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The optimal choice of medication administration route regarding intravenous, intramuscular, and subcutaneous injection.

Jin JF, Zhu LL, Chen M, Xu HM, Wang HF, Feng XQ, Zhu XP, Zhou Q - Patient Prefer Adherence (2015)

Bottom Line: Safety and efficacy must be the preferred principles to be considered (eg, epinephrine should be given intramuscularly during an episode of systemic anaphylaxis).If the safety and efficacy of two injection routes are equivalent, clinicians should consider more about patient preference and pharmacoeconomics because patient preference will ensure optimal treatment adherence and ultimately improve patient experience or satisfaction, while pharmacoeconomic concern will help alleviate nurse shortages and reduce overall health care costs.Besides the principles, the following detailed factors might affect the decision: patient characteristics-related factors (body mass index, age, sex, medical status [eg, renal impairment, comorbidities], personal attitudes toward safety and convenience, past experience, perception of current disease status, health literacy, and socioeconomic status), medication administration-related factors (anatomical site of injection, dose, frequency, formulation characteristics, administration time, indication, flexibility in the route of administration), and health care staff/institution-related factors (knowledge, human resources).

View Article: PubMed Central - PubMed

Affiliation: Division of Nursing, Division of Nursing, Zhejiang University, Hangzhou, People's Republic of China.

ABSTRACT

Background: Intravenous (IV), intramuscular (IM), and subcutaneous (SC) are the three most frequently used injection routes in medication administration. Comparative studies of SC versus IV, IM versus IV, or IM versus SC have been sporadically conducted, and some new findings are completely different from the dosage recommendation as described in prescribing information. However, clinicians may still be ignorant of such new evidence-based findings when choosing treatment methods.

Methods: A literature search was performed using PubMed, MEDLINE, and Web of Sciences™ Core Collection to analyze the advantages and disadvantages of SC, IV, and IM administration in head-to-head comparative studies.

Results: "SC better than IV" involves trastuzumab, rituximab, antitumor necrosis factor medications, bortezomib, amifostine, recombinant human granulocyte-macrophage colony-stimulating factor, granulocyte colony-stimulating factor, recombinant interleukin-2, immunoglobulin, epoetin alfa, heparin, and opioids. "IV better than SC" involves ketamine, vitamin K1, and abatacept. With respect to insulin and ketamine, whether IV has advantages over SC is determined by specific clinical circumstances. "IM better than IV" involves epinephrine, hepatitis B immu-noglobulin, pegaspargase, and some antibiotics. "IV better than IM" involves ketamine, morphine, and antivenom. "IM better than SC" involves epinephrine. "SC better than IM" involves interferon-beta-1a, methotrexate, human chorionic gonadotropin, hepatitis B immunoglobulin, hydrocortisone, and morphine. Safety, efficacy, patient preference, and pharmacoeconomics are four principles governing the choice of injection route. Safety and efficacy must be the preferred principles to be considered (eg, epinephrine should be given intramuscularly during an episode of systemic anaphylaxis). If the safety and efficacy of two injection routes are equivalent, clinicians should consider more about patient preference and pharmacoeconomics because patient preference will ensure optimal treatment adherence and ultimately improve patient experience or satisfaction, while pharmacoeconomic concern will help alleviate nurse shortages and reduce overall health care costs. Besides the principles, the following detailed factors might affect the decision: patient characteristics-related factors (body mass index, age, sex, medical status [eg, renal impairment, comorbidities], personal attitudes toward safety and convenience, past experience, perception of current disease status, health literacy, and socioeconomic status), medication administration-related factors (anatomical site of injection, dose, frequency, formulation characteristics, administration time, indication, flexibility in the route of administration), and health care staff/institution-related factors (knowledge, human resources).

Conclusion: This updated review of findings of comparative studies of different injection routes will enrich the knowledge of safe, efficacious, economic, and patient preference-oriented medication administration as well as catching research opportunities in clinical nursing practice.

No MeSH data available.


