Study comparing IM and SQ

Subject: Study comparing IM and SQ Wed Aug 15 2007, 07:44

I’ve decided to go with IM because of a study someone posted a link to on one of the Yahoo groups. Forgive me if you're here because I'd give you credit.

Now bear with me because I'm not a nurse or medical professional. Please correct me if I’m using incorrect terminology. But as I understood it, the study looked at the bioavailability of Hcg injected SQ v. IM. There were two groups of women. One with a BMI greater than 28 and one with a BMI less than 28. The bioavailabilty of the Hcg varied by injection method and BMI.

The higher than 28 BMI women had the lowest bioavailability of Hcg when injecting SQ. The less than 28 BMI women had the highest bioavailability when injecting IM, but their bioavailability when injecting SQ was still higher than when the higher than 28 BMI women injected IM. Golly, I hope that makes sense.

Maybe this will make it clearer and I'll try to find the link. From highest bioavailability to lowest:

Less than 28 BMI/IM-->Highest
Less than 28 BMI/SQ
Greater than 28 BMI/IM
Greater than 28 BMI/SQ-->Lowest

So, since most of us probably have a BMI of at least 28 or we wouldn't be here in the first place :evil: it seems to me our absorption is still going to lag behind someone fitter even if we inject IM.

The study was for fertility level doses, but for me, I still think it makes sense to inject IM. Here’s the link to the journal article. There is a chart that graphically displays the results. I do realize it was worked in all cases. I just want to maximize the Hcg’s bioavailability ESPECIALLY in the beginning.

http://humrep.oxfordjournals.org/cgi/content/full/18/11/2294

Lisa or another RN will have to comment more specifically. Anything I'm missing or is my logic all off?

Subject: Hmmm... Wed Aug 15 2007, 10:49

Very interesting, thanks for the info! greet 3

Last edited by on Sun Aug 19 2007, 12:49; edited 1 time in total

This is another study on IM vs SC injections methods.

Each route of administration has advantages and disadvantages (see Table 1). Based on these features, as well as on drug formulation, certain drugs must be administered by one route only, while others may be given by more than one route (see Table 2). Greater injection volumes (2 to 5 ml) may be given by the 1M route (Ansel et al., 2004; Wilkinson, 2001). However, because of the distance from the skin surface to the muscle, IM administration requires a longer needle than does SC. IM injections typically use needles 1 to 2 inches in length (Woods & Kabat, n.d.)....

SC injections are usually limited to no more than 2 ml (Ansel et al., 2004). The SC route is not used for drugs that are irritating to the tissue because irritants can cause pain, necrosis, and sloughing at the site of injection (Wilkinson, 2001). For patients requiring multiple doses, SC injections offer a broader range of alternative sites (Ansel et al., 2004). SC injections typically use needles 3/8 to 5/8 inches in length (Woods & Kabat, n.d.).

Drugs that must be self-administered by the patient and involve multiple dosing are routinely given by the SC route (Ansel et al., 2004). Treatment regimens may require once daily or more frequent dosing. Examples of drugs delivered SC include soluble drugs, hormones such as insulin (Ansel et al., 2004), low-molecular- weight heparins (Careinternet. net, 2003), and biologics.

Pharmacokinetic Comparison

Several factors affect the systemic absorption of a drug following parenteral injection. Among the most important factors is blood circulation to the site of absorption (Wilkinson, 2001). Increased blood flow caused by local application of heat or massage will increase the absorption rate. Conversely, decreased blood flow caused by various disease states or vasoconstrictive agents can decrease the absorption rate. Furthermore, the surface type exposed to drug (for example, stomach, intestine, airway/lungs, skin, subcutaneous tissue, muscle) influences where absorption occurs (Wilkinson, 2001). This area of absorption is determined by the route of drug administration.

The absorption rate with SC injection is constant and slow enough to allow a sustained pharmacodynamic effect (Wilkinson, 2001). Blood supply in the SC area affects absorption, so the more proximal the capillaries are to the site of administration and the more numerous the capillaries, the faster the absorption of the drug. All drug products cross capillary membranes at a faster rate than they cross other tissue membranes (Ansel et al., 2004).

