Key Therapies for Peripheral Neuropathy
Antiretroviral medications.
Physicians who specialize in the treatment of neuropathic pain know that controlling HIV helps prevent problems. By suppressing the virus and improving immune function, you both stop HIV from causing nerve damage and, by improving immune function, decrease the chances of secondary infections that could attack the nerves. So beginning HAART medications in those who have not yet done so may be important to prevent or stop the worsening of neuropathy. However, there may be a Catch 22 in this. If it appears likely that HIV is a major contributor to neuropathy because the symptoms were already present before beginning drug therapy, it is obviously important to suppress the virus.
Yet, as you no doubt know, a number of the most commonly used HAART meds can cause neuropathy. If these are the drugs you are taking at the time that neuropathy develops and they are working well to suppress the virus, you will have to discuss the pros and cons of any possible changes very carefully with your physician.
For those with pre-existing problems (prior to beginning HAART), it may be particularly important to try to choose antiretrovirals that are less likely to cause this problem, and avoid other drugs that may also contribute to nerve damage. On the list of drugs that it may be best to avoid if possible are the antiretrovirals d4T (Zerit®), ddC (Hivid®),
and ddI (Videx®).
Drug switches.
When possible, it is extremely important that drugs (antiretrovirals or others) that are causing peripheral neuropathy be stopped immediately after the beginning of symptoms. Any delay in cessation may result in permanent
problems. It has usually been the case that when causative meds are stopped shortly after symptoms begin, the pain and numbness will be likely to subside over time, and will eventually be completely eliminated. This process may take a number of months, but in the end, the neuropathy and the symptoms it causes will fade away. However, failure to immediately cease the use of problematic drugs may greatly reduce the chances for complete
reversal of symptoms. It appears that the longer the nerve damage continues, the less likely it is that the symptoms caused by it will disappear. Too many people have ended up with permanent pain, numbness, and burning because drug discontinuation was delayed. It is very important to report any symptoms that might indicate neuropathy to your physician
immediately. It is equally important for physicians to seriously consider drug switches, where possible, in order to stop the nerve damage quickly. HIV-knowledgeable physicians are usually very aware of this, and won’t hesitate to consider changing meds. For those stuck with less knowledgeable docs, this may not be the case so educating the physician on
these facts may be crucial.
When considering drug switches, there is one important caveat. Although it would seem appropriate to look for possible substitutions for any drug that appears likely to be contributing to neuropathy, there may not always be available substitutes. This may be a particular problem for people who are very treatment experienced with HAART meds. They may have become resistant to many previously used drugs, and might well be on the only combo currently available to them. In addition, since nucleoside analogues are the most common cause of neuropathy, an obvious substitution is to put together a nuke-sparing combo. However, some people may be intolerant of protease inhibitors or NNRTIs because of the symptoms that they cause. [In such cases, it would be worth trying all the therapies discussed in this guide to counter whatever symptoms are problematic when those drugs are used. You might find that you will be able to use those drugs by accompanying them with appropriate symptom-countering therapies, and thus avoid the use of nucleoside analogue drugs that are contributing to neuropathy.]
In some cases, if the current HAART combo is otherwise working well and providing the anti-HIV benefits needed, and your drug history or med intolerance makes finding substitutes difficult or impossible, it may be necessary to stay with those meds, while attempting to address the neuropathy with the nutrient therapies discussed here that provide mitochondrial support (since damage to the mitochondria is believed to be a cause of neuropathy) and protection against oxidative stress (another cause of nerve damage) and the building blocks to repair nerves. Natural anti-inflammatories might also be useful.
When nukes must be continued to maintain viral control, it would be advisable to try to use the drugs that may be the least likely to cause mitochondrial dysfunction and the neuropathy that could result from that. In general, it is thought that d4T (Zerit®), ddC (Hivid®), ddI (Videx®), and AZT (alone in Retrovir® and also in the combination drugs Combivir® and Trizivir®) have the greatest potential for mitochondrial toxicity, while 3TC (Epivir®)), abacavir (Ziagen®), and tenofovir (Viread®) are less likely to cause the problem. It is important to note that most of the evidence in support of this ranking has been derived from in vitro (test tube) research so whether this will actually be the case in HIV+ people is not perfectly known. However, you will notice from this list that the drugs well known to most often cause neuropathy (the “d” drugs) are at the top of the list of those known to cause mitochondrial dysfunction.
Nutrient therapies.
For all the reasons discussed above, doing everything possible to help counter oxidative stress, prevent mitochondrial damage, and provide the building blocks that the body can use to repair nerves may greatly help to prevent (or prevent worsening of) or even reverse neuropathy. The best results will usually come with a combination of the nutrients discussed here. For example, Phoenix naturopathic physician Kären Van der Veer has found that an integrated treatment approach that includes acupuncture combined with an aggressive nutrient supplementation program is often extremely effective. She recommends giving B-12 injections every day for two weeks, accompanied by folic acid, and then every other day for the next two weeks, and then twice weekly from then on. She also recommends use of B-6, and has found that B-6 will work much faster if injected intramuscularly once every week or two, although oral supplementation will work. She notes that the B-6 injections are painful, but seem to work wonders for neuropathic pain. Along with the B-6, B-12, and folic acid, she recommends oral supplementation with B complex, alpha-lipoic acid, acetyl-carnitine, lecithin, and a broad spectrum of antioxidants. In her patients, this integrated approach is highly successful in reversing neuropathy, and eliminating pain.
Based on the research done to date, the most important nutrients for countering mitochondrial toxicity would be a broad spectrum of antioxidants (which will also counter oxidative stress), the B complex, and the amino acid, acetyl-L-carnitine. Acetylcarnitine was shown to be effective in a study by Youle et al., at 3,000 mg per day.
The most important antioxidants would include vitamin E (800 to 1,200 IU daily), vitamin C (1,000 to 2,000 mg, three times daily with meals), bioflavonoid complex (1 capsule with each meal), carotenoid complex (1 capsule with each meal), selenium (400 to 600 mcg daily, total from all sources, including your multiple), N-acetyl-cysteine (500 mg, three times daily), coenzyme Q-10 (100 to 500 mg daily), and alpha-lipoic acid (200 to 400 mg, three times daily). The latter nutrient may be particularly important.
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http://www.newyorkbuyersclub.org/resources/recommended-reading-files/24-NEUROPATHY.pdf
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