Buprenorphine for Refractory HIV-Associated Peripheral Neuropathy

Key Message : Buprenorphine’s unique pharmacology is valuable for managing neuropathic pain. Buprenorphine is an effective option for HIV-associated peripheral neuropathy in patients already on full-agonist opioids. New options are essential in light of the stigma these patients face due to their HIV status and provider unease associated with their opioid regimens.

Abstract:

Background: HIV can result in a variety of neurologic complications, including HIV peripheral neuropathy (HIV-PN). The most common presentation is distal symmetric polyneuropathy, often in patients with AIDS and resulting in debilitating pain and paresthesias. Potential causes include an inflammatory response to the virus, opportunistic infections, or neurotoxicity of older-generation antiretroviral drugs (1). Treatment for painful HIV-PN is not well elucidated in the literature, with evidence of varying quality supporting treatments such as gabapentin, lamotrigine, cannabis, topical capsaicin, and recombinant human nerve growth factor (2). We present the case of a 67-year-old male with longstanding, painful HIV-PN that responded to sublingual buprenorphine, a therapy not well described for this condition. Challenges associated with this case include treatment refractoriness and concomitant use of full-agonist opioids.

Approach: The patient presented to our palliative care clinic on high-dose gabapentin (1600 mg three times daily), transdermal fentanyl (175 mcg every 48 hours), and oral hydromorphone (4 mg every 6 hours as needed) and reported intolerable pain levels. Attempts to lower his gabapentin were unsuccessful as the patient experienced severe flares of pain. Since the patient had been unable to achieve relief previously with ketamine, methadone, or amitriptyline, the decision to try a buprenorphine induction was made. Low-dose induction was performed and was successful in achieving adequate pain relief at a dose of buprenorphine 8mg SL QAM and buprenorphine 16mg SL QPM. The patient also notably reported improvement in early morning fatigue and quality of life. The patient was transitioned from gabapentin to pregabalin 150 mg every 6 hours. Hydromorphone and capsaicin cream were continued as needed.
Implications/Lessons Learned: Buprenorphine is a valuable adjunct for managing refractory HIV-PN, particularly in patients already receiving full-agonist opioids. Its partial agonist properties and potential to reduce hyperalgesia warrant further clinical exploration.

References: 1. Amato AA, Barohn RJ. Peripheral Neuropathy. In: Longo D, Fauci A, Kasper D, et al, eds. Harrison's Principles of Internal Medicine, 22nd Edition. McGraw Hill; 2026.
2. Egan KE, Caldwell GM, Eckmann MS. HIV Neuropathy-a Review of Mechanisms, Diagnosis, and Treatment of Pain. Curr Pain Headache Rep. Jul 8 2021;25(8):55. doi:10.1007/s11916-021-00971-2