Injectable Success: From Fillers to Botox®

The educated consumer seeks minimal downtime options to address the early signs of aging. These signs include a deepening of facial folds, an increase in muscle-induced wrinkling, and even a loss of facial volume. The use of fillers both dermal and subdermal and the use of the neurotoxin Botox have grown tremendously. The increase demand for these nonsurgical options for facial rejuvenation has created an added responsibility for physicians to remain current in injection technique and product safety. My technique has evolved, along with the predictability of the current fillers and our understanding of the actions of these products, from a safe and conservative fellowship base. A successful injector is one who understands the limitations and possibilities of the available fillers as well as the neurotoxin Botox. The happy patient is one who finds that doctor.

Sumatriptan 6 mg subcutaneous as an effective migraine treatment in patients with cutaneous allodynia who historically fail to respond to oral triptans

The objective of the study was to assess the efficacy of 6 mg subcutaneous (s.c.) sumatriptan to treat migraine and the relationship between response of migraine and cutaneous allodynia in a population of migraine patients who historically failed to respond to oral triptan medications. This was an open-label study consisting of patients with migraines who historically failed to respond to oral triptan medications. Forty-three patients were asked to treat three migraine attacks with 6 mg s.c. sumatriptan. The primary efficacy endpoint was the percentage of patients achieving relief of headache at 2 h. Ninety-one percent of the patients responded to a single dose of s.c. sumatriptan 6 mg. Fifty percent of all patients were pain-free by 2 h and over 30% had a 24-h sustained pain-free response. When administered within 90 min from the onset of migraine (i.e., during the developing phase of cutaneous allodynia), s.c. 6 mg sumatriptan proved to be effective despite the occurrence of allodynia in a group of patients, who historically had failed to respond to oral triptan medications. These findings suggest that the window of opportunity to treat allodynic patients with injectable triptans may be longer (up to 2 h) than with oral triptans (up to 1 h).

CT-Guided Percutaneous Steroid Injection for Management of Inflammatory Arthropathy of the Temporomandibular Joint in Children

OBJECTIVE

The purposes of this study were to retrospectively review an injection technique, to develop a grading system for evaluation of imaging findings, and to report preliminary outcome related to percutaneous CT-guided steroid injection into the temporomandibular joints of children with inflammatory arthropathy.

CONCLUSION

CT-guided steroid injection into the temporomandibular joint of children with inflammatory arthropathy results in clinical and imaging improvement in a substantial proportion of children treated.

Microinfusion using hollow microneedles

PURPOSE

The aim of the study is to determine the effect of experimental parameters on microinfusion through hollow microneedles into skin to optimize drug delivery protocols and identify rate-limiting barriers to flow.

METHODS

Glass microneedles were inserted to a depth of 720-1080 microm into human cadaver skin to microinfuse sulforhodamine solution at constant pressure. Flow rate was determined as a function of experimental parameters, such as microneedle insertion and retraction distance, infusion pressure, microneedle tip geometry, presence of hyaluronidase, and time.

RESULTS

Single microneedles inserted into skin without retraction were able to infuse sulforhodamine solution into the skin at flow rates of 15-96 microl/h. Partial retraction of microneedles increased flow rate up to 11.6-fold. Infusion flow rate was also increased by greater insertion depth, larger infusion pressure, use of a beveled microneedle tip, and the presence of hyaluronidase such that flow rates ranging from 21 to 1130 microl/h were achieved. These effects can be explained by removing or overcoming the large flow resistance imposed by dense dermal tissue, compressed during microneedle insertion, which blocks flow from the needle tip.

CONCLUSIONS

By partially retracting microneedles after insertion and other methods to overcome flow resistance of dense dermal tissue, protocols can be designed for hollow microneedles to microinfuse fluid at therapeutically relevant rates.

Randomized comparison of the single-injection volar subcutaneous block and the two-injection dorsal block for digital anesthesia

BACKGROUND

Two commonly used methods of digital nerve block with local anesthetic are the two-injection dorsal technique and the single-injection volar subcutaneous technique. The authors compared these two digital block techniques with respect to local anesthetic injection pain and recipient preference of anesthetic technique.

METHODS

Twenty-seven volunteers had the long finger of each hand injected with 2% lidocaine with 1:100,000 epinephrine. The two-injection dorsal method was used on one long finger and the other long finger received the volar single-injection technique. Volunteers completed a pain scale for each block and were then asked which technique they would prefer. The area of anesthetic skin was assessed in each finger by pinprick testing, and photographs were taken.