While drugs may be absorbed quickly following IM injection, the absorption rate depends on blood flow at the injection site. Joggers, who have greater blood flow to their legs, may experience a much faster rate of absorption of a drug injected into the thigh than if the same dose were injected into another muscle (Ansel et al., 2004; Wilkinson, 2001). The absorption rate of an aqueous drug administered in the deltoid or vastus lateralis generally is greater than that following injection into the gluteus maximus (Wilkinson, 2001). Blood flow to a muscle can affect the absorption rate of drugs administered by IM injection. Decreased blood flow can reduce the absorption rate (DeWit, 2001; Perry & Potter, 2004). In addition, the decreased muscle mass of many older adults may result in faster absorption of drugs delivered by IM injection (AstraZeneca Oncology, 2003; DeWit, 2001; Perry & Potter, 2004). IM absorption of some drugs in infants and young children may be unpredictable due in part to insufficient muscle tone and vascularity of muscle tissue. from http://findarticles .com/p/articles/ mi_m0FSS/ is_2_14/ai_ n17209134

Studies substantiate that there is little or no difference between IM and SC injections in the delivery, absorption, and efficacy of drugs such as vaccines and hormones.

...Therefore, the immunologic response to the vaccine was similar between IM and SC delivery.

A similar study of human chorionic gonadotropin (hCG) in 40 women showed that administration of hCG via the SC route produced greater serum and follicular fluid levels of hCG than when administered by the IM route (Stelling et al., 2003). [Dr,. Simeon was a smart man!]

In a study designed to determine whether rFSH should be given IM or SC in obese women, 19 patients ranging in body mass indices from 19.9 kg/[m.sup.2] to 42.8 kg/[m.sup.2] were administered rFSH (Steinkampf, Hammond, Nichols, & Slayden, 2003). Serum samples of follicle-stimulatin g hormone (FSH) were analyzed following two doses of the drug. Each patient received one dose of rFSH via the IM route and the second dose by the SC route. Resulting data in both obese and nonobese patients showed that SC administration achieved serum concentrations of FSH similar to those achieved when rFSH was given IM (Steinkampf et al., 2003). from http://findarticles .com/p/articles/ mi_m0FSS/ is_2_14/ai_ n17209134/ pg_2

Administration

Ease of administration. Administration may be easier with SC than with IM injections. Although site preparation prior to injection is the same with the two routes (Woods & Kabat, n.d.), the nurse must know and be guided by anatomical landmarks for delivering IM injections. These landmarks may be difficult to determine in patients who are very obese or emaciated. Patient body mass also may dictate the required route of administration, or at least it may determine the appropriate needle length (Wilkinson, 2001). For example, patients who are emaciated may require shorter needles for IM injections because of the shorter distance between the skin surface and muscle (AstraZeneca Oncology, 2003). Because needles of smaller bore and length tend to cause less discomfort during administration, SC injection may cause less pain than an IM injection (Woods & Kabat, n.d.).

With SC injection, the nurse has a substantial, firm area of skin to hold during the injection and delivery of medication (DeWit, 2001; Perry & Potter, 2004). This helps to immobilize the injection site. More sites and a larger overall surface area are available for SC administration than for IM injection. The abdomen, arms, and legs offer sites for SC injections; sites for IM injections are limited to smaller surface areas covering the large muscles, such as areas of the thigh over the vastus lateralis and areas of the buttock over the gluteus medius (AstraZeneca Oncology, 2003). Using the thigh as an example, there is a greater surface area available for SC than IM injections. In addition, some muscles may be sensitive to touch, making them unsuitable for IM injections (AstraZeneca Oncology, 2003). Injections into muscles that are not relaxed will result in more pain and a greater tendency to bleed. Muscles that twitch during assessment of landmarks should not be used for IM injection.

Safety profile. Because of the depths below the skin surface at which the larger blood vessels are located, a SC injection is less likely than an IM injection to pierce a blood vessel (DeWit, 2001). Damage to a nerve is also less likely with SC injection, again because the major nerve fibers generally are located below the depth of penetration of SC needles (DeWit, 2001). In addition, SC injections are unlikely to make contact with bone. In contrast, IM injections carry a greater risk of causing injury to a blood vessel, nerve, or bone (Ansel et al., 2004), often causing complications of muscle contractures and nerve injury in patients (AstraZeneca Oncology, 2003; DeWit, 2001).

