To start, let's talk about the different ways drugs can be administered. You're probably familiar Routes of medication administration are described in the table below. So, they may have to be given by injection instead. The administration of a medicine is a common but important clinical procedure. But don't take our word for it, register for free and unlock 7 days of unlimited. Drug Administration - Explore from the MSD Manuals - Medical Consumer Version. Drugs are introduced into the body by several routes. They may be.
Routes to the Various Medicine: Take
Simons et al conducted a prospective, randomized, blinded, placebo-controlled, six-way cross-over study of IM versus SC injection of epinephrine 0. An identical dose of epinephrine injected IM into the deltoid did not result in significant elevation of C max in comparison with endogenous epinephrine concentrations measured after saline solution injections. Therefore, IM injection of epinephrine into the thigh was recommended as the preferred route and site of injection of epinephrine in the initial treatment of anaphylaxis; otherwise, the advantage of IM epinephrine versus SC epinephrine will disappear.
The SC group exhibited faster and more pronounced effects in decreasing new cortical lesions development and cortical atrophy progression compared with IM group. For the treatment of rheumatic diseases, the antimetabolite drug methotrexate MTX can be administered weekly by different routes: Studies compared the serum concentrations and the pharmacokinetics of low-dose MTX after both IM and SC injections in patients with rheumatoid arthritis.
SC administration may be a more convenient and less painful way of administering low-dose MTX. Although serum MTX levels were not significantly affected by the route of administration, seven out of eight preferred self-administration by the SC route at home. Self-administration was associated with reduced hospital visits and improved patient satisfaction; therefore, parenteral MTX should be prescribed by the SC route instead of the IM route. The total smaller volume of administered drug and the improved usability of a pre-attached needle in combination with a smaller prefilled syringe resulted in preference of the patients of HC over MC.
Human chorionic gonadotropin hCG is used to induce final oocyte maturation and to provide luteal phase support during in vitro fertilization treatment. SC administration achieves a significantly higher hCG level in serum SC hCG obtains the desired clinical effects with less patient inconvenience. Hahner et al evaluated the pharmacokinetics and safety of hydrocortisone after SC and IM injection mg and after SC administration of sodium chloride 0.
Both IM and SC injections increased serum cortisol rapidly and were well tolerated. Regarding the administration route of hydrocortisone, eleven SC administration of mg hydrocortisone shows excellent pharmacokinetics for emergency use with a good safety profile and is preferred by patients over IM injection.
A prospective randomized double-blind cross-over study compared intermittent IM and SC morphine boluses for postoperative analgesia. The majority of patients indicated a strong preference for the SC route despite no significant differences in pain scores, respiratory rate, arterial oxygen saturation, heart rate, mean arterial pressure, sedation, or nausea scores between IM and SC administration of morphine.
Postoperative analgesia by SC morphine bolus injection is as effective as IM injection with a similar side-effect profile but with greater patient acceptance and less risk. Significantly shorter mean T max and greater mean C max were achieved following SC dosing of morphine with rHuPH20 than without rHuPH20, although the extent of exposure of morphine was similar. Some medications have been observed with the existence of optimal injection route Table 1. Obviously, it is inappropriate to simply say that one injection route is overwhelmingly better than another route.
With respect to insulin and ketamine, there seems to be conflict over whether IV is superior to SC. This can also partly be explained by the fact that the ketamine dose was different between two studies 0.
The belief that insulin delivered by the IV route should act more rapidly and decrease blood glucose levels faster than the SC route has become questionable because continuous SC insulin infusion using an insulin pump seemed to control the glycemia better compared to IV insulin infusion in medical intensive care unit patients. Bodur et al explained that continuous SC insulin infusion could avoid extra problems brought by IV insulin infusions including fold dilution 50 IU in 50 mL which may bring slight variations in the preparation of the final syringe and change the concentration of insulin considerably, adsorption of insulin to the surface of the syringe and the lines, and sharing the lumens of central catheters where other treatments are streamed with the potential for interference with infusion rates.