RESULTS

Although there was a lower pain score for the volar single-injection block, the difference in pain scores between the two techniques was not statistically significant. However, 22 of the 27 subjects indicated that they would select the volar over the dorsal block if a future block was required, and this preference for the volar block was statistically significant.

CONCLUSIONS

Although the difference in pain scores between the two techniques was not statistically significant, volunteers who received both blocks would prefer the volar single-injection subcutaneous block if given a choice. Therefore, the single-injection volar subcutaneous block is recommended as the technique of choice for anesthesia of the digit, except in patients for whom anesthesia over the dorsum of the proximal phalanx is required. These patients may prefer a supplementary dorsal nerve block or a traditional two-injection block.

Long-term subcutaneous interferon beta-1a therapy in patients with relapsing-remitting MS

OBJECTIVE

To conduct systematic long-term follow-up (LTFU) of patients in the Prevention of Relapses and Disability by Interferon beta-1a Subcutaneously in Multiple Sclerosis (PRISMS) study to provide up to 8 years of safety, clinical and MRI outcomes on subcutaneous (s.c.) interferon (IFN) beta-1a in relapsing-remitting multiple sclerosis (RRMS).

METHODS

The original cohort of 560 patients was randomized to IFNbeta-1a, 44 or 22 microg three times weekly (TIW) or to placebo; after 2 years, patients on placebo were rerandomized to active treatment and the blinded study continued for a further 4 years. The LTFU visit was scheduled 7 to 8 years after baseline.

RESULTS

LTFU was attended by 68.2% of the original PRISMS study cohort (382/560 patients). 72.0% (275/382) were still receiving IFNbeta-1a s.c. TIW. Patients originally randomized to IFNbeta-1a 44 microg s.c. TIW showed lower Expanded Disability Status Scale progression, relapse rate and T2 burden of disease up to 8 years compared with those in the late treatment group. Brain parenchymal volume did not show differences by treatment group. Overall, 19.7% of patients progressed to secondary progressive MS between baseline and LTFU (75/381). No new safety concerns were identified and treatment was generally well tolerated.

CONCLUSIONS

Despite the limitations inherent in any long-term study (for example, potential differences between returning and nonreturning patients), these results indicate that patients with relapsing-remitting multiple sclerosis can experience sustained benefit over many years from early interferon beta-1a subcutaneous therapy three times weekly compared with patients whose treatment is delayed. This effect was more apparent in the patients receiving the higher dose.

Avoiding and treating dermal filler complications

All fillers are associated with the risk of both early and late complications. Early side effects such as swelling, redness, and bruising occur after intradermal or subdermal injections. The patient has to be aware of and accept these risks. Adverse events that last longer than 2 weeks can be attributable to technical shortcomings (e.g., too superficial an implantation of a long-lasting filler substance). Such adverse events can be treated with intradermal 5-fluorouracil, steroid injections, vascular lasers, or intense pulsed light, and later with dermabrasion or shaving. Late adverse events also include immunologic phenomena such as late-onset allergy and nonallergic foreign body granuloma. Both react well to intralesional steroid injections, which often have to be repeated to establish the right dose. Surgical excisions shall remain the last option and are indicated for hard lumps in the lips and visible hard nodules or hard granuloma in the subcutaneous fat.

Drugs given by a syringe driver: a prospective multicentre survey of palliative care services in the UK

The use of a syringe driver to administer drugs by continuous subcutaneous infusion is common practice in the UK. Over time, drug combinations used in a syringe driver are likely to change and the aim of this survey was to obtain a more recent snapshot of practice. On four separate days, at two-week intervals, a questionnaire was completed for every syringe driver in use by 15 palliative care services. Of 336 syringe drivers, the majority contained either two or three drugs, but one-fifth contained only one drug. The median (range) volume of the infusions was 15 (9.5-48) mL, and duration of infusion was generally 24 hours. Only one combination was reported as visually incompatible, and there were 13 site reactions (4% of total). Laboratory physical and chemical compatibility data are available for less than half of the most frequently used combinations.

The history of subcutaneous oxygen therapy

Soon after the discovery of oxygen, experiments began on the use of oxygen for therapeutic purposes, including subcutaneous administration of oxygen, on humans and animals. The history of subcutaneous oxygen therapy (SQOT) is examined in the context of the growing understanding of the use and methods of oxygen administration. Little was written about this therapy until the 19th century, despite an advocacy for its use in some circles. There was resurgence in the use of SQOT in the early 20th century. Investigators in the field of anesthesia, including such notable figures as Paul M. Wood, Ralph M. Waters, and John Henry Evans, contributed to the growth in popularity of the therapy and to the literature on the subject. Although SQOT has been supplanted by other means of administration, it may have a role in management of some inflammatory or pain conditions.

