Injecting Copaxone into arm?

[katie4242]

I just have a quick ? for all of you expert Copaxone users.  When the nurse taught me how to inject into my arm, she said to stand with my arm held straight out, elbow extended, palm up.  Then inject into the "bat wing" area of fat that hangs down.  I have done it this way each time without any problem, but everybody seems to talk about how difficult it is to inject in the arms.  Am I doing something wrong?  

Katie

p.s.  Just a side note to let everyone know how wonderful I think you are.  I don't usually comment on other people's posts, mostly because I'm newly diagnosed, and don't have much to add.  On the other hand, I am here daily and I appreciate all of the great advice that is given to everyone!  I have learned so much and am very grateful!

[Sarahsmom46]

Funny I am reading you post and I just did my nightly injection 10 minutes ago - in my arm. I hate doing my arms because I do it wrong every time.  Pain...

If the way she showed you does not cause a charley horse pain and the fluid in the injection did not come back out, then you did it right.  The right arm seems to be the toughest place to inject if you happen to be right handed.

You will come up with your "favorite" spots.  Mine are my tummy and upper thighs.  Remember what they told you about rotating the injection sites.  You will not regret sticking to this regime.

We're glad to have you with us too. We have all been where you are now.  

Julie

[katie4242]

What do you mean when you say "the fluid in your injection did not come back out"?  Sometimes there is a little dot of clear liquid on my skin when I take the autoject away.  I usually just soak this up with a cotton ball.  I have been faithfully rotating areas.  Tomorrow am is left arm day.  I think my favorite spots so far (it's only been a month) are definitely my stomach, and maybe my hips - plenty of fat to absorb the pain!  
I do live in fear of the dreaded IPIR.  

Thanks for your help!

[COBOB]

I don't have a problem injecting over the triceps, but I put my arm on the arm of the couch and I don't use the autoinjector.

Bob

[Lulu54]

Hi Katie, thanks for the kind words about the forum - I will agree with you that this is a very special place.

Most people complain about the arms because that is where most pepole have the least amount of fat to inject.  It sounds like you are doing just fine with this.

Julie was talking about exactly what you mention - the medicine dribbling back out of the injection site just a bit.  It is nothing to worry about , it just happens sometimes.

Doing the batwing thing makes sense - the video and my training had my placing my hand on the opposite shoulder and then reaching over the arm to get the fatty part.  For the past month or so I have been injecting with my arm straight down and using the fatty part - but I have plenty of fat to hit.  

As for your worry of  IPIR- I had it happen last spring and knew immediately what it was.  It also passed pretty quick- less than 5 minutes.  If you are aware of this possible side effect, you will know how to react if it does happen to you.  It is a fairly rare thing - and there are no long term complications if it does happen.  It IS NOT a heart attack.  I know some people here who had problems with this and switched DMDs. I'll just hope that you continue to have no problems.

If you have more problems or questions, feel free to ask.  Congrats on working to master the copaxone.

be well, Lulu

[Willowwoman777]

I don't inject into my arms. They were leaving softball size lumps, so my neuro told me to split my tummy in half and figure each half into the rotation.

[twopack]

If you consistently have clear fluid leak out after the injection, you may be withdrawing the needle too quickly.  Remember to count to ten slowly as the injection starts.  This means the medication will all be delivered long before you finish counting.  This delay in removing the needle from the skin should cut down on the amount of leaking fluid you encounter.

Mary

[cainer]

well i dont do arms- it hurts!!!  i just cant  it hurts to much- tick

[COBOB]

My problem is thighs.  Out of 4 shots so far, I have hit a vessel twice and manage to get good sized hematomas on both thighs.  For me, arms are easy.

Bob

[jensequitur]

Yup - I'm one of the people that used to be on Copaxone, but discontinued it due to 'adverse reactions.'  After the fifth IPIR I decided that the threat of having another one was keeping me from being compliant (taking my medication on time.)  Plus the reaction I was having was starting to resemble an allergic reaction.