Safety, efficacy, patient preference, and pharmacoeconomics are four principles governing the choice of injection route Figure 2. Safety and efficacy must be the preferred principles to be considered. Firstly, clinicians should know whether there is a contraindicational route in some cases. Prescribing information for some medications has described the IV, SC, or IM route-related contraindication information.
For example, calcium gluconate injection is only for IV use. SC or IM injection may cause severe necrosis and sloughing, and thus, they are contraindicational routes. SC promethazine is contraindicated as it may result in tissue necrosis. Norepinephrine bitartrate injection must be diluted in dextrose-containing solutions prior to infusion. Use of IM and SC is contraindicated because of poor absorption and potential local necrosis due to the vasoconstrictive action of the drug.
Chlorpromazine hydrochloride injection is intended for deep IM use. The SC route is contraindicated for chlorpromazine administration to avoid causing skin irritation, while IV route is only for severe hiccups, surgery, and tetanus.
Potassium chloride injection must be diluted and infused over a certain period of time. Second, literature, rather than prescribing information, has provided good suggestions regarding safety and efficacy issue in the choice of injection route. For example, epinephrine should be given intramuscularly during an episode of systemic anaphylaxis, IM morphine should not be given for pain management, and IM redback spider antivenom should not be recommended in the treatment of redback spider bite.
Besides the four principles, the following detailed factors are related with the choice of injection route:.
Further studies are needed. First, it is necessary to conduct prospective intervention studies with multiple outcome measures following a switch to a more appropriate injection route.
Second, both retrospective and prospective pharmacoeconomic studies should be encouraged. Third, patient preference is important in medical decision making when choosing treatment methods because it has implications for adherence and quality of life. Therefore, future drug efficacy and safety studies should include contemporaneous, actual patient preference where possible, utilizing appropriate measures. Fourth, it is interesting to evaluate the association of potential determinants with the choice of injection route.
For example, the effect of dosing frequency on the choice of injection route for bortezomib remains to be investigated. In patients with multiple myeloma, once-weekly IV or twice-weekly SC bortezomib has been proven to offer non-inferior efficacy and improved safety profile compared with standard twice-weekly IV administration. We did not focus on one point in the form of a Cochrane-style systematic review or meta-analysis because controversial conclusions derived from comparative studies of injection routes are currently rare and our objective is to enrich the knowledge of optimally selecting administration route following a panorama investigation.
Some limitations of this review are as follows: Second, we did not include the comparative studies of injection routes without any difference in efficacy, safety, cost, or patient preference, and such exclusion criteria would restrict the vision of advantages brought by SC administration. For example, even though insignificant difference in safety and efficacy has not been observed when comparing SC route and IV route, SC administration may still be preferred because it is usually more time efficient for the patient and institution.
However, a new horizon might be opened up by this updated review with plenty of new findings. In this updated review, we summarized the findings of comparative studies of different injection routes, which will enrich the knowledge of safe, efficacious, economic, and patient preference-oriented medication administration as well as catching research opportunities in clinical nursing practice.
Patients are complex because of biological, medical, socioeconomic, and cultural factors. Personalized therapeutics would go deep into routine practice and improve patient-specific outcomes if clinical practitioners perform comprehensive interventions, such as optimally choosing administration route, dosage and administration consultation services provided by pharmacy, prospective review of the appropriateness of physician orders by pharmacists, and phar-macotherapeutic monitoring following injection therapy.
National Center for Biotechnology Information , U. Journal List Patient Prefer Adherence v. Published online Jul 2. Author information Copyright and License information Disclaimer.
The full terms of the License are available at http: Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. This article has been cited by other articles in PMC. Abstract Background Intravenous IV , intramuscular IM , and subcutaneous SC are the three most frequently used injection routes in medication administration.
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. Introduction Injections are among the most common health care procedures throughout the world, with at least 16 billion administered in developing and transitional countries each year. Open in a separate window.
