Pain following controlled cutaneous insertion of needles with different diameters

Enhancing the Injectability of High Concentration Drug Formulations Using Core Annular Flows

Highly concentrated biological drug formulations would offer tremendous benefits to global health, yet they cannot be manually injected using commercial syringes and needles due to their high viscosities. Current approaches to address this problem face several challenges such as crosscontamination, high cost, needle clogging, and protein inactivation. This work reports a simple method to enhance formulation injectability using a core annular flow, where the transport of highly viscous fluids through a needle is enabled by coaxial lubrication by a less viscous fluid. A phase diagram to ensure optimally lubricated flow while minimizing the volume fraction of lubricant injected is established. The technique presented here allows for up to a 7x reduction in injection force for the highest viscosity ratio tested. The role of buoyancy-driven eccentricity in governing nominal pressure reduction is also examined. Finally, the findings are implemented into the development of a double barreled syringe that significantly expands the range of injectable concentrations of several biologic formulations.

User experience for manual injection of 2 mL viscous solutions is enhanced by a new prefillable syringe with a staked 8 mm ultra-thin wall needle

OBJECTIVES

User experience was compared between a new pre-fillable 2.25 mL glass syringe equipped with an ultra-thin-wall (UTW) 8 mm staked needle and a marketed BD Neopak™ syringe equipped with a special-thin-wall (STW) 12.7 mm staked needle.

METHODS

Participants simulated subcutaneous injections with both syringes alone (formative Human Factors study) and in combination with a needlestick-prevention device (validation Human Factors study).

RESULTS

Usability results of both studies showed higher success rates for delivering the full dose of 2 mL viscous solution (30 cP) with the 8mmUTW syringe than with the 12.7mmSTW one (63% vs. 42% in the formative study). The use of the 8mmUTW syringe demonstrated also better ease of use and acceptance results and 72% of formative study participants preferred this new syringe over the current one when delivering the viscous solution. Using a shorter needle also showed a benefit in decreasing the injection-related anxiety. Besides, in the case of a non-recommended injection technique, the calculated risk of accidental intramuscular injection is reduced by 2 to 13 times with the 8mmUTW syringe.

CONCLUSION

Altogether, the results obtained demonstrated an improvement of the user experience with this new syringe compared to the current one in the manual delivery of 2 mL viscous solutions.

Modeling, design, and machine learning-based framework for optimal injectability of microparticle-based drug formulations

Inefficient injection of microparticles through conventional hypodermic needles can impose serious challenges on clinical translation of biopharmaceutical drugs and microparticle-based drug formulations. This study aims to determine the important factors affecting microparticle injectability and establish a predictive framework using computational fluid dynamics, design of experiments, and machine learning. A numerical multiphysics model was developed to examine microparticle flow and needle blockage in a syringe-needle system. Using experimental data, a simple empirical mathematical model was introduced. Results from injection experiments were subsequently incorporated into an artificial neural network to establish a predictive framework for injectability. Last, simulations and experimental results contributed to the design of a syringe that maximizes injectability in vitro and in vivo. The custom injection system enabled a sixfold increase in injectability of large microparticles compared to a commercial syringe. This study highlights the importance of the proposed framework for optimal injection of microparticle-based drugs by parenteral routes.

Pain-less injection: principles and pearls

There has been an exponential growth in the number of dermatologic procedures performed over the past two decades. This surge in procedural volumes is accompanied by increasing utilization of local anesthetics. A proper technique in administering local anesthesia is necessary to minimize pain and promote comfort, as it is often regarded as the most painful part of cutaneous procedures. Pain is a psychophysiological phenomenon that involves attention, cognitive appraisal, and emotion. Sensory feedback and anxiety are two important aspects of pain perception. This article aims to introduce a novel way that minimizes pain and discomfort associated with local anesthetics. It is the authors' experience that painless injection is achievable by keeping syringes/needles out of sight, proceeding with injection without pre-procedure warning, and engaging patients in a conversation or simple tasks.

Quantitative Evaluation of Bleeding during Blood Vessel Puncture Caused by Fine Needle in Lower Abdomen

Inserting a fine needle presents a trade-off problem between safety and accuracy. As one of the serious complications due to tissue damages during needle insertion, severe bleeding often occurs owing to blood vessel puncture. However, there are few researches to evaluate the safety quantitatively regarding bleeding during the fine needle insertion. Therefore, the purpose of this study was the quantitative evaluation of the amount of bleeding due the artery and vein puncture depending on the needle size. We developed a blood circulation system for measuring the amount of bleeding due to blood vessel puncture. Using the system, the amount of bleeding due to different needle sizes was evaluated. The results suggested that the amount of bleeding per unit time increased depending on the needle radius. According to ordinal safety standards, the 22-gauge needle is appropriate for insertion into the lower abdomen.

LBEC0101, an etanercept biosimilar for the treatment of rheumatoid arthritis

Introduction: Treatment of rheumatoid arthritis (RA) has been revolutionized by the introduction of biologic disease-modifying antirheumatic drugs, such as tumor necrosis factor (TNF) inhibitors. With patent expiry approaching for many expensive biologic molecules, such as etanercept, more affordable biosimilar drugs are being developed. LBEC0101 is an etanercept biosimilar approved in Japan and South Korea for all etanercept indications including RA. Areas covered: We discuss the pharmacological characteristics, pharmacokinetics, efficacy, and safety of LBEC0101 compared with the etanercept reference product (ETN-RP). Preclinical studies showed that the binding affinity to TNFα and biological activity of LBEC0101 were similar to those of the ETN-RP. The pharmacokinetic profile of LBEC0101 was also similar to that of the ETN-RP. A Phase III, randomized, double-blind, 54-week study showed that the efficacy of LBEC0101 was equivalent to that of the ETN-RP in RA patients. An extension study showed that efficacy was sustained long-term in patients receiving LBEC0101 and in those switching from the ETN-RP to LBEC0101. The safety profile of LBEC0101 was also confirmed to be comparable with the ETN-RP. Expert opinion: LBEC0101 has shown equivalent pharmacokinetics and efficacy and comparable safety to the ETN-RP, and the lower cost of LBEC0101 provides a good cost-benefit ratio.

