Prepare to be Poked – Needles and RA Treatments Go Hand-in-Hand
For those who live with type I diabetes, injecting insulin multiple times a day becomes a regular routine. But rheumatoid arthritis patients are also likely to face using needles to administer a variety of medications.
After receiving a diagnosis, there is a progression of RA treatments recommended by the American College of Rheumatology (ACR)[i] that usually begin with chemical-based disease modifying drugs (DMARDs) like methotrexate, sulfasalazine, leflunomide (Arava), and hydroxychloroquine (Plaquenil). All of these drugs are available in pill form. Even though available in pill form, many people cannot tolerate the side effects of the most commonly used DMARD, methotrexate, as it is prone to cause nausea. Methotrexate is also available in an injectable liquid form and many rheumatologists will prescribe this form when side effects can’t be tolerated. If this is the case, the patient must learn to self-inject or have a friend inject them with a syringe once a week. Injecting oneself is an activity that falls pretty low on people’s wish lists. But it can be mastered with a little practice. Most doctors will help patients with their first injection teaching them the proper techniques including sterilization, filling the syringe, getting rid of air bubbles, jabbing into the skin, and disposal of needles.
I self-inject 22.5mg of methotrexate every week as I could not tolerate the nausea caused by taking pills orally. I pick Friday as my injection day in case of side effects as I will then have the weekend to deal with them. The medicine arrives from my mail order pharmacy in small vials containing the yellow liquid. The mail order pharmacy sends syringes but I find them to have large needles and too big to easily handle the small amount of liquid being injected. I pick up syringes at my local pharmacy that are designed for insulin injections as they have tiny, short needles and are easy to handle. I also have a box of alcohol pads and a sharps disposal bucket for the used syringes. It is usually best to inject into a part of the body that contains some fatty tissue as there is less discomfort. For me that is the stomach but I have a friend who injects into her thigh (she actually has her husband do the injection). After disinfecting the injection site and the top of the vial with alcohol, I fill the syringe from the vial as it is held upside down. I add more medicine than needed and then tap the syringe to get the air bubbles to the top. I then squirt out the extra medicine and air bubbles until the right amount is left in the syringe. Now comes the fun part. I take a breath and quickly jab the needle into the skin. Once the needle is in, I gently and slowly inject the medicine. I remove the needle and dispose of the syringe in the sharps bucket. Using small needles usually means no bleeding. Sometimes a drop of medicine comes out and you can just wipe it away.
For those RA patients with moderate to severe disease activity or poor prognosis including functional limitations, rheumatoid nodules, vasculitis, positive rheumatoid factor or anti– cyclic citrullinated peptide antibodies, or bony erosions documented by imaging, the use of biological treatments is recommended by the ACR treatment guidelines. These guidelines likely apply to a vast majority of RA patients and many will find themselves being prescribed biologicals. The first line of biological include the TNF blockers like Enbrel, Humira, Remicade, Cimzia, and Simponi. All except Remicade can be administered via self-injection. The second line of biologicals include Orencia, Actemra, and Rituxan which are administered via an infusion. Orencia is also now approved as a self-inject.
Biological medicines contain genetically engineered antibody proteins which are large and delicate substances which would be destroyed by the acid environment of the stomach. Therefore they must be delivered to the body via injection or infusion. For those which are self-injected, some like Enbrel and Humira come with a preloaded auto-injector pen. After placing the pen on the skin, usually the stomach or thigh, a spring-loaded trigger releases the needle and medicine. The needles in these auto-injector pens are larger in diameter than the small needles used for vaccinations or to inject methotrexate. As such, they do tend to feel like a bee sting. These biologicals also must be stored in the refrigerator and many people warm up the medicine for 15-30 minutes to room temperature before injecting. Some people will apply an ice pack to their skin before injecting to help dull the pain. Other biologicals come in pre-loaded syringes with traditional needles.
Some biologicals like Remicade, Actemra, and Rituxan must be pushed through an IV via infusion over a period of time in order to avoid reactions from the medicine. Orencia is available as both an infusion or self-injection. Infusions require a visit to a clinic where a nurse sets up an IV line in a vein in your arm and a pump slowly pushes the medicine into your body. Depending on the medicine, these infusions can take between 1-6 hours. For Rituxan, pre-medications including solu-medrol (a corticosteroid) and the antihistamine Benadryl are given through the IV in order combat any possible side effects.
Besides self-injecting methotrexate, I’ve used Enbrel auto-inject pens, Humira auto-inject pens, Cimzia pre-filled syringes, and had infusions for Remicade, Orencia, Actemra, and now Rituxan. I’ve come to accept injections and infusions as just part of the fight against RA. If you have RA, you should get used to the fact that you and needles are going to have a lifelong relationship. Yes, you’ll probably hate it as no one likes to be poked with a needle. But the alternative of uncontrolled RA is something that makes the temporary pain tolerable.