Insulinpens in der Diabetesbehandlung

Wesentlicher Bestandteil einer erfolgreichen Insulintherapie ist die korrekte Insulinapplikation. Heutzutage stehen dafür Hilfsmittel zur Verfügung, die die Therapie nicht nur bedienerfreundlicher und sozial verträglicher, sondern auch sicherer machen. Im Zentrum stehen in diesem Zusammenhang die Insulinpens. Die konsistente und präzise Instruktion der Patienten durch ihre Therapeuten erfordert Kenntnisse bezüglich Auswahl des richtigen Pens und der dazu passenden Penkanülen sowie Kenntnisse einiger Details bei der Bedienung der unterschiedlichen Insulinpens. Die Injektionstechnik selbst unterscheidet sich nicht von derjenigen mit Insulinspritzen, wird aber dennoch dargestellt, da es auch hier einige Besonderheiten zu beachten gilt.

Poly-l-lactic acid: consultation on the injection techniques

OBJECTIVES

When poly-L-lactic acid (PLLA) was first introduced (marketed as New-Fill), incorrect injection technique was largely responsible for the manifestation of device-related adverse events in the form of subcutaneous papules and areas of induration. Now marketed as Sculptra, widespread clinical experience with injectable PLLA has resulted in a wealth of information on product reconstitution and correct injection technique. The injection techniques for the optimal use of injectable PLLA are detailed here.

RESULTS

When injecting PLLA it is important to adhere to the product guidelines in terms of injection volume, depth and placement. As the material provides a gradual restoration of volume, PLLA should be injected conservatively, avoiding the possibility of overcorrection. Injections should be sufficiently deep to avoid areas of induration in the superficial layers of the dermis. Areas above hypermobile muscles should also be avoided to prevent localized coalescence of injected material. While utilization of a specific injection technique depends on the position and severity of the volume deficiency, all injections use a 26-gauge needle and are separated by 0.5-1.0 cm. In the lower face a 'criss-cross' and 'tunnelling' technique should be employed, depositing the material into the deep dermis at the junction with the hypodermis, followed by massage every 3-4 injections. Massage should be continued by the patient for at least a week following the treatment session. The 'criss-cross' and 'tunnelling' procedures involve the deposition of 0.1-0.2 mL of PLLA per injection. Material injected into the temple area should be deposited deep next to the bone with a 'depot' technique. Injections around the orbits or perioral region are possible, but should not be attempted without sufficient training.

CONCLUSION

Adhering to the correct injection technique enables the physician to provide durable, natural-looking volume restoration with a very low incidence of device-related adverse events.

Liquid injectable silicone for soft tissue augmentation

Liquid injectable silicone is a unique soft tissue augmenting agent that may be effectively utilized for the correction of specific cutaneous and subcutaneous atrophies. Although historical complications have occurred, resulting likely from the presence of adulterants and impurities, modern purified silicone products approved by the Food and Drug Administration for injection into the human body may be employed with minimal complications when strict protocol is followed. In this article the present authors review the history and controversy regarding silicone as well as describe the appropriate indications, patient selection, instrumentation, treatment protocol, and anticipated complications involved with the use of liquid injectable silicone for soft tissue augmentation. Although its use is controversial, the present authors maintain that liquid injectable silicone is an important and effective augmenting agent for the long-term correction of scars and facial contour defects such as HIV facial lipoatrophy. Furthermore, it is a treatment modality deserving of continued investigation.

Effects of melatonin on orphanin FQ/nociceptin-induced hyperalgesia in mice

The pain modulatory properties of melatonin (MT) are generally recognized but the detail of the interaction between melatonin and opioid system in pain regulation is not fully understood. The present study was undertaken to investigate the modulatory effect of melatonin (MT) on the hyperalgesic effect of Orphanin FQ/Nociceptin (OFQ/NC, NC), a member of opioid peptide family. Intracerebroventricular (i.c.v.) administration of NC (10 microg/mouse) induced significant hyperalgesic effect in tail-flick test in mice; i.c.v. (5, 10, 50 microg/mouse) or intraperitoneal (i.p.) (5, 10, 50 mg/kg) co-injection of melatonin dose-dependently reversed NC-induced hyperalgesia and showed a profound analgesic effect. The antihyperalgesia effect of MT could be significantly antagonized by i.c.v. co-injection of luzindole (10 microg/mouse) (an antagonist of MT receptor) or naloxone (10 microg/mouse) (antagonist of traditional opioid receptor). Taken together, all the results suggested that MT could produce a luzindole and naloxone sensitive reversing effect on NC-induced hyperalgesia at supraspinal and peripheral level in mice. The augmentation effect of MT on the traditional opioid system may be one of the mechanisms of this antihyperalgesia action induced by MT. The present work will help to elucidate the mechanism of the pain modulation effect of MT, and also will help to represent new interesting modulating therapeutic targets for the relief of pain.