Subcutaneous Injection of Drugs: Literature Review of Factors Influencing Pain Sensation at the Injection Site

The subcutaneous administration route is widely used to administer different types of drugs given its high bioavailability and rapid onset of action. However, the sensation of pain at the injection site might reduce patient adherence. Apart from a direct effect of the drug itself, several factors can influence the sensation of pain: needle features, injection site, volume injected, injection speed, osmolality, viscosity and pH of formulation, as well as the kind of excipients employed, including buffers and preservatives. Short and thin needles, conveniently lubricated and with sharp tips, are generally used to minimize pain, although the anatomic injection site (abdomen versus thigh) also affects the sensation of pain. Large subcutaneous injection volumes are associated with pain. In this sense, the maximum volume generally accepted is around 1.5 ml, although volumes of up to 3 ml are well tolerated when injected in the abdomen. Injected volumes of up to 0.5–0.8 ml are not expected to increase substantially the pain produced by the needle insertion. Ideally, injectable products should be formulated as isotonic solutions (osmolality of about 300 mOsm/kg) and no more than 600 mOs/kg have to be used in order to prevent pain. A pH close to the physiological one is recommended to minimize pain, irritation, and tissue damage. Buffers are frequently added to parenteral formulations to optimize solubility and stability by adjusting the pH; however, their strength should be kept as low as possible to avoid pain upon injection. The data available recommend the concentration of phosphate buffer be limited to 10 mM and that the concentration of citrate buffer should be lower than 7.3 mM to avoid an increased sensation of pain. In the case of preservatives, which are required in multiple-dose preparations, m-cresol seems to be more painful than benzyl alcohol and phenol.

Funding: Sandoz SA.

Penetration force and cannula sliding profiles of different pen needles: the PICASSO study

Purpose

Pen needles used for insulin injections can have different characteristics that affect a patient’s injection experience. The aim of the study was to investigate in a standardized laboratory setting the penetration force and sliding force of different 31/32/33/34 gauge pen needles available in 3.5/4/5/8 mm length and 3/5 bevel tips for subcutaneous injection through pen needles and injection pens.

Methods

Eight different commercially available pen needles were tested in this experimental study. The needle was inserted into a polyurethane substrate at a specific constant speed and the force for insertion was recorded as a function of penetration depth. A load cell was utilized to measure force during the different stages of insertion.

Results

Maximum load was lower with the PiC G32×4 when compared with the G32×4 5-bevel needle (p<0.0001), while it was not significantly lower with the PiC G32×4 when compared to the G32×4 3-bevel needle (p=0.064). The comparison of G33×4 PiC and G34×3.5 PiC needles with G32 needles demonstrated significantly lower maximum loads with G33 and G34 (p<0.0001). No difference between needles emerged for sliding results.

Conclusion

Newer pen needles represent a significant improvement in insulin delivery, reducing the amount of force required to penetrate tissues. Needle tip sharpness and other factors that can reduce the force of insertion such as lubrication are important parameters that can be optimized to increase patient acceptance.

The Injection Technique Factor: What You Don't Know or Teach Can Make a Difference

IN BRIEF To be consistently effective, insulin must be delivered into subcutaneous tissue. If insulin is delivered intramuscularly, its uptake and action become variably faster, leading to suboptimal, inconsistent glucose control. The best strategy to avoid intramuscular injection is to use the shortest needles available. Injection sites should be rotated systematically to prevent lipohypertrophy, which also substantially affects insulin uptake and action. New evidence-based insulin delivery recommendations are available, and awareness of them should lead to more effective use of insulin therapy, improved clinical outcomes, and considerable cost savings.

Fine-needle aspiration of cutaneous, subcutaneous, and intracavitary masses in dogs and cats using 22- vs 25-gauge needles

BACKGROUND

Fine-needle aspiration (FNA) is a common procedure as a diagnostic tool in veterinary medicine. However, it is unclear whether the gauge of the needle affects the quality of cytology.

OBJECTIVE

This study compared the quality of cytologic samples obtained via FNA using 22- or 25-gauge needles.

METHODS

Fine-needle aspiration was performed on 50 masses (cutaneous, subcutaneous, or intracavitary) obtained from client-owned animals. The size of the needle was randomly assigned using either of the following two sequences: 22-25-22 gauge or 25-22-25 gauge. Samples were evaluated by two board-certified clinical pathologists to assess cellularity, blood contamination, amount of cellular debris, degree of cellular trauma, and the overall ability to make a diagnosis for each sample.

RESULTS

No significant difference was detected between the 22- and 25-gauge needle samples for cellularity, whereas a significant difference was present for blood contamination, amount of cellular debris, and degree of cellular trauma. The overall ability to make a diagnosis was not significantly affected by the needle gauge. The degree of cellular trauma was significantly increased in intracavitary samples.

CONCLUSIONS AND CLINICAL RELEVANCE

Needle gauge is a contributing factor to FNA sample quality. However, it did not affect the overall ability to make a diagnosis. Samples obtained using 25-gauge needles resulted in less blood contamination yet increased cellular trauma compared to 22-gauge needle samples.

Evaluating the Impact of Human Factors and Pen Needle Design on Insulin Pen Injection

BACKGROUND

Limited published data exists quantifying the influence of human factors (HF) and pen needle (PN) design on delivery outcomes of pen injection systems. This preclinical in vivo study examines the impact of PN hub design and applied force against the skin during injection on needle penetration depth (NPD).

METHOD

To precisely locate injection depth, PN injections (20 µl; 2 IU, U-100 volume equivalent) of iodinated contrast agent were administered to the flank of Yorkshire swine across a range of clinically relevant application forces against the skin (0.25, 0.75, 1.25, and 2.0 lbf). The NPD, representing in vivo needle tip depth in SC tissue, from four 32 G × 4 mm PN devices (BD Nano^™ 2nd Gen and three commercial posted-hub PN devices; n = 75/device/force, 1200 total) was measured by fluoroscopic imaging of the resulting depot.

RESULTS

The reengineered hub design more closely achieved the 4 mm target NPD with significantly less variability ( P = .006) than commercial posted-hub PN devices across the range of applied injection forces. Calculations of IM (intramuscular) injection risk completed through in silico probability model, using NPD and average human tissue thickness measurements, displayed a commensurate reduction (~2-8x) compared to conventional PN hub designs.

CONCLUSIONS

Quantifiable differences in injection depth were observed between identical labeled length PN devices indicating that hub design features, coupled with aspects of variable injection technique, may influence injection depth accuracy and consistency. The reengineered hub design may reduce the impact of unintended individual technique differences by improving target injection depth consistency and reducing IM injection potential.

Local anesthesia and anxiolytic techniques for oculoplastic surgery

This study discusses local anesthetic agents, administration techniques, ancillary considerations, and safety precautions for oculoplastic surgery including eyelid, lacrimal, orbital, and temporal artery biopsy procedures. Methods for reducing patient apprehension and discomfort including systemic premedication, topical pre-anesthetic, visual, auditory and tactile distraction techniques, regional blocks, small gauge needles, warmed lidocaine, and buffered lidocaine are discussed.

