Faulty syringes

A board to discuss the Multiple Sclerosis modifying drug Rebif

Faulty syringes

Postby Punchy » Sat Dec 01, 2007 9:06 am

I have had four bad lots of syringes in a row, where the plunger does not go all the way down with the auto-injector, leaving some of the medication behind.

I called Serono and apparently there is an on-going investigation, as this is a wide-spread problem in Canada. And they've known about it for months.

Their only solution was to recommend switching to manual injection. I don't feel ready to do that yet but I guess I don't have much of a choice. :(

At $130 per syringe, I am less than impressed.

I am curious to know about others' experiences with this problem?
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Postby dignan » Sat Dec 01, 2007 11:40 am

I think I've had two syringes this year that didn't work properly with the autoinjector. I use the autoinjector for half of my injections. Interesting that it's a common problem.
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Postby GeoGuy » Sat Dec 01, 2007 6:43 pm

I have had the same problem but I thought it was an issue with the auto-injector spring wearing out prematurely. I also had issues with removing the syringe cap using the auto-injector. A little of the rebif would be sucked out and form a drop on the end of the needle every time I pulled the cap off with the auto-injector.

I decided to take the leap and try injecting with the syringe by itself and found that it is actually easier that way! Here is what I do, maybe it will help you.

I always store the Rebif in the fridge with the needle pointing up and I keep the days syringe that way while it comes to room temperature. When I am about to uncap, I pull back on the plunger about one millimeter to keep liquid from exiting the needle tip (I read that on a thread here, but I can't remember which one, or who wrote it - thanks to whoever you are, it seems to work). Then I invert the syringe, tap it once lightly to make sure the air bubble is at the top, and proceed with the injection. I think it is less painful this way because you have complete control over how fast the needle and the meds go in.

The down side is that I have had to give up injecting in my arms since it takes two hands to do this method. One to work the syringe and one to pinch up enough skin. Since I started injecting this way I have had fewer injection site reactions than I did using the auto-injector, so skipping two locations has not been a problem.

I hope this helps. Good luck and let us know how it goes.

Jack
RRMS since 01/07.
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Postby CureOrBust » Sat Dec 01, 2007 8:21 pm

Its been a while since I was on rebif, so don't forget the salt with this post.
GeoGuy wrote:... I pull back on the plunger about one millimeter to keep liquid from exiting the needle tip (I read that on a thread here, but I can't remember which one, or who wrote it - thanks to whoever you are, it seems to work). Then I invert the syringe, tap it once lightly to make sure the air bubble is at the top, and proceed with the injection.
Maybe I have misunderstood what you have said. I am pretty sure that getting air in the syringe is a big no-no for intravenous injections, so I worked on the assumption that it wasn't the best for subcutaneous injections either. It sounds as if you would be injecting the bubble as well. I think I was shown to tap the bubble to the top and make sure I expel it before injecting.

GeoGuy wrote:The down side is that I have had to give up injecting in my arms since it takes two hands to do this method.
When i started rebif (a few years ago now, and stopped not to long after) they told me that injecting in the arms was no longer recommended. Personally, I heard the auto-injector go off without a syringe in it, and chickened out of using it. Its a little strange to me that people see this as the cowards way.

GeoGuy wrote:One to work the syringe and one to pinch up enough skin.
I'm pretty sure "pinching" the skin to inject into is also not recommended.

Again, I am no longer on rebif, so things could of changed and i could of been doing it wrong in the first place.
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Postby GeoGuy » Sat Dec 01, 2007 10:05 pm

Cure,

You are right, air in an intravenous injection is a bad thing, but for subcutenious injections like interferon it is the norm. Each Rebif syringe comes with an air bubble in it. The air is injected along with the med. The idea is to pass the ar through the needle last to insure the full dose of medication is injected. Hence making sure the air bubble is at the top of the syringe before injecting. I ask my rebif nurse about the air and she said it would dissseminate through the fatty layer under the skin harmlessly.