Results SC versus IV Trastuzumab Trastuzumab is a key agent for human epidermal growth factor receptor 2 HER2 -positive breast cancer in both the early and metastatic settings.
Antitumor necrosis factor medications Antitumor necrosis factor anti-TNF medications are indicated for the treatment of chronic inflammatory conditions such as rheumatoid arthritis, inflammatory bowel disease, and psoriasis. Bortezomib Bortezomib is indicated for treating relapsed multiple myeloma and mantle cell lymphoma. Amifostine Amifostine is a cytoprotective agent.
Recombinant human granulocyte-macrophage colony-stimulating factor Recombinant human granulocyte-macrophage colony-stimulating factor rhGM-CSF can stimulate the production of white blood cells and thus prevent neutropenia following chemotherapy.
Granulocyte colony-stimulating factor Granulocyte colony-stimulating factor G-CSF can stimulate the bone marrow to produce granulocytes and stem cells. Recombinant interleukin-2 Recombinant human interleukin-2 rIL-2 has demonstrated survival benefits over chemotherapy for the majority of patients with metastatic renal cell carcinoma mRCC. Insulin Bodur et al compared continuous SC insulin infusion via an insulin pump with the traditional continuous IV infusion method for tight glycemic control among patients in medical intensive care unit.
Ketamine Ketamine can suppress hyperalgesia and allodynia. Opioids Daoust et al assessed the impact of age, sex, and route of administration on the incidence of adverse events due to opioid administration in the emergency department. IM versus IV Epinephrine Epinephrine has a pivotal role as first-line treatment for acute anaphylaxis.
Pegaspargase Pegaspargase, a modified version of L-asparaginase that is covalently conjugated to monomethoxypolyethylene glycol, is important for treatment of acute lymphoblastic leukemia.
Antibiotics Generally, antibiotics available for IM injection should be considered as an economically efficient alternative to IV injections in appropriate patients. Morphine IV morphine has a more rapid and extensive initial effect compared with IM, which is supported by the findings of the pharmacokinetic study by Dale et al. IM versus SC Epinephrine A prospective, randomized, blinded, parallel-group study in 17 children with a history of anaphylaxis compared two injection methods SC injection of 0.
Methotrexate For the treatment of rheumatic diseases, the antimetabolite drug methotrexate MTX can be administered weekly by different routes: Human chorionic gonadotropin Human chorionic gonadotropin hCG is used to induce final oocyte maturation and to provide luteal phase support during in vitro fertilization treatment. Hydrocortisone Hahner et al evaluated the pharmacokinetics and safety of hydrocortisone after SC and IM injection mg and after SC administration of sodium chloride 0.
Morphine A prospective randomized double-blind cross-over study compared intermittent IM and SC morphine boluses for postoperative analgesia. Discussion Principles and detailed factors determining the choice of injection route Some medications have been observed with the existence of optimal injection route Table 1. Table 1 Medications that have been observed with advantages of one route over the other route.
Principles and affecting factors associated with the choice of injection route. BMI, body mass index. Sex SC-IG for lifelong treatment of primary antibody deficiencies Medication administration-related factors Anatomical site of injection SC bortezomib, IM epinephrine 24 , Dose SC versus IV rituximab regarding bioavailability Administration time SC versus IV: Indication SC versus IV ketamine for different purposes [postoperative analgesia and dissociative conscious sedation] 57 , Flexibility in the route of administration eg, among prescribing patterns of morphine including IV-to-oral, IV-to-SC, IV-only, SC-only and mixed mode, the mixed mode achieves the best clinical outcomes Further research opportunities Further studies are needed.
Conclusion In this updated review, we summarized the findings of comparative studies of different injection routes, which will enrich the knowledge of safe, efficacious, economic, and patient preference-oriented medication administration as well as catching research opportunities in clinical nursing practice.