Needle size for vaccination procedures in children and adolescents

BACKGROUND

This is an update of a Cochrane Review first published in 2015. The conclusions have not changed.Hypodermic needles of different sizes (gauges and lengths) can be used for vaccination procedures. The gauge (G) refers to the outside diameter of the needle tubing. The higher the gauge number, the smaller the diameter of the needle (e.g. a 23 G needle is 0.6 mm in diameter, whereas a 25 G needle is 0.5 mm in diameter). Many vaccines are recommended for injection into muscle (intramuscularly), although some are delivered subcutaneously (under the skin) and intradermally (into skin). Choosing an appropriate length and gauge of a needle may be important to ensure that a vaccine is delivered to the appropriate site and produces the maximum immune response while causing the least possible harm. Guidelines conflict regarding the sizes of needles that should be used for vaccinating children and adolescents.

OBJECTIVES

To assess the effects of using needles of different sizes for administering vaccines to children and adolescents on vaccine immunogenicity (the ability of the vaccine to elicit an immune response), procedural pain, and other reactogenicity events (adverse events following vaccine administration).

SEARCH METHODS

We updated our searches of CENTRAL, MEDLINE, Embase, and CINAHL to October 2017. We also searched proceedings of vaccine conferences and two trials registers.

SELECTION CRITERIA

Randomised controlled trials evaluating the effects of using hypodermic needles of any gauge or length to administer any type of vaccine to people aged from birth to 24 years.

DATA COLLECTION AND ANALYSIS

Three review authors independently extracted trial data and assessed the risk of bias. We contacted trial authors for additional information. We rated the quality of evidence using the GRADE system.

MAIN RESULTS

We included five trials involving 1350 participants in the original review. The updated review identified no new trials. The evidence from two small trials (one trial including infants and one including adolescents) was insufficient to allow any definitive statements to be made about the effects of the needles evaluated in the trials on vaccine immunogenicity and reactogenicity.The remaining three trials (1135 participants) contributed data to comparisons between 25 G 25 mm, 23 G 25 mm, and 25 G 16 mm needles. These trials included infants predominantly aged from two to six months undergoing intramuscular vaccination in the anterolateral thigh using the World Health Organization (WHO) injection technique (skin stretched flat, needle inserted at a 90° angle and up to the needle hub in healthy infants). The vaccines administered were combination vaccines containing diphtheria, tetanus, and whole-cell pertussis antigens (DTwP). In some trials, the vaccines also contained Haemophilus influenzae type b (DTwP-Hib) and hepatitis B (DTwP-Hib-Hep B) antigen components.Primary outcomesIncidence of vaccine-preventable diseases: No trials reported this outcome.Procedural pain and crying: Using a wider gauge 23 G 25 mm needle may slightly reduce procedural pain (low-quality evidence) and probably leads to a slight reduction in the duration of crying time immediately after vaccination (moderate-quality evidence) compared with a narrower gauge 25 G 25 mm needle (one trial, 320 participants). The effects are probably not large enough to be clinically relevant.Secondary outcomesImmune response: There is probably little or no difference in immune response, defined in terms of the proportion of seroprotected infants, between use of 25 G 25 mm, 23 G 25 mm, or 25 G 16 mm needles to administer a series of three doses of a DTwP-Hib vaccine at ages two, three, and four months (moderate-quality evidence, one trial, numbers of participants in analyses range from 309 to 402. The immune response to the pertussis antigen was not measured).Severe and non-severe local reactions: 25 mm needles (either 25 G or 23 G) probably lead to fewer severe and non-severe local reactions after DTwP-Hib vaccination compared with 25 G 16 mm needles (moderate-quality evidence, one trial, 447 to 458 participants in analyses). We estimate that one fewer infant will experience a severe local reaction (extensive redness and swelling) after the first vaccine dose for every 25 infants vaccinated with the longer rather than the shorter needle (number needed to treat for an additional beneficial outcome (NNTB) with a 25 G 25 mm needle: 25 (95% confidence interval (CI) 15 to 100); NNTB with a 23 G 25 mm needle: 25 (95% CI 17 to 100)). We estimate that one fewer infant will experience a non-severe local reaction (any redness, swelling, tenderness, or hardness (composite outcome)) at 24 hours after the first vaccine dose for every 5 or 6 infants vaccinated with a 25 mm rather than a 16 mm needle (NNTB with a 25 G 25 mm needle: 5 (95% CI 4 to 10); NNTB with a 23 G 25 mm needle: 6 (95% CI 4 to 13)). The results are similar after the second and third vaccine doses.Using a narrow gauge 25 G 25 mm needle may produce a small reduction in the incidence of local reactions after each dose of a DTwP vaccine compared with a wider gauge 23 G 25 mm needle, but the effect estimates are imprecise (low-quality evidence, two trials, 100 to 459 participants in analyses).Systemic reactions: The comparative effects of 23 G 25 mm, 25 G 25 mm, and 25 G 16 mm needles on the incidence of postvaccination fever and other systemic events such as drowsiness, loss of appetite, and vomiting are uncertain due to the very low quality of the evidence.

AUTHORS' CONCLUSIONS

Using 25 mm needles (either 23 G or 25 G) for intramuscular vaccination procedures in the anterolateral thigh of infants using the WHO injection technique probably reduces the occurrence of local reactions while achieving a comparable immune response to 25 G 16 mm needles. These findings are applicable to healthy infants aged two to six months receiving combination DTwP vaccines with a reactogenic whole-cell pertussis antigen component. These vaccines are predominantly used in low- and middle-income countries. The applicability of the findings to vaccines with acellular pertussis components and other vaccines with different reactogenicity profiles is uncertain.

A Delphi-Based Consensus Statement on the Management of Anticoagulated Patients With Botulinum Toxin for Limb Spasticity

OBJECTIVE

To create a consensus statement on the considerations for treatment of anticoagulated patients with botulinum toxin A (BoNTA) intramuscular injections for limb spasticity.

DESIGN

We used the Delphi method.

SETTING

A multiquestion electronic survey.

PARTICIPANTS

Canadian physicians (N=39) who use BoNTA injections for spasticity management in their practice.

INTERVENTIONS

After the survey was sent, there were e-mail discussions to facilitate an understanding of the issues underlying the responses. Consensus for each question was reached when agreement level was ≥75%.

MAIN OUTCOME MEASURES

Not applicable.