http://findarticles .com/p/articles/ mi_m0FSS/ is_2_14/ai_ n17209134/ pg_3

Complications from IM injections can include abscess formation (AstraZeneca Oncology, 2003), local induration, erythema, persistent pain, hematoma, bleeding, and, ultimately, discontinuation of drug administration (DeWit, 2001). Less common side effects can include intramuscular hemorrhage, cellulitis, tissue necrosis, and gangrene (Bergeson, Singer, & Kaplan, 1982). IM injections on occasion cause a great deal of tenderness and may damage local muscle cells (AstraZeneca Oncology, 2003), which may limit mobility for a short time. Among eiders, the problems associated with lack of mobility must be considered, even if only for a few hours or a few days. Complications from SC injections, however, are usually limited to wheal and flare reactions. More serious side effects could include abscess and tissue sloughing at the injection site (AstraZeneca Oncology, 2003; Wilkinson, 2001).

Muscle mass. The choice of giving IM or SC injections is determined, in part, by the patient's muscle mass. Reduced muscle mass alters drug absorption from IM injections (DeWit, 2001; Perry & Potter, 2004). Moreover, IM injections can exacerbate muscle pain due to musculoskeletal disorders, especially in older adults. There is a loss of muscle tone, strength, and mass in these individuals (Inouye, 2004). If an IM injection contributes to impaired mobility in an older adult, other sequelae might include falls and joint pain from favoring the injection site. from http://findarticles .com/p/articles/ mi_m0FSS/ is_2_14/ai_ n17209134/ pg_4

Infection and immunosuppressants. The risk of infection is present with both SC and IM injections because the needle breaks the protective barrier of the skin and introduces the skin's normal bacteria into the tissue beneath (Alcantara, Tucker, & McCarroll, 2002; Brown & Ebright, 2002; Rangel & Cassiani, 2000; Satyanarayana & Mathur, 2003). Injections may cause abscesses or skin and soft tissue infections. Because it is the surface of the needle that pushes bacteria through the skin and beyond the integument, a needle of larger bore and greater length will push a greater surface area of skin tissue, potentially colonized with bacteria, to a greater depth. Additionally, if a blood vessel is damaged by the needle (a more likely occurrence with an IM injection, as discussed previously), the risk of infection will be even greater if bacteria are introduced into the circulatory system. It is possible that patients taking immunosuppressants who develop an infection after an IM or SC injection may be at increased risk of adverse outcomes due to decreased immune responses (Brown & Ebright, 2002). from http://findarticles .com/p/articles/ mi_m0FSS/ is_2_14/ai_ n17209134/ pg_5

In many cases, SC is the preferred route for administering a drug by injection. Even when IM injection is the established route for administering a certain treatment, SC injection may be a viable option. In these situations, nurses can serve as patient advocates by suggesting a change to the SC route. In helping to ensure use of the most appropriate method of drug administration, nurses will make an important contribution to improving patient care by reducing pain at the injection site, improving patient quality of life, reducing cost of patient care, and reducing the potential for infection.

Table 1.
Advantages of SC and IM injections
Subcutaneous Advantages Intramuscular Advantages
* Greater area for target * Can give greater volume of drug
injection sites. product (2 to 5 ml).
* Fewer landmarks required for * Drugs irritating to SC tissue may
targeting injection sites. be given IM.
* Shorter needles can be used
(3/8 to 5/8 inch).
* Readily self-administered.
* Good for multiple dosing.
* Muscle mass not an issue.
* Less discomfort and
inconvenience for patients
with neurological disease
or limited mobility.
* Better safety profile.
Source: Adapted from Ansel et al., 2004; Woods & Kabat, n.d.

from http://findarticles .com/p/articles/ mi_m0FSS/ is_2_14/ai_ n17209134/ pg_6
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Phase 2 started 12/31/07
Day 24, R3P2:
1 st week loss 6.2 loss
2nd week loss 2.2 loss Total down 11.0LBS

Subject: Re: Study comparing IM and SQ Fri Aug 17 2007, 07:48

Thanks so much! So much information and just trying to sort it all out. I think I may just get supplies for both IM and SQ so I have both options. Looks like there are advantages and disadvantages to both.

Thanks again!

