Dermatologica Sinica

CORRESPONDENCE
Year
: 2021  |  Volume : 39  |  Issue : 2  |  Page : 91--92

Skin injury due to failure of an auto-injector device after injection of biologics


Yuichi Yoshida, Naomi Tani, Osamu Yamamoto 
 Division of Dermatology, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, Tottori University, Yonago, Japan

Correspondence Address:
Prof. Osamu Yamamoto
Division of Dermatology, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, Tottori University, 86 Nishi-Cho, Yonago-Shi, Tottori 683-8503
Japan




How to cite this article:
Yoshida Y, Tani N, Yamamoto O. Skin injury due to failure of an auto-injector device after injection of biologics.Dermatol Sin 2021;39:91-92


How to cite this URL:
Yoshida Y, Tani N, Yamamoto O. Skin injury due to failure of an auto-injector device after injection of biologics. Dermatol Sin [serial online] 2021 [cited 2021 Sep 28 ];39:91-92
Available from: https://www.dermsinica.org/text.asp?2021/39/2/91/319144


Full Text



Dear Editor,

We report a case of skin injury caused by an auto-injector device after administration of a biologic agent in a patient with ulcerative colitis.

A 66-year-old Japanese man was referred to our department for a complication caused by using an auto-injector. He had a 6-month history of ulcerative colitis. He had been treated with anti-tumor necrosis factor (anti-TNF, 100 mg/4 weeks) for 2 months. During subcutaneous injection of golimumab (Simponi-Janssen) using an auto-injector into the left upper arm by a nurse, the needle of the device became stuck. The nurse tried to pull it out, but it was difficult to remove the device. A physical examination showed a hanging injector in his left upper arm, causing continuous pain by the pulling force of the device [Figure 1]a. The needle seemed to be hooked and embedded in the subcutis [Figure 1]b. It was successfully removed by cutting the skin surface under local anesthesia. However, the stuck device caused an ulcer [Figure 1]c.{Figure 1}

Biologics against TNFα has been used for the treatment of various diseases including ulcerative colitis, rheumatoid arthritis, and psoriasis. Golimumab is one of the anti-TNF antibodies and is effective for ulcerative colitis.[1] The medicine is delivered subcutaneously by an auto-injection device. Instructions recommend giving an injection to an area of thick fat such as the abdomen. There have been only a few reports of device failures in children due to epinephrine injectors.[2] The difficulty in removing the device was caused by a hooked needle chip. Although we could not find a report of an uncommon complication caused by an auto-injector for biologics, the reason for the failure in our case seems to be compatible with that in the previous report. It is most likely that the tip of the needle accidentally hit the bone and became bent during auto-injection. We propose that users, especially men, avoid injection in an upper arm because the thickness of fat may not be sufficient in that region. In addition, when an accident happens, the device should be removed as soon as possible. If the device is not removed, necrosis of the lesion might occur due to the continuous pulling power of the auto-injector.

Although there is little evidence to support age- or BMI-specific needle length recommendations for an auto-injector device, the evaluation of used injector may lead to improvements in the design. A shorter needle length may be a more appropriate choice for the devices.[3] Another way is to use alternative delivery methods for biologics such as nanotechnologies that increase bioavailability in the future.[4] In addition, we are hoping for a breakthrough in the development of needle-free devices for delivery of most biologics.[5]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Olivera P, Danese S, Pouillon L, Bonovas S, Peyrin-Biroulet L. Effectiveness of golimumab in ulcerative colitis: A review of the real world evidence. Dig Liver Dis 2019;51:327-34.
2Goldman RD, Long KC, Brown JC. Hooked epinephrine auto-injector devices in children: four case reports with three different proposed mechanisms. Allergy Asthma Clin Immunol 2020;16:19.
3Ibrahim M, Kim H. Unintentional injection to the bone with a pediatric epinephrine auto-injector. Allergy Asthma Clin Immunol 2018;14:32.
4Deng S, Gigliobianco MR, Censi R, Di Martino P. Polymeric nanocapsules as nanotechnological alternative for drug delivery system: Current status, challenges and opportunities. Nanomaterials (Basel) 2020;10:847.
5Bardou M, Luu M, Walker P, Auriel C, Castano X. Efficacy of a novel prefilled, single-use, needle-free, device (Zeneo) in achieving intramuscular agent delivery. Adv Ther 2017;34:252-60.