Katie, how do you compress the autoject so you can inject with one hand?  That's been my biggest problem.  I can't compress and push the button with one hand.

When I was taking Copaxone, I found that old injection sites sometimes had scar tissue in them, so the medication would go in very slow, and sometimes dribble out.  I also had problems with lipoatrophy - denting of the thighs and stomach.

[HVAC]

What you have to worry about with the arm in my humble opinion is not going into the right location or having the needle too deep and hitting the ulnar nerve. I have hit the ulnar nerve twice. Once when I did not check the depth and it was cranked to the highest setting by accident. When you hit this nerve it is worse than hitting your funny bone.

Sounds like you are doing it fine. I had other issues with my arms and just took them out of the rotation.

Alex

[Sarahsmom46]

I have a knack for getting into the muscle instead of the fat layers in my arms.  Maybe I need to pull out the directions the SS nurse gave me last year and relearn to procedure.

Does anyone consistently use heat or ice before or after the injection?  

Julie

[katie4242]

I was using ice afterward and it does help - I just don't have time because we have three kids who need to eat and be ready for school / daycare and I have to get to work.  I inject in the morning after my shower so my skin is already a little warm.  I do think that the heat would help, but again, I don't have time.  The SS nurse that I talked to today said that consistent use of the ice could damage the skin and make injections more difficult.

Jensequitur:  I don't know how I do it with one hand.  Let me think .... I hold it, push it together which also pushes it into my skin a little bit, then hit the button with my thumb.  Sometimes it takes me a few tries to work up the nerve to hit that blue button.  I'm very afraid of the IPIR.  You had 5!!  That is awful!  Are they really bad?

[jensequitur]

The trick is not to panic, of course!  

I started feeling weird and out of sorts immediately, but I knew what was going on, so I just sat there and tried to relax.  I started sweating profusely, all over my body.  My breathing felt constricted, and if I tried to breathe deeply, it would make me cough.  I felt like a balloon - I had the sensation of being filled up with something, although I didn't have any actual swelling.  My face and my upper torso got really red.  It took about twenty minutes to start feeling better, although I never really felt right that day.  I decided I would go to work, but I realized quickly (as we're going around the turns in the road!) that I was getting nauseous, and it would be better if I stayed home.

That was the first one.  I injected into the back of my arm, and I must have hit a blood vessel.    They say that if you always inject into the recommended areas, you'll avoid the IPIR.  Since I wasn't sure why the first one had happened, I left the arms out of my injection rotation.  The second one was in my leg - went too far left.  I knew why that had happened, and avoided that area.  Every time it happened, it seemed to be because I hadn't chosen my injection site very well.  

But the last one was in my leg, in an area that I had injected in before.  I think the reason it went badly was because I have a lot of scar tissue in the leg from previous injections.  It went very slowly, and when it finally went in, then BAM! the IPIR hit me.  This IPIR was different.  I had the usual stuff that I've already described, but I also had facial swelling, and my skin itched like crazy.  It itched so much that I had to sit on my hands so I wouldn't scratch myself.

So I opted for Betaseron.  I figured that the risk of the IPIR was discouraging me from taking the medication, so I was better off with something else.  

Now, this is very important:  Whichever DMD you take, your neuro should be tracking your progress with MRIs, or at least keeping track of your relapses.  This was something my neuro never did.  I had three relapses a year while on Copaxone.  The Copaxone wasn't working for me, but the neuro didn't say "Hey, you're having a lot of relapses - you should switch to another DMD."

What they say is that some people do better on Copaxone, and some do better on an interferon-based drug, like Betaseron, Rebif or Avonex.  They're currently doing research on a blood test which they hope will predict who will do better with an interferon-based drug.

http://med.stanford.edu/ism/2010/march/sclerosis.html

[jensequitur]

Oh, and I think the ice pack did damage my skin.  I would keep it on until it was completely numb, and sometimes the injection area looked a little frostbitten from the cold!