Related in: MedlinePlus

Principles and affecting factors associated with the choice of injection route.Abbreviation: BMI, body mass index.
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f2-ppa-9-923: Principles and affecting factors associated with the choice of injection route.Abbreviation: BMI, body mass index.

Mentions: Safety, efficacy, patient preference, and pharmacoeconomics are four principles governing the choice of injection route (Figure 2). Safety and efficacy must be the preferred principles to be considered. Firstly, clinicians should know whether there is a contraindicational route in some cases. Prescribing information for some medications has described the IV, SC, or IM route-related contraindication information. For example, calcium gluconate injection is only for IV use. SC or IM injection may cause severe necrosis and sloughing, and thus, they are contraindicational routes.107 The preferred parenteral route of administration for promethazine hydrochloride injection is deep IM injection. SC promethazine is contraindicated as it may result in tissue necrosis. When used intravenously, promethazine hydrochloride injection should be given in concentration no greater than 25 mg/mL at a rate not to exceed 25 mg/min.108 The FDA required a boxed warning for promethazine hydrochloride injection on September 16, 2009, highlighting the risk of serious tissue injury when this drug is administered incorrectly. Norepinephrine bitartrate injection must be diluted in dextrose-containing solutions prior to infusion. Use of IM and SC is contraindicated because of poor absorption and potential local necrosis due to the vasoconstrictive action of the drug.109 For methylprednisolone sodium succinate and hydrocortisone sodium succinate, IM administration is contraindicated for treatment of idiopathic thrombocytopenic purpura, and IV is the only injection route for this indication, although the two medications can be given intravenously or intramuscularly for other indications. Chlorpromazine hydrochloride injection is intended for deep IM use. The SC route is contraindicated for chlorpromazine administration to avoid causing skin irritation, while IV route is only for severe hiccups, surgery, and tetanus. Potassium chloride injection must be diluted and infused over a certain period of time. IV push/bolus, SC, and IM are contraindicated routes that would result in the patient receiving too much potassium too quickly.


The optimal choice of medication administration route regarding intravenous, intramuscular, and subcutaneous injection.

Jin JF, Zhu LL, Chen M, Xu HM, Wang HF, Feng XQ, Zhu XP, Zhou Q - Patient Prefer Adherence (2015)

Principles and affecting factors associated with the choice of injection route.Abbreviation: BMI, body mass index.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4494621&req=5

f2-ppa-9-923: Principles and affecting factors associated with the choice of injection route.Abbreviation: BMI, body mass index.
Mentions: Safety, efficacy, patient preference, and pharmacoeconomics are four principles governing the choice of injection route (Figure 2). Safety and efficacy must be the preferred principles to be considered. Firstly, clinicians should know whether there is a contraindicational route in some cases. Prescribing information for some medications has described the IV, SC, or IM route-related contraindication information. For example, calcium gluconate injection is only for IV use. SC or IM injection may cause severe necrosis and sloughing, and thus, they are contraindicational routes.107 The preferred parenteral route of administration for promethazine hydrochloride injection is deep IM injection. SC promethazine is contraindicated as it may result in tissue necrosis. When used intravenously, promethazine hydrochloride injection should be given in concentration no greater than 25 mg/mL at a rate not to exceed 25 mg/min.108 The FDA required a boxed warning for promethazine hydrochloride injection on September 16, 2009, highlighting the risk of serious tissue injury when this drug is administered incorrectly. Norepinephrine bitartrate injection must be diluted in dextrose-containing solutions prior to infusion. Use of IM and SC is contraindicated because of poor absorption and potential local necrosis due to the vasoconstrictive action of the drug.109 For methylprednisolone sodium succinate and hydrocortisone sodium succinate, IM administration is contraindicated for treatment of idiopathic thrombocytopenic purpura, and IV is the only injection route for this indication, although the two medications can be given intravenously or intramuscularly for other indications. Chlorpromazine hydrochloride injection is intended for deep IM use. The SC route is contraindicated for chlorpromazine administration to avoid causing skin irritation, while IV route is only for severe hiccups, surgery, and tetanus. Potassium chloride injection must be diluted and infused over a certain period of time. IV push/bolus, SC, and IM are contraindicated routes that would result in the patient receiving too much potassium too quickly.