Rat/mouse hemokinin-1, a mammalian tachykinin peptide, markedly potentiates the antinociceptive effects of morphine administered at the peripheral and supraspinal level

Rat/mouse hemokinin 1 (r/m HK-1) is a mammalian tachykinin peptide whose biological functions are not fully understood. Our recent report showed that i.c.v. administration of r/m HK-1 could produce dose- and time-related antinociceptive effect at nanomole concentration, and naloxone significantly antagonized this effect. Thus, we provide indirect evidence favoring a role of NK1 supraspinal receptors in the inhibitory control of descending pain pathways, a role that seems to partially involve the activation of the endogenous opioid systems. Based on this report, the present study was conducted to further investigate the direct functional interaction between supraspinal tachykinin (r/m HK-1) and opioid systems. The results demonstrate that i.c.v. administration of r/m HK-1 (5 nmol/kg) could significantly potentiate the antinociceptive effects of morphine which was injected at peripheral and supraspinal level. These antinociceptive effects were blocked by prior treatment with the classical opioid receptors antagonist naloxone, indicating that the potentiated analgesic response is mediated by opioid-responsive neurons. Consistent with previous biochemical data, a likely mechanism underlying the peptide-mediated enhancement of opioid analgesia may center on the ability of r/m HK-1 to release endogenous opioid peptides. We suggest that there may be a cascade amplification mechanism in pain modulation when the two agents were co-administrated. The synergistic analgesic relationship of morphine and r/m HK-1 established here supports the hypothesis that supraspinal tachykinin and peripheral and central opioid systems have a direct functional interaction in the modulation of local nociceptive responses.

An injection depot formulation of buprenorphine: extended bio-delivery and effects

AIM

Buprenorphine is an effective medication for treatment of opioid dependence. An injectable depot formulation of buprenorphine has been developed using biodegradable polymer microcapsule technology. This formulation may offer effective treatment of opioid dependence and enhance treatment delivery while minimizing risks of patient non-adherence or illicit diversion of the medication. This report provides a characterization of the bio-delivery of this injectable depot in humans and of the relationship of drug blood levels to pharmacodynamic indices.

METHOD AND PARTICIPANTS

The data are from two studies in which 11 opioid-dependent volunteers each received a single depot injection containing 58 mg of buprenorphine, and include previously unreported detailed plasma concentration data over a 6-week time-course following depot administration and examination of their relationship to pharmacodynamic indices.

FINDINGS

Mean plasma buprenorphine increased gradually following depot administration, peaked at 2-3 days with a mean concentration of 1.25 ng/ml and then decreased gradually, approaching undetectable levels (< 0.10 ng/mL) by 6 weeks. There was substantial between-subject consistency in several aspects of buprenorphine bio-delivery, including time to first detectable blood level (4 hours), peak blood level (2 days) and undetectable blood level (6-6.5 weeks). In contrast, there was marked between-subject variability in the magnitude of peak buprenorphine concentrations, ranging from 0.17 to 3.47 ng/ml. Extent of opioid blockade was tested by weekly opioid challenges with 3 mg subcutaneous hydromorphone; subjective response and pupillary constriction were related inversely to both buprenorphine and norbuprenorphine plasma concentrations (r=0.84-0.95).

CONCLUSION

The data document that this depot formulation provides effective buprenorphine delivery for several weeks and that effects persist even at fairly low buprenorphine plasma concentrations. Suggestions are offered for further research needed to develop this formulation for clinical use as a detoxification and/or maintenance pharmacotherapy for opioid dependence.