I started Rebif in February of this year and all the info from Serono and the Rebif nurse indicated that the back of he arm is still an acceptable place to inject. I gave it up, not only because of my switch from the auto-injector, but also because my arms are so thin. You're right about the sound of the auto-injector. It feels about the same way, like a sledge hammer driving a spike in to you. Another reason to switch to syringe only. More than one Rebif nurse has told me that the auto-injector was developed for people that are needle adverse - you don't see it going in.

Pinch may be to strong a phrase. Basically what you want to do is lift a section of the skin away from the muscle to increase the thickness of the subcutenious layer. Typically what I do is take a section of skin about 3 inchs wide and squeeze together about an inch. On me, this make a layer of skin and fatty tissue about an inch thick, enough to keep the needle in the fat layer and out of the muscle. Pinching to small an area is bad. I did that once and had a knot that took two weeks to go away, so it definately takes some practice.

Thanks for questioning what I wrote. It's this knid of open dialog that makes the forum so powerful.

Take care.

Jack
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Re: Faulty Syringes

Postby NHE » Sun Dec 02, 2007 1:27 am

GeoGuy wrote:You are right, air in an intravenous injection is a bad thing, but for subcutenious injections like interferon it is the norm. Each Rebif syringe comes with an air bubble in it. The air is injected along with the med. The idea is to pass the ar through the needle last to insure the full dose of medication is injected. Hence making sure the air bubble is at the top of the syringe before injecting. I ask my rebif nurse about the air and she said it would dissseminate through the fatty layer under the skin harmlessly.

The same is true of Avonex. I've discovered that if you remove all of the air from the syringe prior to the IM injection, then there will be about 65 µL which will remain in the syringe. With Avonex, this represents a loss of about 2 µg of the medication. As an alternative, I dilute the vial with 1.25 mL, and after attaching the needle, add about 4 air bubbles (roughly 200 µL of air) to the syringe after inverting it, and inject the whole lot. This method leaves only about 5 µL in the syringe and maximizes my dosage to about 32.5 µg (in this approximation I've figured that there are probably a few µL of fluid stuck to the side of the vial which cannot be removed). The nurse representative from Biogen did not feel that injecting a small amount of air intramuscularly would be a problem.

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Postby scoobyjude » Sun Dec 02, 2007 2:39 pm

I don't know if this is the same problem but for the last 6 months or so I've had at least a few syringes that would not plunge all the way. I manually inject and still was not able to fully push it down. I called MS Lifelines to alert them and their only response was not to force the syringe. Just to push it as far as it would go. I usually only had a very small amount of medication or just air left (I also pull slightly back on the syringe prior to injection so no medication leaks) so I didn't think it was a big deal. I also remember the injection nurse telling me that I shouldn't worry about injecting the air bubble when doing a subcutaneous injection. She said the air bubble was helpful to make sure that all of the medication was expelled. Judie
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Postby carolsue » Sun Dec 02, 2007 5:50 pm

I know the conversation here is about subcutaneous injection, but I was very interested to learn that the danger of air bubbles for IV injections has been overstated. I learned this when I having an IV steroid course a few years ago, and watched with horror as a bunch of air bubbles went into into my vein! From Wikipedia:

"A blood clot or other solid mass, or an air bubble, can be delivered into the circulation through an IV and end up blocking a vessel; this is called embolism. Peripheral IVs have a low risk of embolism, since large solid masses cannot travel through a narrow catheter, and it is nearly impossible to inject air through a peripheral IV at a dangerous rate. The risk is greater with a central IV.

Air bubbles of less than 30 milliliters generally dissolve into the circulation harmlessly. A larger amount of air, if delivered all at once, can cause life-threatening damage to pulmonary circulation, or, if extremely large (3-8 milliliters per kilogram of body weight), can stop the heart.

One reason veins are preferred over arteries for intravascular administration is because the flow will pass through the lungs before passing through the body. Air bubbles can leave the blood through the lungs. A patient with a heart defect causing a right-to-left shunt is vulnerable to embolism from smaller amounts of air.

Fatality by air embolism is vanishingly rare, in part because it is also difficult to diagnose."
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Postby CureOrBust » Mon Dec 03, 2007 4:02 am

well, I am now all "learned up" to start self injection again.
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