RESULTS

When injecting BoNTA in anticoagulated patients: (1) BoNTA injections should not be withheld regardless of muscles injected; (2) a 25G or smaller size needle should be used when injecting into the deep leg compartment muscles; (3) international normalized ratio (INR) level should be ≤3.5 when injecting the deep leg compartment muscles; (4) if there are clinical concerns such as history of a fluctuating INR, recent bleeding, excessive or new bruising, then an INR value on the day of injection with point-of-care testing or within the preceding 2-3 days should be taken into consideration when injecting deep compartment muscles; (5) the concern regarding bleeding when using direct oral anticoagulants (DOACs) should be the same as with warfarin (when INR is in the therapeutic range); (6) the dose and scheduling of DOACs should not be altered for the purpose of minimizing the risk of bleeding prior to BoNTA injections.

CONCLUSIONS

These consensus statements provide a framework for physicians to consider when injecting BoNTA for spasticity in anticoagulated patients. These consensus statements are not strict guidelines or decision-making steps, but rather an effort to generate common understanding in the absence of evidence in the literature.

Practical differences between luteinizing hormone-releasing hormone agonists in prostate cancer: perspectives across the spectrum of care

BACKGROUND

Androgen deprivation therapy (ADT) with luteinizing hormone-releasing hormone (LHRH) agonists is well established for the treatment of men with metastatic prostate cancer. As clear differences in efficacy, safety, or tolerability between the available LHRH agonists are lacking, the healthcare management team needs to look to practical differences between the formulations when selecting therapy for their patients. Moreover, as the economic burden of prostate cancer rises alongside earlier diagnosis and improved survival, the possibility for cost savings by using products with specific features is growing in importance.

METHODS

A review was conducted to summarize the information on the different LHRH agonist formulations currently available and offer insight into their relative benefits and disadvantages from the perspectives of physicians, a pharmacist, and a nurse.

RESULTS

The leuprorelin acetate and goserelin acetate solid implants have the advantage of being ready to use with no requirement for refrigeration, whereas powder and microsphere formulations have to be reconstituted and have specific storage or handling constraints. The single-step administration of solid implants, therefore, has potential to reduce labor time and associated costs. Dosing frequency is another key consideration, as administering the injection provides an opportunity for face-to-face interaction between the patient and healthcare professionals to ensure therapy is optimized and give reassurance to patients. Prostate cancer patients are reported to prefer 3- or 6-monthly dosing, which aligns with the monitoring frequency recommended in European Association of Urology guidelines and has been shown to result in reduced annual costs compared with 1-month formulations.

CONCLUSIONS

A number of practical differences exist between the different LHRH agonist preparations available, which may impact on clinical practice. It is important for healthcare providers to be aware and carefully consider these differences when selecting treatments for their prostate cancer patients.

Impact of Injection Speed, Volume, and Site on Pain Sensation

BACKGROUND

Painful subcutaneous insulin injections may decrease treatment compliance. Improving injection comfort therefore represents a particular area of technological research in which steady progress has been made since the introduction of the insulin pen in 1985. Injection pain can be influenced by many variables, but relatively little is known about their impact. This study investigated the impact of injection volume (range 0-2250 µL), speed (range 0-800 µL/sec), and site (abdomen vs thigh) on pain sensation.

METHOD

In random order, patients (n = 80) with type 1 or type 2 diabetes received 24 saline injections subcutaneously through a 27G ultra-thin-wall needle. Injections were performed in the abdomen (n = 19) and thigh (n = 5) with predefined speed-volume combinations. For each injected speed-volume combination, patients scored their pain sensation on a 100 mm visual analog scale (VAS).

RESULTS

The mean pain scores for speed-volume combinations were all in the lower part (<20 mm) of the VAS, indicating zero to mild pain. Pain sensation was statistically higher ( P < .05) with the 2250 µL volume compared to other injection volumes (range 4.3-5.1 mm) and with thigh compared to abdomen injections (2.1 mm). Pain sensation did not change with increasing injection speed. Patient acceptance of the injection pain was high for all injections (range 93.7-98.7%).

CONCLUSIONS

In summary, large volume and thigh injections are rated more painful, but the clinical impact of these findings is likely marginal considering the low absolute pain levels and high patient acceptance rates. Injection speed does not influence pain sensation.

Use of Wide-awake Local Anesthesia No Tourniquet in Hand and Wrist Surgery

WALANT (wide-awake local anesthesia no tourniquet) appears to be a safe and effective anesthesia technique for many hand and wrist surgeries. Patient satisfaction is high because of the avoidance of preoperative testing and hospital admission. Postoperative recovery is rapid, and procedures can be done in outpatient settings, resulting in substantial savings in time and money.

Finer Needles Reduce Pain Associated With Injection of Local Anesthetic Using a Minimal Insertion Injection Technique

BACKGROUND

The injection of local anesthetic into the skin is often the only memorable event described by the patient after dermatologic procedures.

OBJECTIVE

The authors compared the pain felt during injection of local anesthetic using a minimal needle insertion technique with a 30- or 33-gauge needle.

MATERIALS AND METHODS

Three hundred eighteen patients with tumors on the head and neck were injected with lidocaine using a previously described technique with either a 30- or 33-gauge needle. After injection, patients were surveyed using the visual assessment scale for pain.

RESULTS

Seventy-seven percent of patients felt no pain with injection on the face using a 33-gauge needle compared with 64% with a 30 gauge, whereas 94% of patients felt no pain on the scalp with a 33-gauge needle compared with 54% with a 30 gauge. Visual analog scale scores were also significantly decreased on the face and scalp using the smaller needle. There was no difference in pain between the 2 needles with injection on the neck.

CONCLUSION

This study further validates the use of this technique for the injection of lidocaine and the preference of a 33 gauge over a 30-gauge needle for the initial injection on the face and scalp.

Role of clove oil in solvent exchange-induced doxycycline hyclate-loaded Eudragit RS in situ forming gel

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Role of clove oil (CO) in doxycycline hyclate (DH)-loaded Eudragit RS (ERS) in situ forming gel (ISG) was investigated.

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CO could solubilize ERS and increase the viscosity of ISG and also minimize DH burst release with sustainable DH release.

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ISGs comprising CO could expel through the 27-gauge needle and transform into matrix depot in simulated crevicular fluid.

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Antimicrobial activities against all test bacterias were increased when increasing CO and N-methyl pyrrolidone (NMP) ratio.

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DH-loaded ERS ISG comprising CO could be used as a local drug delivery system for periodontitis treatment.

