Main Article Content
Pain, ustekinumab, subcutaneous injection
Background: Adherence to subcutaneous biologic agents for the treatment of psoriasis can be negatively influenced by injection pain.
Objective: To explore the differences in injection site pain when patients are pre-treated with heat or cold, versus no pre-treatment prior to administration of a subcutaneous biologic agent.
Methods: In an observational cohort study, patients receiving subcutaneous injections of ustekinumab were randomly assigned to receive pretreatment with ice, heat, or no intervention over three visits. Post-dose, patients rated pain on a 100 mm visual analogue scale (VAS).
Results: There was an increase in the VAS score for both heat (2.51, P=0.30) and ice (3.33, P=0.16), compared to no intervention. No differences were found between the two intervention groups (-0.83, P=0.73). On average, females had the same VAS scores with ice compared to that of no intervention (-0.12, P=0.97) and a non–significant decrease of 3.29 points (P=0.38) with heat. Males had increased pain scores by 5.65 points (P=0.07) with ice and by 6.39 points (P=0.04) with heat.
Limitations: Pain is a subjective measurement and objective quantification is difficult.
Conclusions: On average, neither heat nor cold application reliably reduced pain. Our results do not support the application of heat or cold prior to ustekinumab injection.
2. Betegnie AL, Gauchet A, Lehmann A, et al. Why do patients with chronic inflammatory rheumatic diseases discontinue their biologics? An assessment of patients’ adherence using a self-report questionnaire. J Rheumatol. 2016; 43:724-30. doi: 10.3899/jrheum.150414.
3. Bolge SC, Goren A, Tandon N. Reasons for discontinuation of subcutaneous biologic therapy in the treatment of rheumatoid arthritis: a patient perspective. Patient Prefer and Adherence. 2015; 9:121–31. doi: 10.2147/PPA.S70834.
4. Lebwohl MG, Kavanaugh A, Armstrong AW, Van Voorhees AS. US perspectives in the management of psoriasis and psoriatic arthritis: Patient and physician results from the population-based multinational assessment of psoriasis and psoriatic arthritis (MAPP) survey. Am J Clin Dermatol. 2016; 17:87-97. doi: 10.1007/s40257-015-0169-x.
5. Kinoshita H, Kawa G, Hiura Y, et al. Effectiveness of skin icing in reducing pain associated with goserelin acetate injection. Int J Clin Oncol. 2010; 15:472-5. doi: 10.1007/s10147-010-0095-0.
6. Al-Qarqaz F, Al-Aboosi M, Al-shiyab D, et al. Using cold air for reducing needle-injection pain. Int J Dermatol. 2012; 51:848-52. doi: 10.1111/j.1365-4632.2011.05383.x.
7. Skiveren J1, Kjaerby E, Nordahl Larsen H. Cooling by frozen gel pack as pain relief during treatment of axillary hyperhidrosis with botulinum toxin A injections. Acta Derm Venereol. 2008; 88:366-9. doi: 10.2340/00015555-0465.
8. Leff DR, Nortley M, Dang V, et al. The effect of local cooling on pain perception during infiltration of local anaesthetic agents, a prospective randomised controlled trial. Anaesthesia. 2007; 62:677-82.
9. Kuwahara RT, Skinner RB. Emla versus ice as a topical anaesthetic. Dermatol Surg. 2001; 27:495-6.
10. Bechara FG, Sand M, Altmeyer P, et al. Skin cooling for botulinum toxin A injection in patients with focal axillary hyperhidrosis: a prospective, randomised, controlled study. Ann Plast Surg. 2007;58(3):299-302.
11. Davoudi A, Rismanchian M, Akhavan A, et al. A brief review on the efficacy of different possible and nonpharmacological techniques in eliminating discomfort of local anaesthesia injection during dental procedures. Anesth Essays Res. 2016; 10:13-6. doi: 10.4103/0259-1162.167846.
12. Kuzu N, Ucar H. The effect of cold on the occurrence of bruising, haematoma and pain at the injection site in subcutaneous low molecular weight heparin. Int J Nurs Stud. 2001; 38:51-9.
13. Smith KC, Comite SL, Balasubramanian S, et al. Vibration anaesthesia: a noninvasive method of reducing discomfort prior to dermatologic procedures. Dermatol Online J. 2004; 10:1.
14. Mally P, Czyz CN, Chan NJ, et al. Vibration anaesthesia for the reduction of pain with facial dermal filler injections. Aesthetic Plast Surg. 2014; 38:413-8. doi: 10.1007/s00266-013-0264-4.
15. Hogan ME, vanderVaart S, Perampaladas K, et al. Systematic review and meta-analysis of the effect of warming local anaesthetics on injection pain. Ann Emerg Med. 2011; 58:86-98.e1. doi: 10.1016/j.annemergmed. 2010.12.001.
16. Mader TJ, Playe SJ, Garb JL. Reducing the pain of local anaesthetic infiltration: warming and buffering have a synergistic effect. Ann Emerg Med. 1994; 23:550-4.
17. Colaric KB, Overton DT, Moore K. Pain reduction in lidocaine administration through buffering and warming. Am J Emerg Med. 1998; 16:353-6.
18. Scott J, Huskisson EC. Graphic representation of pain. Pain. 1976; 2:175-84.
19. Ohnhaus EE, Adler R. Methodological problems in the measurement of pain: a comparison between the verbal rating scale and the visual analogue scale. Pain. 1975; 1:379-84.
20. Price DD, Bush FM, Long S, Harkins SW. A comparison of pain measurement characteristics of visual analogue and simple numerical rating scales. Pain. 1994; 56:217-26.
21. Maurer AJ, Lissounov A, Knezevic I, et al. Pain and sex hormones: a review of current understanding. Pain Manag. 2016; 6:285-96. doi: 10.2217/pmt-2015-0002.
22. Fillingim RB, King CD, Ribeiro-Dasilva MC, et al. Sex, gender, and pain: a review of recent clinical and experimental findings. J Pain. 2009; 10:447-85. doi: 10.1016/j.jpain.2008.12.001.
23. Manson JE. Pain: sex differences and implications for treatment. Metabolism. 2010; 59 Suppl 1:S16-20. doi: 10.1016/j.metabol.2010.07.013.
24. Craft RM, Mogil JS, Aloisi AM. Sex differences in pain and analgesia: the role of gonadal hormones. Eur J Pain. 2004; 8:397-411.
25. Harrison JL, Davis KD. Cold-evoked pain varies with skin type and cooling rate: a psychophysical study in humans. Pain. 1999; 83:123-35.
26. Kennard MA. The responses to painful stimuli of patients with severe chronic painful conditions. J Clin Invest. 1952; 31:245-52.
27. Riley JL 3rd, Robinson ME, Wise EA, et al. Sex differences in the perception of noxious experimental stimuli: a meta-analysis. Pain. 1998; 74:181-7.
28. Otto MW, Dougher MJ. Sex differences and personality factors in responsivity to pain. Percept Mot Skills. 1985; 61:383-90.
29. Levine FM, De Simone LL. The effects of experimenter gender on pain report in male and female subjects. Pain. 1991; 44:69-72.
30. Feine JS, Bushnell MC, Miron D, et al. Sex differences in the perception of noxious heat stimuli. Pain. 1991;44:255-62.
31. Bertrand AL, Garcia JB, Viera EB, et al. Pupillometry: the influence of gender and anxiety on the pain response. Pain Physician. 2013; 16:E257-66.