Bottom Line: Safety and efficacy must be the preferred principles to be considered (eg, epinephrine should be given intramuscularly during an episode of systemic anaphylaxis).If the safety and efficacy of two injection routes are equivalent, clinicians should consider more about patient preference and pharmacoeconomics because patient preference will ensure optimal treatment adherence and ultimately improve patient experience or satisfaction, while pharmacoeconomic concern will help alleviate nurse shortages and reduce overall health care costs.Besides the principles, the following detailed factors might affect the decision: patient characteristics-related factors (body mass index, age, sex, medical status [eg, renal impairment, comorbidities], personal attitudes toward safety and convenience, past experience, perception of current disease status, health literacy, and socioeconomic status), medication administration-related factors (anatomical site of injection, dose, frequency, formulation characteristics, administration time, indication, flexibility in the route of administration), and health care staff/institution-related factors (knowledge, human resources).

View Article: PubMed Central - PubMed

Affiliation: Division of Nursing, Division of Nursing, Zhejiang University, Hangzhou, People's Republic of China.

ABSTRACT

Background: Intravenous (IV), intramuscular (IM), and subcutaneous (SC) are the three most frequently used injection routes in medication administration. Comparative studies of SC versus IV, IM versus IV, or IM versus SC have been sporadically conducted, and some new findings are completely different from the dosage recommendation as described in prescribing information. However, clinicians may still be ignorant of such new evidence-based findings when choosing treatment methods.

Methods: A literature search was performed using PubMed, MEDLINE, and Web of Sciences™ Core Collection to analyze the advantages and disadvantages of SC, IV, and IM administration in head-to-head comparative studies.

Results: "SC better than IV" involves trastuzumab, rituximab, antitumor necrosis factor medications, bortezomib, amifostine, recombinant human granulocyte-macrophage colony-stimulating factor, granulocyte colony-stimulating factor, recombinant interleukin-2, immunoglobulin, epoetin alfa, heparin, and opioids. "IV better than SC" involves ketamine, vitamin K1, and abatacept. With respect to insulin and ketamine, whether IV has advantages over SC is determined by specific clinical circumstances. "IM better than IV" involves epinephrine, hepatitis B immu-noglobulin, pegaspargase, and some antibiotics. "IV better than IM" involves ketamine, morphine, and antivenom. "IM better than SC" involves epinephrine. "SC better than IM" involves interferon-beta-1a, methotrexate, human chorionic gonadotropin, hepatitis B immunoglobulin, hydrocortisone, and morphine. Safety, efficacy, patient preference, and pharmacoeconomics are four principles governing the choice of injection route. Safety and efficacy must be the preferred principles to be considered (eg, epinephrine should be given intramuscularly during an episode of systemic anaphylaxis). If the safety and efficacy of two injection routes are equivalent, clinicians should consider more about patient preference and pharmacoeconomics because patient preference will ensure optimal treatment adherence and ultimately improve patient experience or satisfaction, while pharmacoeconomic concern will help alleviate nurse shortages and reduce overall health care costs. Besides the principles, the following detailed factors might affect the decision: patient characteristics-related factors (body mass index, age, sex, medical status [eg, renal impairment, comorbidities], personal attitudes toward safety and convenience, past experience, perception of current disease status, health literacy, and socioeconomic status), medication administration-related factors (anatomical site of injection, dose, frequency, formulation characteristics, administration time, indication, flexibility in the route of administration), and health care staff/institution-related factors (knowledge, human resources).

Conclusion: This updated review of findings of comparative studies of different injection routes will enrich the knowledge of safe, efficacious, economic, and patient preference-oriented medication administration as well as catching research opportunities in clinical nursing practice.

No MeSH data available.


Related in: MedlinePlus