Periaqueductal grey CB1 cannabinoid and metabotropic glutamate subtype 5 receptors modulate changes in rostral ventromedial medulla neuronal activities induced by subcutaneous formalin in the rat

This study was undertaken to analyze the involvement of periaqueductal gray (PAG) cannabinoid or group I metabotropic glutamate receptors in the formalin-induced changes on the rostral ventromedial medulla (RVM) ON- and OFF-cells activities. S.c. injection of formalin into the hind paw produced a transient decrease (4-6 min) followed by a longer increase (25-35 min) in tail flick latencies. Formalin also increased basal activity in RVM ON-cells (42+/-7%) and decreased it in OFF-cells (35+/-4%). Intra-PAG microinjection of (R)-(+)-[2,3-dihydro-5-methyl-3-(4-morpholinylmethyl) pyrrolo[1,2,3-de]-1,4-benzoxazin-6-yl]-1-naphthalenylmethanone mesylate (WIN 55,212-2) (2 nmol/rat), a cannabinoid receptor agonist, prevented the formalin-induced changes in RVM cell activities. Higher dosages of WIN 55,212-2 (4-8 nmol/rat) increased the tail flick latencies, delayed the tail flick-related onset to ON-cell burst, and decreased the duration of OFF-cell pause. Furthermore, WIN 55,212-2 at a dosage of 8 nmol/rat decreased RVM ON-cell (57+/-7%) and increased OFF-cell ongoing activities (26+/-4%). These effects were prevented by N-piperidino-5-(4-chlorophenyl)-1-(2,4dichlorophenyl)-4-methyl-3-pyrazolecarboxamide SR141716A, (1 pmol/rat), a CB1 cannabinoid receptor antagonist, or by 2-methyl-6-(phenylethynyl)pyridine (MPEP 20 nmol/rat), a selective mGlu5 glutamate receptor antagonist. T7-(hydroxyimino) cyclopropa[b]chromen-1alpha-carboxylate ethyl ester (CPCOOE/50 nmol/rat) and (S)-(+)-alpha-amino-4-carboxy-2-methylbenzeneacetic acid (LY367385, 20 nmol/rat), selective mGlu1 glutamate receptor antagonists, were ineffective in preventing the WIN-induced effects. This study suggests that s.c. injection of formalin modifies RVM neuronal activities and this effect is prevented by PAG cannabinoid receptor stimulation. Moreover, the physiological stimulation of PAG mGlu5, but not mGlu1 glutamate receptors, seems to be required for the cannabinoid-mediated effect.

A randomized, multicentre, open-label, parallel-group trial of the tolerability of interferon beta-1a (Rebif) administered by autoinjection or manual injection in relapsing-remitting multiple sclerosis

Injection site reactions (ISRs) are a common side effect of subcutaneous interferon beta therapy, particularly during initiation of therapy. Retrospective analysis of two clinical trials showed that patients using an autoinjector experienced fewer ISRs than patients administering interferon beta manually. This randomized, open-label trial compared the occurrence of ISRs in relapsing remitting multiple sclerosis patients subcutaneously injecting interferon beta-1a manually or with autoinjector. In total, 1825 patients (autoinjector, 932; manual injection, 893) were included in the intention-to-treat analysis. Significantly fewer patients using the autoinjector experienced ISRs, based on physician assessment, compared with manual injection (78.7% versus 85.4%; P <0.001). There was no statistical difference on primary study endpoint: number of patients experiencing moderate to severe ISRs after 12 weeks' therapy (25.3% versus 23.2%, P =0.449). The patient-reported proportion of any ISR during the treatment period was significantly greater for the manual injection group (71.8% versus 66. 1%; P<0.001). The decreased incidence of ISRs with the autoinjector compared to manual injection seen in this short-term study, coupled with ease of use of the autoinjector, suggest that it could improve compliance, and therefore therapeutic outcomes in some patients.

Sugar micro needles as transdermic drug delivery system

We designed and fabricated an array of sugar micro needles of the length ranging from 150 micro m to 2 mm for transdermic delivery of drugs. Micro needles were molded out of maltose mixed with pharmaceutical material, being expected bio-degradable in the human skin. To test basic tolerance to the healthy human skin, a clinical experiment was carried out for 10 healthy adult volunteers. 500 microm-needles containing 5 wt% of ascorbate-2-glycoside were inserted into the skin of the forearm and snapped off to be left in the skin. They spontaneously dissolved by hydrolysis to release ascorbate in the epidermis and the dermis. No dermatological problems were observed in terms of the International Contact Dermatitis Research Group criteria. These observations indicate that the present system is a novel approach to achieve transdermic drug delivery.

The use of botulinum toxic injection to treat excessive drooling in children with neurological conditions

Drooling is a frequent complaint in children with chronic neurological conditions. This is due to poor neuromuscular coordination of the oropharyngeal musculature. Treatment options such as anticholinergic medications and surgical treatment have generally been unsuccessful or associated with side effects and complications. A new treatment for these children is botulinum toxin injection into the parotid glands to decrease saliva production. This article reports on two cases in which this modality was effectively utilized to treat this neurological condition.