Solvent exchange induced in situ forming gel (ISG) is the promising drug delivery system for periodontitis treatment owing to the prospect of maintaining an effective high drug level in the gingival crevicular fluid. In the present study, the influence of clove oil (CO) on the characteristics of doxycycline hyclate (DH)-loaded ISG comprising Eudragit RS (ERS) was investigated including viscosity/rheology, syringeability, in vitro gel formation/drug release, matrix formation/solvent diffusion and antimicrobial activities. CO could dissolve ERS and increase the viscosity of ISG and its hydrophobicity could also retard the diffusion of solvent and hinder the drug diffusion; thus, the minimization of burst effect and sustained drug release were achieved effectively. All the prepared ISGs comprising CO could expel through the 27-gauge needle for administration by injection and transform into matrix depot after exposure to the simulated gingival crevicular fluid. The antimicrobial activities against Staphylococcus aureus, Escherichia coli, Streptococcus mutans and Porphyromonas gingivalis were increased when the ratio of CO and N-methyl pyrrolidone (NMP) was decreased from 1:1 to 1:10 owing to higher diffusion of DH except that for C. albicans was increased as CO amount was higher. Therefore, CO could minimize the burst while prolonging the drug release of DH-loaded ERS ISG for use as a local drug delivery system for periodontitis treatment.

Evaluation of Pain and Specimen Quality by Use of a Novel 25-Gauge Blood Collection Set With Ultra-Thin Wall Cannula and 5-Bevel Tip Design

BACKGROUND

Phlebotomy has significant impact on overall patient satisfaction. Smaller gauge needles, such as a 25 gauge, may lessen patient discomfort but increase hemolysis and tube-filling times. Our studies evaluated the effect of a 5-bevel, 25-gauge blood collection set (BCS) with ultra-thin wall cannula [BD Vacutainer® UltraTouch™ Push Button BCS (UltraTouch)] on patient pain and anxiety compared with two 3-bevel, thin-wall, 23-gauge BCSs [BD Vacutainer® Safety-Lok™ (Safety-Lok) and Greiner Bio-One Vacuette® (Vacuette)]. Our studies also evaluated the 25-gauge UltraTouch for sample quality and tube filling compared with the 3-bevel, thin-wall, 23-gauge BD Vacutainer Push Button BCS.

METHODS

We conducted 2 studies with 214 subjects to compare pain and anxiety regarding future phlebotomy with the 3 aforementioned devices. Another study with 52 subjects assessed hemolysis in specimens collected with the UltraTouch and Push Button BCS; bench testing evaluated tube-filling times with these devices. A questionnaire captured pain upon needle insertion, overall pain, and anxiety regarding future phlebotomy. Hemolysis was evaluated visually, by Hemolysis Index and hemolysis-sensitive indicators potassium (K) and lactate dehydrogenase (LDH).

RESULTS

A statistically significant decrease was noted for overall pain with UltraTouch compared with Vacuette and with insertion pain compared with Safety-Lok. There was no significant difference in anxiety regarding future phlebotomy. No increase was observed in Hemolysis Index, K or LDH. Tube-filling times were comparable for each device.

CONCLUSIONS

The 25-gauge UltraTouch provided less overall pain compared with the 23-gauge Vacuette, less pain upon needle insertion than the 23-gauge Safety-Lok, and no compromise in specimen quality or flow rate.

Silica microparticles for sustained zero-order release of an anti-CD40L antibody

Silica microparticle hydrogel depot (HG) formulation was prepared using spray drying of silica-based sol-gels for the sustained delivery of MR1 antibody which binds to CD40 ligand (CD40L). The formulation was tested in vitro for antibody release, surface morphology, particle size, rheology, and injectability. In vivo pharmacokinetic evaluation was performed for the microparticle formulation and free MR1 antibody in BALB/c female mice. Serum samples up to day 62 were assessed using an enzyme-linked immunosorbent assay. In vitro release indicated that the MR1 antibody was uniformly encapsulated in silica microparticles, and less than 5% burst release of the antibody was observed. In vivo pharmacokinetics showed a zero-order release up to 62 days from the MR1 silica microparticle HG-controlled release composition.

Impact of Needle Diameter on Long-Term Dry Needling Treatment of Chronic Lumbar Myofascial Pain Syndrome

Supplemental digital content is available in the text.

Objective

To investigate the impact of diameter of needles on the effect of dry needling treatment of chronic lumbar myofascial pain syndrome.

Design

Forty-eight patients with chronic lumbar myofascial pain syndrome were randomly allocated to 3 groups. They received dry needling with needles of diameter 0.25 (group A), 0.5 (group B), and 0.9 mm (group C). Visual analog scale evaluation and health survey were conducted at baseline and 3 months after the treatment.

Results

Visual analog scale scores were significantly different in all groups from baseline to 3 months. Visual analog scale scores at 3 months showed differences between group C and the other 2 groups. When baseline and 3 months after treatment (0 day and 3 months) in each of the 3 groups was compared, there was a difference between group C and group B. The Short Form (36) Health Survey scores from baseline to 3 months were different within the treatment groups.

Conclusions

Visual analog scale score evaluations at 3 months showed efficacy in all groups. Results of 3 months showed that efficacy of treatment with larger needles (0.9-mm diameter) was better than that of smaller ones (0.5-mm diameter). The Short Form (36) Health Survey scores at 3 months indicated that treatments with needles of varying diameters were all effective, and when the results of 3 months were compared, there was no difference between the 3 groups.

Left/Right Pain Asymmetry With Injectable Cosmetic Treatments for the Face

BACKGROUND

Pain is processed and experienced differently on the left (L) and right (R) sides of the body; however, L/R pain asymmetry with cosmetic treatments of the face has not been evaluated.

OBJECTIVES

The authors compared patient ratings of L/R facial pain during and immediately after injectable cosmetic treatments.

METHODS

In this cross-sectional multicenter pragmatic study, pain levels were evaluated for 302 patients who underwent facial treatments with botulinum toxin (BTX) and/or impermanent soft-tissue filler (STF). Patients indicated pain intensity on each side of the face with a visual analogue scale (VAS; 0, no pain; 10, worst pain).

RESULTS

Combined mean VAS scores for BTX and STF treatments (L, 3.79 vs R, 3.42), and individual scores for BTX (L, 3.60 vs R, 3.30) or STF (L, 4.22 vs R, 3.69) treatments were significantly different, with pain rated as worse on the L side of the face (all P < 0.01). When treatments were performed first on the L side, patients rated the overall experience as significantly less painful than when treatments were begun on the R side. BTX treatments with a 29-gauge (G) needle were significantly more painful than with a 33-G needle.

CONCLUSIONS

To lessen pain with injectable facial treatments, the authors recommend placing the first injection on the L side of the face and, when possible, employing a high-G needle.

