“Injections?” you may squeak as the rheumatologist tells you that you need to start a regimen of self injecting medication to treat your rheumatoid arthritis (RA). Perhaps the recommendation for injectable drugs was on your first visit to the rheumatologist or a subsequent visit or you are facing this now. At some point in your treatment plan you will learn that injections are a prominent part of treatment for many RA patients. It is a decision we all face at some point or another as these drugs are making great strides in slowing the progression of illness. There is currently no cure for RA.
For many people with RA the thought of self injecting medications is scary. After all, these medications are not your average drugs. Many are introduced to Methotrexate (MTX) injections first as a injectable treatment if the oral tablets are causing gastrointestinal upset. The first rheumatologist I saw wanted to start me on MTX injections on day one. My reaction? I got a second opinion because I was so flabbergasted! I am glad I got a second opinion, but I now know that starting MTX early is acceptable when the RA is acting aggressively. Back then, all I knew was MTX was chemotherapy in my world as a oncology nurse and I wasn’t jumping off that cliff on day one. A lack of education could have saved me years of treatments that did not work because when caught early and treated aggressively, RA can be slowed or even suspended in remission.
Enbrel was my first injectable medication for RA. It is a biologic which is a drug that is made to specifically target certain cells in the immune system to help prevent inflammation. Specifically, Enbrel is a TNF inhibitor. It works to block the tumor necrosis factor of the immune system. Even as a nurse, I did not understand the in’s and out’s of the immune system to this level. Tumor? Necrosis? To me, tumor was equated with cancer and necrosis means death of tissue. And I was going to inject this? LOL! Sometimes being a nurse isn’t the best thing when nurse become patient. I share this so that you will know you are not alone and to acknowledge the fear of these treatments is real, even for nurses, but it can be overcome with education. My fault was that I had injected insulin as a diabetic for years and assumed I knew the ropes with self injecting. I did not when it came to these specialty drugs. I had to learn.
Drugs such as Enbrel and Humira are often first line biologic agents when the oral disease modifying anti-rheumatoid drugs (DMARD) alone are not controlling the progression of illness. I had to do my homework before I began biologic therapy to educate myself so I would feel comfortable with treatment. My rheumatologist was the cornerstone of this self education, but I also used reliable web sites, and I asked other RA patients about their experience with this medication in Facebook groups for RA patients. As I learned more, I began to get more comfortable with the idea of biologics and you will too. Below is a photo of the Enbrel auto-injector, which is a prefilled pen with a needle tip that you pop off and press the button to give yourself a shot. This delivery method is the most simplistic to use and because of the design it allows you to give the drug in the privacy of your home instead of having to go to the rheumatology clinic for the injection.
In consideration of biological therapy we must weight the side effects that the drug can present. These are highly specialized drugs. When you mess with the immune system one major side effect is opening yourself up to infection. That alone is a scary side effect, but when you start reading the list of side effects for Enbrel, as an example, you will see convulsions, chest pain, difficulty breathing are among the severe reactions. A list of reactions can give you pause, but I had to weight my thought of “do I really want to go down this road?” or face the alternative of rapidly advancing disability. For me, starting therapy was the best choice as my RA was behaving aggressively and had failed to respond to oral medications alone.
Once you commit to self injecting a medication you may face the fear of the injection itself. Will it hurt? Can I do it? What if I can’t do it? What if I mess it up? All of these questions are valid and normal. You should discuss them openly with your rheumatologist. Many rheumatologists offices have sample auto-injectors you can handle to get familiar with the way they work and practice using them. The nurse is often the one to walk you through this education. Once your prescription is filled, you may be asked to come to the rheumatology clinic for your first injection so they can walk you through it to answer any questions you have and to help you learn the technique. To reinforce your teaching, the package insert in the medication that has step by step instructions with pictures that is often accompanied by a video link you can watch to see how to give the injection. I should caution that reading the package insert and/or watching a video should never be substituted for hands on training in your doctor’s office. If you do not feel comfortable giving yourself the injection, inform your prescribing doctor and make arrangements to receive your injection in the office until you are confident you can do it yourself.
Not all injectable medications come in auto-injectors. Some of them come in prefilled syringes, such as Cimzia, as seen below.
The syringes are designed for an arthritic grip and have the advantage of allowing you to control the rate at which the medication enters your body by the pressure you place on the plunger. When using an auto-infuser the medication is delivered swiftly with the push of the pen button. As a nurse, I preferred the prefilled syringes, but I know they aren’t for everyone. It takes education, preparation, and practice to become comfortable with prefilled syringe injections, but you can be taught easily.
Injectable biologics are given subcutaneously which simply means that the medicine is given in the fatty layer of tissue instead of the muscle. Because the drug is to be given in the fatty layer, the pen tips or needles are often fine and short. This minimizes the risk of hitting muscle or a blood vessel. In my experience, Enbrel and Humira stung on injection like a bee sting but it did not last. This sensation was alieved by removing the medication from the refrigerator about 15 minutes prior to injection and letting it come closer to room temperature before injecting. In addition, I slightly iced the area to be injected right before using the auto-injector to numb the skin. Caution should be taken if using these tips not to leave medication out of the refrigerator more than 30 minutes and not to ice the area to be injected more than 5 minutes and to never apply ice directly to the skin. When I shifted to Cimzia, Orencia, and Actemera injections I did not have any burning on injection as these were all prefilled syringes and I could give the medication slowly. Because I was able to control the speed of the injection, it did not burn so I did not need to follow the steps above.
Methotrexate is not a biologic, but an antimetabolite that is considered a disease modifying anti-rheumatic drug (DMARD) when used for RA. It is not understood how MTX works on the immune system, only that is does alter it in some way to reduce inflammation. MTX comes in auto-injectors and vials that you can be taught to use to draw up your own dose.
Regardless of the injectable drug you may find prescribed, do ask questions of your medical staff, conduct your own research, and utilize RA support groups to gather information from others who have used the medication. Only you can decide if injectable medication is a course of therapy for you. Your prescribing physician and medical team should be supportive in your learning process. If you do not feel you have adequate preparation and you have voiced this to your medical team without any consideration, then I would recommend shopping for another healthcare provider.
The next installment of this series is about infusions. Last week, I gave links for real help to assist with the cost of these very expensive medications used to treat RA. Please leave a comment or ask a question, share on social media, and give me some feedback. I hope this series has been beneficial to your healthcare.