The ventrogluteal region (targeting the gluteus medius1,16) and the vastus lateralis region are free of major nerves and blood vessels.3,17,18 The safety of the ventrogluteal region as an area for administering IM injections is established and the area is identified as a preferred site within clinical practice guidelines.1,3,12,16-18,20 Nevertheless, nurses are reluctant to use this site, possibly because of a lack of confidence in identifying the area or the absence of recommendations by nursing authors or within nursing education.17,18,20,21 The ventrogluteal site is identifiable by a prominent and easily palpable bony landmark; however, it is a small area, which may be an issue in the setting of repeated injections.17,18

Inexperience with injection techniques and inaccurate landmarking can result in injection-site pain or injury.18,22 Sciatic nerve pain can occur, though rarely, if a dorsogluteal injection is given too low.20,23-25 This risk can be attenuated by selecting the upper and outer quadrant of the buttock.3,10 Both the sciatic nerve and the superior gluteal artery are only a few centimeters from this site so care should be taken to landmark the injection accurately.22 Other injection-related side effects are granuloma; intravascular injection; muscle fibrosis and contracture; tissue necrosis; hematoma; abscess; cellulitis; and injury to blood vessels, bone, and peripheral nerves.3,18



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In a small study conducted by Boyd and colleagues at MD Anderson Cancer Center in Houston, Texas, 146 of 251 intended gluteal IM injections (58%) administered by nurses were deemed successful by pelvic CT scan, while 105 (42%) were associated with subcutaneous nodules, indicating subcutaneous placement. Successful IM injection was associated with self-reported indicators of nursing experience, injection-site location method, depth of needle insertion, and use of nonsyringe hand. Common reasons for unsuccessful IM injection included poor injection-site selection and not advancing the needle to full length. It was estimated that needles 38 mm (1.5 inches) or more would be needed for successful IM injection in 14% to 34% of patients.26

IN THE SETTING OF HR+ METASTATIC BREAST CANCER


Fulvestrant, an estrogen receptor antagonist, is indicated for the treatment of hormone receptor-positive (HR+) metastatic breast cancer in postmenopausal women who have failed antiestrogen therapy.9 It is administered as a once-monthly IM injection with a 21-gauge, 1.5 inch (40 mm) needle. Oral therapies (eg, tamoxifen [Soltamox, generics] and aromatase inhibitors) are also routinely used for this indication. However, despite the assumed convenience of oral therapy, nonadherence or suboptimal adherence is a significant issue with this modality. Poor adherence to tamoxifen, for example, has a significant association with increased risk of death from breast cancer.27

A 2006 survey of patients with breast cancer conducted by the Sussex Psychosocial Oncology Group revealed an initial preference for oral endocrine medications.28 However, almost 50% of respondents admitted to inconsistent adherence to current oral therapies, and patients’ perception of therapy safety and efficacy was more important than route of administration.28 IM fulvestrant may be beneficial from an adherence standpoint because it is administered in a clinical setting; moreover, the controlled setting offers the opportunity for closer monitoring of adverse events.27,29