Footnotes Disclosure The authors report no conflicts of interest in this work. Pharmaceutical drug use principle issued. Correct recognition and management of anaphylaxis: Intravenous versus subcutaneous access for palliative care patients.
Intravenous versus subcutaneous drug administration. Switching from intravenous to subcutaneous formulation of abatacept: Subcutaneous versus intravenous formulation of trastuzumab for HER2-positive early breast cancer: Comparison of subcutaneous versus intravenous administration of rituximab as maintenance treatment for follicular lymphoma: Subcutaneous vs intravenous rituximab in patients with non-Hodgkin lymphoma: Subcutaneous absorption of monoclonal antibodies: Effects of subcutaneous and intravenous golimumab on inflammatory biomarkers in patients with rheumatoid arthritis: Rheumatology Oxford ; Considering patient preferences when selecting anti-tumor necrosis factor therapeutic options.
Am Health Drug Benefits. Subcutaneous versus intravenous administration of bortezomib in patients with relapsed multiple myeloma: Pharmacokinetic, pharmacodynamic and covariate analysis of subcutaneous versus intravenous administration of bortezomib in patients with relapsed multiple myeloma.
Updated survival analysis of a randomized phase III study of subcutaneous versus intravenous bortezomib in patients with relapsed multiple myeloma. Subcutaneous versus intravenous bortezomib: High incidence and severity of injection site reactions in the first cycle compared with subsequent cycles of subcutaneous bortezomib.
Subcutaneous versus intravenous bortezomib in patients with relapsed multiple myeloma: The drug passes through the intestinal wall and travels to the liver before being transported via the bloodstream to its target site. The intestinal wall and liver chemically alter metabolize many drugs, decreasing the amount of drug reaching the bloodstream. Consequently, these drugs are often given in smaller doses when injected intravenously to produce the same effect.
When a drug is taken orally, food and other drugs in the digestive tract may affect how much of and how fast the drug is absorbed.
Thus, some drugs should be taken on an empty stomach, others should be taken with food, others should not be taken with certain other drugs, and still others cannot be taken orally at all. Some orally administered drugs irritate the digestive tract. For example, aspirin and most other nonsteroidal anti-inflammatory drugs NSAIDs can harm the lining of the stomach and small intestine to potentially cause or aggravate preexisting ulcers.
Other drugs are absorbed poorly or erratically in the digestive tract or are destroyed by the acid and digestive enzymes in the stomach. A drug product can be prepared or manufactured in ways that prolong drug absorption from the injection site for hours, days, or longer. Such products do not need to be administered as often as drug products with more rapid absorption. Sometimes a drug is given through the skin—by needle subcutaneous, intramuscular, or intravenous route , by patch transdermal route , or by implantation.
For the subcutaneous route, a needle is inserted into fatty tissue just beneath the skin. After a drug is injected, it then moves into small blood vessels capillaries and is carried away by the bloodstream. Alternatively, a drug reaches the bloodstream through the lymphatic vessels see Figure: Helping Defend Against Infection.
Protein drugs that are large in size, such as insulin, usually reach the bloodstream through the lymphatic vessels because these drugs move slowly from the tissues into capillaries. The subcutaneous route is used for many protein drugs because such drugs would be destroyed in the digestive tract if they were taken orally. Certain drugs such as progestins used for hormonal birth control may be given by inserting plastic capsules under the skin implantation.
Although this route of administration is rarely used, its main advantage is to provide a long-term therapeutic effect for example, etonogestrel that is implanted for contraception may last up to 3 years.
The intramuscular route is preferred to the subcutaneous route when larger volumes of a drug product are needed. Because the muscles lie below the skin and fatty tissues, a longer needle is used. Drugs are usually injected into the muscle of the upper arm, thigh, or buttock. How quickly the drug is absorbed into the bloodstream depends, in part, on the blood supply to the muscle: The sparser the blood supply, the longer it takes for the drug to be absorbed.
