Subcutaneous (SC) Administration Of Bortezomib: A Pilot Survey Of Oncology Nurses

The SC route of administration for bortezomib was approved in the USA in January 2012 and the EU in September 2012, in addition to the intravenous (IV) route. Although there is limited guidance in the US Prescribing Information and EU SmPC regarding how to administer SC bortezomib, more broadly there is a lack of clear direction in the literature on administering SC injections. Studies in non-oncology fields suggest that injection site reactions, pain, and bruising can be reduced by using small, short needles, the air bubble rather than purge technique, and slower injections. Inconsistent or poor administration techniques may increase injection site reactions and could contribute to patients stopping effective treatment. Thus, it is important to identify how oncology nurses are administering SC bortezomib. This observational survey of oncology nurses practicing in US community oncology clinics (Cancer Clinics of Excellence) aimed to identify the techniques used and explore nurses’ opinions about SC bortezomib administration.

A 41-question electronic survey on SC bortezomib administration was developed, with all questions based on current literature regarding appropriate techniques for administering SC injections. The questions explored site of administration, needle length, angle of insertion, use of air purge or bubble technique, and duration of administration. Questions were also included regarding convenience of SC administration, nurses’ opinions on patients’ preferences for administration site, and correlation between facility layout and administration site. Nurses at 19 clinics who had administered SC bortezomib were invited to participate in the survey, with limitations imposed on respondent numbers to ensure country-wide input.

A total of 43 nurses from 17 clinics responded to the survey. The majority (74%) had been practicing oncology nursing for >5 years, including 21% for >20 years. Most respondents (93%) indicated that oncologists were responsible for ordering bortezomib for SC administration. Nurse practitioners shared this responsibility according to 53% of respondents. 60% of nurses indicated that they always/sometimes provided input into the decision to use SC administration, with 40% always/sometimes responsible for bortezomib reconstitution. Nurses reported using the abdomen (98%), thigh (19%), and arm (53%) for SC bortezomib. Only the abdomen and thigh were used in the phase 3 study of SC vs IV bortezomib (Moreau et al, Lancet Oncol 2011). The abdomen (88%) and arm (12%) were nurses’ preferred sites due to presence of more tissue, ease of access, less irritation, and patient preference. Nurses believed that patients preferred SC injections in the abdomen (72%) and arm (28%). Nurses’ injection site preferences differed significantly according to facility layout. All respondents indicated a preference for abdominal injection in private/somewhat private facilities, while the abdomen (76%) and arm (24%) were preferred in non-private facilities (p=0.02). Nurses used 25 gauge 5/8 inch (42%) and 27–30 gauge ≤1/2 inch (56%) needles, with both 45º (61%, 42%) and 90º (39%, 58%) angles of insertion used with these respective needle sizes (p=0.21). The air purge technique was used by 49% of nurses, with 51% using an air bubble. Nurses took 3–5 (49%), 5–10 (35%), 10–30 (9%), and >30 seconds (7%) to administer each mL of SC bortezomib injection. All but 1 nurse (98%) indicated that SC administration was much more or somewhat more convenient than IV, with 95% indicating that SC administration took much less or somewhat less time than IV. Most nurses (86%) believed that patients preferred the SC route for reasons including less time spent at clinic, avoidance of IV access, and less toxicity. All nurses completely agreed (77%) or somewhat agreed (23%) that developing a practice guideline would be important, and all but 1 completely agreed (67%) or somewhat agreed (30%) that nurses would change their practice to be consistent with such a guideline.

These findings indicate the heterogeneity of techniques used for SC bortezomib administration, and will help inform the development of practice guidelines with the aim of achieving greater consistency among oncology nurses.

Martin:ONS: Edge: Membership on an entity’s Board of Directors or advisory committees; Millennium: The Takeda Oncology Company: Employment. Zhu:Millennium: The Takeda Oncology Company: Employment. Agretelis:Millennium: The Takeda Oncology Company: Employment; Takeda Pharmaceutical Company Limited: Equity Ownership.