[twopack]

For my arms, I can hold the compressed barrell pieces together and stretch the tip of my index finger to the trigger.  I lightly touch the end to the skin of my arm and fire.  Once triggered, it doesn't matter if the barrel remains compressed.  I count to ten slowly and then withdraw straight out.

On days that my hands are too weak to do this, I push the syringe against the skin to release the safety, hit the trigger and then pull back immediately to make sure the pressure isn't forcing the needle deeper than I want it to be.

I set the autoinjector at only a four or five for the arm.  That's deep enough since the skin and subcutaneous tissue dangle away from the muscle there without the thicker layer of fat on the other injection sites.

I try not to push against the skin much with the autoinjector at any site.  Instead, I steady the tip lightly against the skin with one hand and trigger with the other.  After many months, I know the depth that works for me at each site.  This technique has given me a lot of consistency in giving myself the most comfortable injections.

I was told that if I see the round impression of the barrel on my skin immediately after the injection, it is a sign I have used too much pressure.

One more thing ---
Even though the large majority of my injections are pretty painless these days (still get some sting afterwards though) there is that initial piercing of the skin that can trigger a TOO BIG reflex jump.  It's like watching intently for the toast to pop up from the toaster, knowing it's coming ...... any moment now ....... ready ...... ready ...... and you still jump out of your skin when it happens.

I've found I can sometimes avoid that (and some discomfort) if I start to hum a little or just go ahead and begin to chant ow, ow, ow before hitting the trigger.  Seems if I ow about it first I can make a liar out of myself.  This has been especially helpful on my thighs where I had begun to anticipate pain.

As the routine gets more familiar, you can let your hands inject while your mind visits other places.

Katie, I've never had trouble with my arms either.  We must both have had good instruction.  You're doing fine!
Mary

[Sarahsmom46]

Mary, you make a good point at the end in mentioning good instruction. Good instruction makes a lot of difference. Either I was a bad student or the nurse who came to get me started was not that great.  I had to have another nurse come back again because I had too much distraction the first time. My son and his GF were there trying to be so helpful.  These posts are sure helping as a refresher.

Julie

[twopack]

Julie, I did use heat before and a cold pack afterwards on my thighs for a while.  It seemed to help.  I have had arthritis for years that responds well to heat application (love those parafin baths for the hands!) so I think there is a comfort association for me in heat application.  It doesn't have to have a "real" reason to work.

If the sting wants to hang around I will still use cold applications.  I have a net bag of those plastic ice cubes in the freezer that are perfect for the job.  (They are meant to keep a beverage cold like an ice cube without watering it down as they thaw.)  They conform like a bag of peas but I don't have the worry that someone will try to eat something that's been refrozen 50 times.

Remember the rules for heat or cold application:
Never place directly against the skin.
Never apply to areas with altered sensation.
Never use while sleeping.
Remove after 20 minutes for safety.
If needed long term, 20 minutes on alternated with 20 minutes off is more effective than constant use.

Mary

[meg321]

Hi Katie,

I am off the copaxone until we decide it is causing my hives or not.  My skin reactions never changed, but i didnt mind....and i have had no relapses for a very long time, that was a miracle !!

My nurse showed me how to put a large rubber band on the autoject so you could use one hand, you just wrap it around the top section, and twist it to the other section, this holds it down so you dont have to push it.

Good luck with it....

meg

[katie4242]

O-kay, now I'm confused.  My nurse told me to push the autoject into my skin to get the two pieces to come together.  Is that right, or is that too much pressure?  

[COBOB]

I just take the syringe and point the needle upward at a 45 degree angle and slide it in all the way to the hub over the triceps and inject.  No lumps, bumps or bruising.  Not having the same luck in my thighs.  Two hematomas out of four sticks.

