethoxazole is
• Chronic: Irritable bowel syndrome; hypothyroidism; recommended if the baseline CD4 count is < 350 c/mm and/
3
hypercalcaemia; pregnancy; chronic CNS disorders (e.g. or an AIDS-defining illness (or WHO stages 3 and 4 disease)
Parkinson’s disease, paraplegia et cetera); drugs (e.g. is present.
50
antidepressants, calcium channel blockers, analgesics,
including opioids).
Suggested end-of-life care:
(Note: Bold indicates conditions that are frequent among the • Paracetamol/acetaminophen650 mg po/pr–100 mg
HIV-infected patients.) po/pr or IV every 4–6 h as needed: maximum daily
dose = 4 g.
Management: Treat the cause. Where feasible, encourage the • Naproxen 250 mg po bid–500 mg po bid (short course ×
patient to mobilise and take in more fluids and increase 2–3 days. Can be repeated).

http://www.sajhivmed.org.za 35 Open Access