Reducing SCIG Side Effects
By Michelle Greer, RN   | Download Article |

For individuals receiving immune globulin (IG) therapy, the subcutaneous (SC) route of administration is often a preferred option. Many people begin SCIG with their first treatment, while others switch to SCIG after a loading dose of intravenous IG (IVIG) or after being treated with IVIG for a period of time. A primary reason for switching from IVIG to SCIG is a reduction in the incidence of systemic side effects that, for some, are intolerable. Examples of systemic side effects with IVIG include headache, nausea and blood pressure fluctuations, as well as more severe adverse reactions such as blood clots and aseptic meningitis.

With SCIG, the most commonly reported side effect is injection site reactions - swelling, redness and/or irritation - that occur at the needle insertion site and are typically localized. These reactions usually resolve within 24 to 48 hours after the infusion is completed. They are more common in the first several infusions, and their incidence normally decreases over time.

While systemic side effects occur with much less frequency with SCIG than with IVIG, in some cases, SCIG site reactions can be severe. In more severe cases, the swelling can be significant, leading to pronounced redness and increased irritation, and even pain. For the first several SCIG infusions, a nurse should train patients on all aspects of SCIG therapy, including a number of techniques discussed here to reduce the magnitude of these reactions.

Needle Size

The gauge (the size of the hole in the needle) and length of the needle can be contributing factors to site reactions. SCIG needles come in 24, 26 and 27 gauges, with 24 being the largest. The larger the number of the gauge, the smaller the needle, so a larger number gauge means a thinner needle being inserted. In some cases, larger gauges are required due to the volume of drug to be administered or if a more viscous drug is required for accurate flow.

There are several layers in the skin. To ensure proper absorption of the IG, the correct needle length must be selected so that, when inserted, the needle tip is in the subcutaneous tissue and the medication is infused therein. If the needle is too short or too long, the medication will not infuse into the subcutaneous tissue, increasing the potential for a more severe reaction.

SCIG needles are available in several lengths. Based on height and weight of the patient, the correct one will be chosen for a patient upon initiation of therapy. Needle length can also be changed at any time if it’s determined inappropriate or if a patient’s weight fluctuates. This is especially important for children as they grow.

Needle Set

The subcutaneous needle is not just a needle alone; it is referred to as a needle set. The set consists of a needle, a backing that sits up against the skin and a short piece of tubing extension that attaches to the longer infusion tubing. In some cases, the material or shape of the backing may contribute to the irritation of the skin. There are many brands of these sets, so if one isn’t comfortable, there are options.

Infusion Site

It is important to choose the proper infusion site. Typical locations for SCIG injections include the abdomen, posterior upper arms and anterior thighs. However, for HYQVIA, the recommended infusion sites are upper to mid abdomen and upper thigh. HYQVIA should not be administered in the arms. Most people who self-administer SCIG do not typically select the upper arms because insertion of the needle requires two hands; however, if someone is assisting them, it is an appropriate site. SCIG should not be administered in the buttocks.

Injection sites should be at least 2 inches from the umbilicus. If multiple sites are required for infusion, the sites should be 2 inches or more apart. The skin over the insertion site should be free from scars, varicose veins, bruising and other types of skin irritation or breakdown. It’s also helpful to not choose the same insertion site over and over (although some believe that using the same site helps reactions dissipate over time).

Infusion Volume

The total volume of IG infused in relation to the number of sites is also important. A patient can choose to infuse in only one site or up to six sites. It may be better to infuse in a greater number of sites to reduce the volume infused in each site, which can decrease the chance for irritation.

While systemic side effects occur with much less frequency with SCIG than with IVIG, in some cases, SCIG site reactions can be severe.

Insertion Technique

Learning how to properly insert a subcutaneous needle, especially if there are multiple sites, is vital to the success of the infusion. The first step is to ensure the skin is properly cleaned. Typically, the site is cleaned with an alcohol wipe. Sufficient time should be given to allow the alcohol to dry before piercing the skin with a needle. When the tubing and needle are primed, meaning the IG is run through the tubing, care should be taken to not let even a drop of IG come through the tip of the needle. The goal is to have a “dry stick,” which means no IG is on the skin or the needle (both should be dry and sterile). This will reduce the chance of the layers of skin being irritated with alcohol or IG solution. Any allergies or sensitivities to latex or adhesives also need to be considered.

Once the needle is in place, it should be secured properly, since excessive movement can also contribute to site reactions. After the infusion is complete, the needle should be carefully removed and discarded. The sites can typically be left uncovered after removal. However, if there is any bleeding, a gauze or bandage can be applied for a short time.

SCIG Brand

There are currently several brands available for SCIG infusion (Table 1). All but one are solely IG solutions, whereas HYQVIA is a combination product. If one brand is causing site reactions and the patient is sure he or she has considered all other sources of irritation, a brand switch may be considered. Any switch should be discussed with the patient’s physician.

Proper Technique Is Key

SCIG infusions can eliminate the many side effects that often accompany IVIG infusions. However, even with SCIG, reactions can occur. But with training and an understanding of proper techniques, successful SCIG infusions are possible.

Michelle Greer, RN, is senior vice president of sales for Nufactor.