For the intravenous route, a needle is inserted directly into a vein. A solution containing the drug may be given in a single dose or by continuous infusion. For infusion, the solution is moved by gravity from a collapsible plastic bag or, more commonly, by an infusion pump through thin flexible tubing to a tube catheter inserted in a vein, usually in the forearm.
Intravenous administration is the best way to deliver a precise dose quickly and in a well-controlled manner throughout the body. It is also used for irritating solutions, which would cause pain and damage tissues if given by subcutaneous or intramuscular injection.
An intravenous injection can be more difficult to administer than a subcutaneous or intramuscular injection because inserting a needle or catheter into a vein may be difficult, especially if the person is obese. When given intravenously, a drug is delivered immediately to the bloodstream and tends to take effect more quickly than when given by any other route. Consequently, health care practitioners closely monitor people who receive an intravenous injection for signs that the drug is working or is causing undesired side effects.
Also, the effect of a drug given by this route tends to last for a shorter time. Therefore, some drugs must be given by continuous infusion to keep their effect constant. For the intrathecal route, a needle is inserted between two vertebrae in the lower spine and into the space around the spinal cord. The drug is then injected into the spinal canal.
A small amount of local anesthetic is often used to numb the injection site. This route is used when a drug is needed to produce rapid or local effects on the brain, spinal cord, or the layers of tissue covering them meninges —for example, to treat infections of these structures. Anesthetics and analgesics such as morphine are sometimes given this way.
A few drugs are placed under the tongue taken sublingually or between the gums and teeth bucally so that they can dissolve and be absorbed directly into the small blood vessels that lie beneath the tongue. These drugs are not swallowed. The principal site of absorption is the small intestine where there is a large surface area. Drugs absorbed from the gastrointestinal tract enter the portal venous blood and thus pass through the liver before entering the systemic circulation for delivery to the receptors.
This is known as the first-pass hepatic metabolism and explains the reason for large differences between effective oral and intravenous doses in drugs that undergo extensive hepatic extraction and metabolism. The sublingual or buccal routeoffers some theoretical advantages for drug administration. Absorption occurs directly into the systemic circulation as there is no first pass metabolism.
Thus this route of administration permits rapid onset of drug effect since it by-passes the liver. However, few drugs utilise this route, buprenorphine is the most commonly used — it is rapidly absorbed and has a long duration of action 6 h but is associated with a high incidence of side effects namely nausea, vomiting and sedation.
Transdermal administration of drugs provides sustained therapeutic plasma concentrations of the drug and decreases the likelihood of loss of therapeutic efficacy owing to peaks and troughs associated with conventional intramuscular injections.
There is a low incidence of side-effects due to the small fluctuations in plasma concentrations of drugs used and this contributes to high patient compliance. The rectal route is a useful alternative to oral administration of analgesia, particularly if severe pain is accompanied by nausea and vomiting.
Drugs administered into the proximal rectum are subjected to first-pass metabolism. However, drugs administered from a low rectal site reach the general circulation without first passing through the liver. The unpredictability of this route is largely explained by whether the drug passes through the liver or not. The slow and sometimes erratic absorption means that this route is not the ideal route for management of those in acute pain but is better suited for maintaining analgesia.
Additionally, some drugs can cause irritation of the rectal mucosa. Informed consent must be sought prior to administration of any rectal preparation especially if given during general anaesthesia. Parenteral administration may be required to ensure absorption of the active form of the drug and may be the only suitable route of administration. Sub-cutaneous, intramuscular IM , intravenous IV , epidural and intrathecal routes are commonly used.
Routes of drug entry
Prescription drugs can be taken in multiple ways, including oral, enteral, Various pills in blister packs. Jorg Greuel/Digital Vision/Getty Images. There are many routes of medication administration (the way that a drug is. A route of administration in pharmacology and toxicology is the path by which a drug, fluid, The route or course the active substance takes from application location to the . Rate of extent of absorption of the drug from different routes. The IV route was linked with higher rates of all adverse events, the SC the appropriate and flexible use of different routes of administration for.