LEVEL OF EVIDENCE 2

A feature study of innovative high-speed lancing device and safety lancet

The study developed two models of an innovative high-speed lancing device and safety lancet, where the specially designed structure causes high-speed motion of the lancet, resulting in only one puncture of the skin. The two experimental models and other lancing devices sold on market were compared in order to: (1) measure the forces of lancets piercing animal skin by a load cell; (2) observe the wound areas caused by lancing devices under a microscope. The experimental results showed that, after using this innovative high-speed lancing device, the maximum force of a lancet piercing skin is only 1/3 of the force of conventional lancing devices, and the duration of the former under the skin is 1/6 of the latter. In addition, the wound area caused by the innovative lancing device is 20 % smaller than those of the conventional lancing devices. Usage of this innovative high-speed safety lancet shows that its maximum skin-piercing force is only 2/3 of conventional safety lancets, its duration under the skin is 1/4 of conventional safety lancets, and the wound area is 12 % smaller. In conclusion, both the innovative high-speed lancing device and safety lancet are proved effective in alleviating pain for diabetics and shortening the recovering time for wounds, thus, providing a more comfortable process for the self-monitoring of blood glucose.

New Insulin Delivery Recommendations

Many primary care professionals manage injection or infusion therapies in patients with diabetes. Few published guidelines have been available to help such professionals and their patients manage these therapies. Herein, we present new, practical, and comprehensive recommendations for diabetes injections and infusions. These recommendations were informed by a large international survey of current practice and were written and vetted by 183 diabetes experts from 54 countries at the Forum for Injection Technique and Therapy: Expert Recommendations (FITTER) workshop held in Rome, Italy, in 2015. Recommendations are organized around the themes of anatomy, physiology, pathology, psychology, and technology. Key among the recommendations are that the shortest needles (currently the 4-mm pen and 6-mm syringe needles) are safe, effective, and less painful and should be the first-line choice in all patient categories; intramuscular injections should be avoided, especially with long-acting insulins, because severe hypoglycemia may result; lipohypertrophy is a frequent complication of therapy that distorts insulin absorption, and, therefore, injections and infusions should not be given into these lesions and correct site rotation will help prevent them; effective long-term therapy with insulin is critically dependent on addressing psychological hurdles upstream, even before insulin has been started; inappropriate disposal of used sharps poses a risk of infection with blood-borne pathogens; and mitigation is possible with proper training, effective disposal strategies, and the use of safety devices. Adherence to these new recommendations should lead to more effective therapies, improved outcomes, and lower costs for patients with diabetes.

Phlebotomy, a bridge between laboratory and patient

The evidence-based paradigm has changed and evolved medical practice. Phlebotomy, which dates back to the age of ancient Greece, has gained experience through the evolution of medicine becoming a fundamental diagnostic tool. Nowadays it connects the patient with the clinical laboratory dimension building up a bridge. However, more often there is a gap between laboratory and phlebotomist that causes misunderstandings and burdens on patient safety. Therefore, the scope of this review is delivering a view of modern phlebotomy to "bridge" patient and laboratory. In this regard the paper describes devices, tools and procedures in the light of the most recent scientific findings, also discussing their impact on both quality of blood testing and patient safety. It also addresses the issues concerning medical aspect of venipuncture, like the practical approach to the superficial veins anatomy, as well as the management of the patient's compliance with the blood draw. Thereby, the clinical, technical and practical issues are treated with the same relevance throughout the entire paper.

NovoPen Echo(®) insulin delivery device

The introduction of insulin pen devices has provided easier, well-tolerated, and more convenient treatment regimens for patients with diabetes mellitus. When compared with vial and syringe regimens, insulin pens offer a greater clinical efficacy, improved quality of life, and increased dosing accuracy, particularly at low doses. The portable and discreet nature of pen devices reduces the burden on the patient, facilitates adherence, and subsequently contributes to the improvement in glycemic control. NovoPen Echo^® is one of the latest members of the NovoPen^® family that has been specifically designed for the pediatric population and is the first to combine half-unit increment (=0.5 U of insulin) dosing with a simple memory function. The half-unit increment dosing amendments and accurate injection of 0.5 U of insulin are particularly beneficial for children (and insulin-sensitive adults/elders), who often require small insulin doses. The memory function can be used to record the time and amount of the last dose, reducing the fear of double dosing or missing a dose. The memory function also provides parents with extra confidence and security that their child is taking insulin at the correct doses and times. NovoPen Echo is a lightweight, durable insulin delivery pen; it is available in two different colors, which may help to distinguish between different types of insulin, providing more confidence for both users and caregivers. Studies have demonstrated a high level of patient satisfaction, with 80% of users preferring NovoPen Echo to other pediatric insulin pens.

Pen needle design influences ease of insertion, pain, and skin trauma in subjects with type 2 diabetes

OBJECTIVE

Pen needles used for subcutaneous injections have gradually become shorter, thinner and more thin walled, and thereby less robust to patient reuse. Thus, different needle sizes, alternative tip designs and needles resembling reuse were tested to explore how needle design influences ease of insertion, pain and skin trauma.

RESEARCH DESIGN AND METHODS

30 subjects with injection-treated type 2 diabetes and body mass index 25-35 kg/m² were included in the single-blinded study. Each subject received abdominal insertions with 18 different types of needles. All needles were tested twice per subject and in random order. Penetration force (PF) through the skin, pain perception on 100 mm visual analog scale, and change in skin blood perfusion (SBP) were quantified after the insertions.

RESULTS

Needle diameter was positively related to PF and SBP (p<0.05) and with a positive pain trend relation. Lack of needle lubrication and small 'needle hooks' increased PF and SBP (p<0.05) but did not affect pain. Short-tip, obtuse needle grinds affected PF and SBP, but pain was only significantly affected in extreme cases. PF in skin and in polyurethane rubber were linearly related, and pain outcome was dependent of SBP increase.

CONCLUSIONS

The shape and design of a needle and the needle tip affect ease of insertion, pain and skin trauma. Relations are seen across different data acquisition methods and across species, enabling needle performance testing outside of clinical trials.

TRIAL REGISTRATION NUMBER

NCT02531776; results.

The Effects of Local Anesthesia Administration on Pain Experience During Interventional Spine Procedures: A Prospective Controlled Trial

OBJECTIVE

It has been postulated that local anesthetic administration may be the most painful part of interventional spine procedures. Despite this, there is a lack of evidence supporting the commonly used traditional technique of anesthetic delivery as part of these procedures. This study tested three hypotheses: 1) alternative method of local anesthesia injection is superior to the traditional method; 2) using the traditional method of injection is not superior to using no local anesthetic; and 3) treatment needle size, anesthetic injection technique, and sedation are associated with pain experienced during procedures.

DESIGN

Prospective, multicenter clinical trial of 127 participants who underwent elective bilateral symmetric interventional spine procedures in outpatient spine clinics.

METHODS

Primary outcomes were pain scores during and after procedures to examine the influence of anesthetic injection method and treatment needle gauge on pain experience using linear mixed model regression analysis. A post-hoc comparison of estimated marginal mean pain scores was completed on both anesthetic injection method and treatment needle gauge.

