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Dr. Elliot Frohman on managing injection site reactions

our of the medica- prevent them. Most patients tions currently will experience a few. If they Fapproved by the understand this possibility, FDA (the U.S. Food and they are a lot less likely to Drug Administration) for consider the medication a controlling MS require regular failure and stop taking it after having injections. At the University of Texas an MS attack. Southwestern Medical Center, we are Second, people must be expertly following approximately 5,000 people instructed on how to prepare their med- with MS. The majority have relapsing- ication and inject it in the best possible remitting MS or secondary-progressive way. Poor technique is a major cause of MS, the relapsing forms of MS, and skin reactions at injection sites—which we’re treating almost all of these in turn lead people to quit treatment. patients with either Betaseron, Avonex, People taking subcutaneous injec- Rebif, or Copaxone. This means our tions (shallow, just under the skin) patients are injecting a medication on tend to have more problems than a regular basis, and they all face the those who take the deeper once-a-week risks and challenges of a continuing intramuscular injection. But any break long-term treatment. of the skin has some potential for Experience in our clinic shows pain, and the deeper injection may clearly that people can do injections produce mild bruising and somewhat and do them safely, but their success more significant pain. Reactions to depends on how well they understand subcutaneous injections are generally what to expect. First, they need a realis- mild. But some may evolve into poten- tic understanding of what a disease- tially serious lesions, culminating in modifying treatment is expected to infections and possible death of skin achieve. These medications reduce the tissue. These require antibiotic therapy. number of attacks—but they do not Some may even require surgical repair.

62 InsideMS n www.nationalmssociety.org/InsideMS.asp Practical pearls and pitfalls Aftermath: Planning: ᮣ Use a 1–2% hydrocortisone ointment ᮣ Allow time for the medication to to prevent red swelling, but do not use warm up to room temperature. such an ointment if there is any sign of ᮣ Ask your health-care provider if a infection. thinner needle (25 gauge) would be right for you. For unknown reasons, women seem to ᮣ If you take the intramuscular injection develop serious skin reactions more and have a lean body mass, ask about often than men do. There also appears to using a shorter needle. be an association between higher-dose ᮣ Stop smoking—At least in our clinic, we interferon and more serious problems. see an association between an increased Daily Copaxone use has caused some likelihood of skin reactions and smoking. people to develop permanent dimpling, pitting, or irregular areas of skin depres- Mechanics: sion, due to changes in fatty tissues over ᮣ Consider an “autoinjector” for subcuta- time. And in one person under my care, neous injections. Avonex was involved in a deep intramus- ᮣ Rotate your injection sites! Consider cular abscess. (He recovered and is still keeping a map instead of relying on using Avonex.) In other words, serious memory. problems are rare, but none of the cur- ᮣ Avoid injecting at or near areas where rent self-injectable drugs are completely an adverse skin reaction occurred in the risk-free. past. The key concept is prevention To minimize pain, try: Both health-care providers and people ᮣ Local anesthetics, such as EMLA or injecting disease-modifying therapy must aerosolized ethyl chloride. be aware of the potential for injection site ᮣ Topical anesthetics, such as gabapentin, reactions, the role of proper injection lidocaine, or clonidine creams. techniques in preventing them, and the ᮣ Apply ice to the site for 30 to 60 sec- importance of careful observation and onds before cleaning and injecting. prompt communication with a health- care professional to manage problems if The countdown: they do occur. ■ ᮣ Wash your hands. ᮣ Clean site thoroughly. Elliot M. Frohman, MD, PhD, FAAN, is associ- ᮣ Apply alcohol with a small pad. ate professor of neurology and the director ᮣ Allow alcohol to dry completely. of the MS Clinical Center at the University of ᮣ Make sure the needle tip is dry and free Texas Southwestern Medical Center in Dal- of any medication. las. He is a long-serving member of the Soci- ᮣ Push the needle in all the way. ety’s Medical Advisory Board.

April–May 2005 n InsideMS 63