Subject: Re: Study comparing IM and SQ Fri Aug 17 2007, 09:29

Flux.... If I may be so bold... ... Now, mind you, I'm pretty tough regarding needles and such.. BUT... I have to say, when time came to stick.. I was REAL happy about those tiny little ones!! :wink 4:
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Subject: Re: Study comparing IM and SQ Fri Aug 17 2007, 10:21

Yeah, I know what you mean. It's all fine and good when I'm researching and deciding, but I have a feeling it will be a bit different when I actually have the supplies in hand and it's time to stick......

I'm also second guessing the dosage I had decided on. In my purely anectdotal observation of folks talking about their dosage, route of administration, initial level of hunger, etc., it seems that higher dosing is working better for SQ and maybe the lower dosing is working better for IM????? Again, ENTIRELY anecdotal, because I'm sure their are people doing just fine with a lower dose SQ. I've actually thought about compiling everyone's info in a spreadsheet so we could see it all in one place. Maybe, I'll work on that and what data we might want to have, but I'll do a separate post about that.

Okay, so here's what I think I'll do, get some of each type of needles since they can be swapped on the syringes. If the IM needles look too scary, I'll go with the SQ. Grrrrrr, why can't doctors at least try this so we're not having to make educated guesses on our own.

But I am so grateful to have found all of you!

Subject: Re: Study comparing IM and SQ Fri Aug 17 2007, 10:37

Hi! I just wanted to let you know that many of us, myself included, ordered our hcg through GHI and they send the syringes with the order. You have no choice, they send the very small syringe and the instructions are to inject Subcutaneously into the belly fat and to inject 250 iu's. Some of us have dropped the dosage to 200 iu's and have found that is working well for us. I'm beginning to think it really makes very little difference IM or SQ and my preference is definitely SQ because it's much easier and I don't even feel it! Also, much less chance of hitting an artery with these tiny needles ... greet 3

Subject: Doses for SQ Sun Aug 19 2007, 12:18

Hi, I'm a new member (as of a few minutes ago), although I have been lurking for awhile. Today is day 8 of injection and 6 of VLCD. It was hard enough to get past the cringing of injecting myself, but finally talked myself into it once I realized that I could use the tiny needles. I started with 150 U/.2 ml (forgot to mention that the little tiny volume appealed to me too!) rotating from glutes, thigh, stomach. The first two days of VLCD were good, felt light and sensed some hunger but kept it at bay. Energy and mood were good. I reread parts of P&I and decided to reduce the dose to 125 U for days 3&4. Hungrier and more fatigued by end of day. Day 5 & 6(yesterday & today) I went back up to 150. I was pretty miserable yesterday-very hungry all day and light headed and spacey. Today I'm hungry and a little low in energy, but better than yesterday.
According to scale, I have lost 7 pounds (8 if you include the 1 pound gained during load). However, it feels like water or glycogen store depletion, as I don't feel any inches gone. I thought I had ~15 pounds to lose to get to a decent %body fat, but now am thinking that if most of this is water, then I likely need to lose even more pounds to truly lose the fat! affraid

I am REALLY concerned that I'm getting the benefit of the HCG. This is not an experiment that I want to repeat.
In your experience, do SQ injectors use a higher does, and if so, what is your recommendations?
Thanks for all of your help, I was really on the fence since first reading the KT book in April, but with all the info here, I got the courage to dive in.
Cindy

Subject: Re: Study comparing IM and SQ Sun Aug 19 2007, 12:30

Hi Choy and welcome

I am on Day 8 too. I would guess to say... that if you are feeling anything but good, UNhungry, and happy.. you might want to increase your dosage a bit.

I was having some headaches the first few days, and have made some adjustments.. BUT... I ordered from GHI Medical.. and they say to use 250iu/.25cc. (I'm surprised you are using so little, but ?? I guess it depends on your source.)

I dropped to 200iu, days 7, and 6, but loss was a few ounces less. So today, I increased back up to 225iu.

You just have to experiment a tiny bit. But if you're uncomfortable and hungry.. that's not right. You might also read through Simeons protocol, and look at the special issues to see if you're following it well.
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Subject: Re: Study comparing IM and SQ Sun Aug 19 2007, 13:58

Welcome Cindy welcome 5

If you didn't do much of Phase 1, you will probably need to go up to 175 or 200. Most of deal with some hunger at the beginning...but it should pass...if not...up your dose.

We're glad you jumped in after lurking around:worm:
We're all here to help each other!
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