CONCLUSIONS

The alternative method was superior (P < 0.05) to the traditional method on post procedural pain scores. Injecting local anesthetic with the traditional or alternative method was not superior to using no local anesthetic. Treatment needle size, pain at one inch of treatment needle insertion, and baseline pain were all significantly (P < 0.05) associated with overall procedural pain. Further studies are needed optimize and justify local anesthetic injections for these procedures.

Subcutaneous Administration of Bortezomib: A Pilot Survey of Oncology Nurses

Subcutaneous (SC) administration of the proteasome inhibitor bortezomib was approved in the United States and European Union in 2012. There is limited guidance regarding how to administer SC bortezomib and a general lack of clear direction on optimal techniques for administering SC chemotherapy injections. Nurses may be utilizing different techniques, and inconsistent techniques may result in injection-site reactions, causing patient discomfort and treatment cessatioin. This observational survey of oncology nurses in community oncology clinics aimed to identify techniques being used and explore nurses’ opinions about SC bortezomib administration. A 44-question electronic survey was developed, based on the current literature regarding appropriate techniques for administering SC injections. A total of 43 nurses from 17 clinics in 12 states responded. The majority (74%) had been practicing oncology nursing for at more than 5 years. Respondents predominantly used and preferred the abdomen for injections (88%); 81% used a skin lift to ensure injection into adipose tissue. There was no relationship between the angle of insertion and the needle length; 51% used an air-bubble technique. Nurses took 3–5 (49%), 5–10 (35%), 10–30 (9%), or > 30 (7%) seconds to administer each mL of SC bortezomib injection. All nurses completely/somewhat agreed that practice guidelines would be important for standardizing SC bortezomib administration. Advanced practice registered nurses (APRNs) shared the responsibility for ordering SC bortezomib, according to 53% of respondents. These findings could help APRNs improve the quality of patient care, may help minimize adverse events and maximize effective therapy, and could help inform the development of practice guidelines.

Needle size for vaccination procedures in children and adolescents

BACKGROUND

Hypodermic needles of different sizes (gauges and lengths) can be used for vaccination procedures. The gauge (G) refers to the outside diameter of the needle tubing. The higher the gauge number, the smaller diameter of the needle (eg a 25 G needle is 0.5 mm in diameter and is narrower than a 23 G needle (0.6 mm)). Many vaccines are recommended for injection into muscle (intramuscularly), although some are delivered subcutaneously (under the skin) and intradermally (into skin). Choosing an appropriate length and gauge of a needle may be important to ensure that a vaccine is delivered to the appropriate site and produces the maximum immune response while causing the least possible harm. There are some conflicting guidelines regarding the lengths and gauges of needles that should be used for vaccination procedures in children and adolescents.

OBJECTIVES

To assess the effects of using needles of different lengths and gauges for administering vaccines to children and adolescents on vaccine immunogenicity (the ability of the vaccine to elicit an immune response), procedural pain, and other reactogenicity events (adverse events following vaccine administration).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2014, Issue 10), MEDLINE and MEDLINE in Progress via Ovid (1947 to November 2014), EMBASE via Ovid (1974 to November 2014), and CINAHL via EBSCOhost (1982 to November 2014). We also searched reference lists of articles and textbooks, the proceedings of vaccine conferences, and three clinical trial registers.

SELECTION CRITERIA

Randomised controlled trials evaluating the effects of using hypodermic needles of any gauge or length to administer any type of vaccine to people aged from birth to 24 years.

DATA COLLECTION AND ANALYSIS

Three review authors independently extracted trial data and assessed the risk of bias. We contacted trial authors for additional information. We rated the quality of evidence using the GRADE system.

MAIN RESULTS

We included five trials involving 1350 participants. Data for the primary review outcomes were either absent (for the incidence of vaccine-preventable diseases) or limited (for procedural pain and crying). The available evidence was compromised by the use of surrogate immunogenicity outcomes, incomplete blinding of outcome assessors, and imprecision for some outcomes. The evidence from two small trials was insufficient to allow any confident statements to be made about the effects of the needles evaluated in the trials on vaccine immunogenicity and reactogenicity.The remaining three trials (1135 participants) contributed data to comparisons between 25 G 25 mm, 23 G 25 mm, and 25 G 16 mm needles. These trials involved infants predominantly aged two to six months undergoing intramuscular vaccination in the anterolateral thigh using the World Health Organization (WHO) injection technique (skin stretched flat, needle inserted at a 90° angle and up to the needle hub in healthy infants). The vaccines administered were combination vaccines containing diphtheria, tetanus, and whole-cell pertussis antigens (DTwP). In some trials, the vaccines also contained Haemophilus influenzae type b (DTwP-Hib) and hepatitis B (DTwP-Hib-HepB) antigen components.We found moderate quality evidence from one trial that there is probably little or no difference in immune response, defined in terms of the proportion of seroprotected infants, between using 25 G 25 mm, 23 G 25 mm, or 25 G 16 mm needles to administer a series of three doses of a DTwP-Hib vaccine at ages two, three, and four months (numbers of participants in analyses range from 309 to 402. Immune response to pertussis antigen not measured).25 mm needles (either 23 G or 25 G) probably lead to fewer severe local reactions (extensive redness and swelling) and fewer non-severe local reactions (any redness, swelling, tenderness or hardness (composite outcome)) after DTwP-Hib vaccination compared with 25 G 16 mm needles. We estimate that one fewer infant will experience a severe local reaction after the first vaccine dose for every 25 infants vaccinated with the longer rather than the shorter needle (number needed to treat (NNT) 25 (95% confidence interval (CI) 15 to 100)). We estimate that one fewer infant will experience a non-severe local reaction at 24 hours after the first, second, and third vaccine doses for every five to eight infants vaccinated with the longer rather than the shorter needle (NNTs range from 5 (95% CI 4 to 10) to 8 (95% CI 5 to 34)) (moderate quality evidence, one trial for first and second doses, two trials for third dose, numbers of participants in analyses range from 413 to 528).Using a wider gauge needle (23 G 25 mm) may slightly reduce procedural pain (low quality evidence) and probably leads to a slight reduction in the duration of crying time immediately after vaccination (moderate quality evidence) compared with a narrower gauge (25 G 25 mm) needle (one trial, 320 participants). The effects are probably not large enough to be of any clinical relevance. The 25 G 25 mm needle may produce a small reduction in the incidence of local reactions after each dose of a DTwP vaccine compared with the 23 G 25 mm needle, but the effect estimates are imprecise (low quality evidence, two trials, numbers of participants in analyses range from 100 to 459).The comparative effects of 23 G 25 mm, 25 G 25 mm, and 25 G 16 mm needles on the incidence of post-vaccination fever, persistent inconsolable crying, and other systemic events such as drowsiness, loss of appetite, and vomiting are uncertain due to the very low quality of the evidence.

