High incidence and severity of injection site reactions in the first cycle compared with subsequent cycles of subcutaneous bortezomib

Recurrent Body Rash Warranted Second Desensitization With Acyclovir in a Myeloma Patient: A Case Report

A 75-year-old woman developed a moderately severe rash about a week and a half after the start of bortezomib (Btb)-based chemotherapy for IgG lambda multiple myeloma; at the time, she was also receiving acyclovir as antiviral prophylaxis in addition to herpes zoster (HZ) vaccination. HZ reactivation rate is high in Btb recipients; therefore, the timing of antiviral prevention is critical in relation to Btb. Attempts were made to identify the offending agent based on the timing of drugs administered and the appearance of skin lesions in relation to other drugs. Both Btb and acyclovir were potential culprits. However, the timing of rash presented on days 9 - 10 revealed the offending agent when the corticosteroid was weaned off while acyclovir continued. A decision was made to administer acyclovir rapid desensitization program (RDP) for our patient.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Treatment of multiple myeloma: thalidomide-, bortezomib-, and lenalidomide-induced peripheral neuropathy

Over the last 15 years, substantial progress has been made in the treatment of patients with multiple myeloma (MM). New chemotherapeutic options with the immunomodulatory drugs thalidomide and lenalidomide and with the proteasome inhibitor bortezomib have increased the response rates before and after autologous hematopoietic stem cell transplantation (ASCT). Incorporation of the novel agents into the treatment of newly diagnosed MM and at relapse is now standard of care also for patients with MM not eligible for ASCT. However, the use of thalidomide and bortezomib is frequently associated with a dose-limiting peripheral neuropathy. In order to take full advantage of the therapeutic potential, a risk assessment for neurotoxicity is needed on a case-by-case basis. This assessment includes pre-existing neurological symptoms due to the MM, any comorbidities, and past or planned treatment regimens. The aim is to achieve maximum efficacy while minimizing the risk of developing chemotherapy-induced polyneuropathy (CIPN). This requires a neurological evaluation of the patient at regular intervals, the implementation of preventive measures, and the development of validated therapeutic strategies for emerging neurotoxic side effects. This review focuses on the incidence, prevention, and management of peripheral neurotoxicity due to thalidomide, bortezomib, and lenalidomide in the treatment of MM.