[jensequitur]

Hey, Katie - if you were injecting point down, then I think the pushing together of the autoject would be fine.  For the arm injection that you described, you might be going too deep into your arm.  Copaxone is a sub-cutaneous injection, which means it's supposed to go into the fat, not the muscle. You don't want to push into the skin too hard because you'll go through that layer.  I don't know how much subcutaneous fat you have - I have plenty, but it's still possible to compress it too much.

The safety lock on the autoject is meant to keep you from injecting unless you push it against the skin, but when I was taking Copaxone, I always held it together with my hand, then pushed the button.  This made it a two-handed procedure, though.  When I started Betaseron the nurse showed me the trick with the rubber band.  Works pretty well and I don't get a hand cramp or arm cramp from trying to twist around.

[twopack]

Thanks Meg for the rubber band trick!  I used it tonight with much success and it did make things so much easier on my hand that is weakened with the one-two punch of OA and MS.

I think you are doing fine Katie.  The safety lock is designed to keep us from trigering the unit to fire before we are ready.  I personally do believe it takes too much pressure to release it by pressing on the skin.  That's why I use the technique I described and enjoyed the rubber band technique.

As Jen says, it is easy to inject too deeply in the arms.  I would have thought we would hear you complaining about sore arms if that was happening when you inject there.  If you have doubts about your technique, ask the nurse in your doctors office to go over things again or watch your technique.  Nurses vary in their experience and willingness to stray from scripted teaching instructions.

Find the person and technique you feel comfortable with and stick to it.
Mary

Mary

[katie4242]

Hmmm.... I do get pretty sore after injecting, but I guess I thought that was just par for the course.  Maybe I'll try compressing the autoject with one hand, and triggering with the other when I inject my thigh this morning.

Thanks for the help!

Katie

[twopack]

by katie4242, 3 hours ago
Hmmm.... I do get pretty sore after injecting, but I guess I thought that was just par for the course.

It's another one of those things that could be, but isn't necessarily.  That's the part that makes this whole disease so frustrating for me.  I like to be sure of things (so I feel like I'm in control, no doubt).  You will build confidence as you try variations on the theme and find what works best for you.

Here's something to keep in mind to determine proper depth of injection.  You want to inject into subcutaneous tissue.  That's the tissue under the skin that can be pinched up with your fingers.   How deep that is varies between people and between our own individual body parts.  

To see how deep you can inject without reaching muscle, pinch up some skin over the area.  (This is generally much harder over areas like the hip and thigh unless you are extremely thin.)  Between your fingers you hold a double layer of SC and fat tissue.  Your needle should pierce no deeper than 1/2 that measurement when the skin is flat, which it is when we use the autoinject.  (My preference these days because I can avoid the mild tissue trauma of a pinch.)

You can inject at various depths of the SC tissue.  Deeper injections may be less painful.  I've wondered if lipoatrophy increases with deeper injections that deposit more drug in fatty tissues but I have nothing other than personal rambling thoughts to support that idea.  

I find it easy to test various depths for comfort by using the autoject settings.  Heard of the Sleep Comfort Numer bed?  This is my personal comfort number setting for Copoxone.  Thigh, hip, abdomen and arm all have their preferred number setting.  I don't have to think about it anymore.

BTW, injecting into muscle isn't harmful to the muscle but it can change the speed of absorption of the drug.  The blood supply is greater to muscle than SC tissue, so drugs injected there will usually absorb faster.  Copaxone is meant to be absorbed slowly over 24 hours.  That's why we're instructed to massage an injection site AFTER 24 hours.  Let it absorb slowly for 24 and then rub out any residual so scar tissue doesn't develop at the site.

Hope something in here helps and doesn't just cause more confusion.  I'd hate to see you slide back into silence.  Every member contributes to make this forum what it is.  People who "read only" are always welcome.  Still, it's been nice finding out you are with us.

Mary