AUTHORS' CONCLUSIONS

Using 25 mm needles (either 23 G or 25 G) for intramuscular vaccination procedures in the anterolateral thigh of infants using the WHO injection technique probably reduces the occurrence of local reactions while achieving a comparable immune response to 25 G 16 mm needles. These findings are applicable to healthy infants aged two to six months receiving combination DTwP vaccines with a reactogenic whole-cell pertussis antigen component. These vaccines are predominantly used in developing countries. The applicability of the findings to vaccines with acellular pertussis components and other vaccines with different reactogenicity profiles is uncertain.

Arterial puncture using insulin needle is less painful than with standard needle: a randomized crossover study

OBJECTIVES

Arterial punctures are important procedures performed by emergency physicians in the assessment of ill patients. However, arterial punctures are painful and can create anxiety and needle phobia in patients. The pain score of radial arterial punctures were compared between the insulin needle and the standard 23-gauge hypodermic needle.

METHODS

In a randomized controlled crossover design, healthy volunteers were recruited to undergo bilateral radial arterial punctures. They were assigned to receive either the insulin or the standard needle as the first puncture, using blocked randomization. The primary outcome was the pain score measured on a 100-mm visual analogue scale (VAS) for pain, and secondary outcomes were rate of hemolysis, mean potassium values, and procedural complications immediately and 24 hours postprocedure.

RESULTS

Fifty healthy volunteers were included in the study. The mean (±standard deviation) VAS score in punctures with the insulin needle was lower than the standard needle (23 ± 22 mm vs. 39 ± 24 mm; mean difference = -15 mm; 95% confidence interval = -22 mm to -7 mm; p < 0.001). The rates of hemolysis and mean potassium value were greater in samples obtained using the insulin needle compared to the standard needle (31.3% vs. 11.6%, p = 0.035; and 4.6 ±0.7 mmol/L vs. 4.2 ±0.5 mmol/L, p = 0.002). Procedural complications were lower in punctures with the insulin needle both immediately postprocedure (0% vs. 24%; p < 0.001) and at 24 hours postprocedure (5.4% vs. 34.2%; p = 0.007).

CONCLUSIONS

Arterial punctures using insulin needles cause less pain and fewer procedural complications compared to standard needles. However, due to the higher rate of hemolysis, its use should be limited to conditions that do not require a concurrent potassium value in the same blood sample.

Quality of Life and Tolerability After Administration of Enfuvirtide with a Thin-Walled Needle: QUALITÉ Study

PURPOSE

Use of enfuvirtide-containing regimens leads to virologic and immunologic benefits and quality of life (QoL) improvements. This study (QUALITE) was designed to primarily identify baseline predictors of QoL improvements and characterize injection site reaction (ISR) signs/symptoms using a thinner/shorter needle.

METHOD

Enfuvirtide-naïve, antiretroviral (ARV)-experienced patients with CD4 counts >50 cells/mm3 enrolled in this prospective, 12-week, multisite, open-label study. Patients self-administered enfuvirtide, 90 mg bid, using thin-walled, 31-gauge/8-mm needles in combination with other ARVs. QoL was evaluated with MOS-HIV.

RESULTS

Of the 361 patients enrolled, 346 contributed to QoL assessments. Baseline median HIV RNA and CD4 counts were 4.21 log10 copies/mL and 203 cells/mm3, respectively. Although no baseline factors were predictive of week 12 QoL improvement, 9 of 11 MOS-HIV domain scores improved significantly, including physical function (p = .0002) and mental health (p = .0006). Through week 12, 87% of patients reported ISRs; 59% and 28% reported worst pain/discomfort grade < or = 1 and grade > or = 2, respectively, and none were considered serious. Patients reported that self-injection minimally impacted daily functioning or activities.

CONCLUSION

Although no predictors of QoL were identified, significant improvements in QoL were observed with minimal clinically significant ISRs (grade > or = 2) using the 31-gauge/8-mm needle.

Recognition of and steps to mitigate anxiety and fear of pain in injectable diabetes treatment

Injectable treatments, such as glucagon-like peptide-1 receptor agonists and insulin, are options for the pharmacologic treatment of type 2 diabetes. Numerous barriers lead to delay in initiating injectable treatment, which, in turn, may lead to inadequate glycemic control and increased risk of diabetes-related complications, underscoring the need to understand and address these barriers. Barriers to the initiation of injectable therapy, strategies to mitigate barriers, and information about needle attributes and their relation to needle pain are reviewed on the basis of published literature retrieval and our clinical experience. Barriers to the initiation of injectable therapy originate from both patients and practitioners. Anxiety about and fear of injection-associated pain has been estimated to affect approximately 30%-50% of patients before the initiation of diabetes education interventions. Advances in needle design have minimized the pain associated with injections, and recent data suggest that actual pain and bleeding associated with various needle gauges (21-gauge to 31-gauge) are mild. Other barriers include concerns about the ability to handle injectable therapy, concerns about treatment side effects, and impacts on quality of life. Practitioners can help to mitigate barriers to injectable treatment for type 2 diabetes by understanding patient perceptions, improving education, and setting realistic expectations about therapy. Strategies for minimizing injection-associated fear and anxiety include a combination of assessment, appropriate needle selection, patient education, behavioral interventions, and monitoring.

Injectable controlled release depots for large molecules

Biodegradable, injectable depot formulations for long-term controlled drug release have improved therapy for a number of drug molecules and led to over a dozen highly successful pharmaceutical products. Until now, success has been limited to several small molecules and peptides, although remarkable improvements have been accomplished in some of these cases. For example, twice-a-year depot injections with leuprolide are available compared to the once-a-day injection of the solution dosage form. Injectable depots are typically prepared by encapsulation of the drug in poly(lactic-co-glycolic acid) (PLGA), a polymer that is used in children every day as a resorbable suture material, and therefore, highly biocompatible. PLGAs remain today as one of the few "real world" biodegradable synthetic biomaterials used in US FDA-approved parenteral long-acting-release (LAR) products. Despite their success, there remain critical barriers to the more widespread use of PLGA LARproducts, particularly for delivery of more peptides and other large molecular drugs, namely proteins. In this review, we describe key concepts in the development of injectable PLGA controlled-release depots for peptides and proteins, and then use this information to identify key issues impeding greater widespread use of PLGA depots for this class of drugs. Finally, we examine important approaches, particularly those developed in our research laboratory, toward overcoming these barriers to advance commercial LAR development.