A65: Procedural Pain with Weekly Injections of Subcutaneous Methotrexate in Children with Rheumatic Disorders

Abstract

Background/Purpose:Procedural pain may have long‐term negative effects on children. The aim of this study was to evaluate the amount of pain associated with weekly subcutaneous injections of methotrexate.Methods:A prospective observational cohort study was conducted from June 2013 through August 2013. All patients with appointments in rheumatology clinic during this period were screened for eligibility. Patients between the ages of 4\N17 years who were currently receiving weekly subcutaneous methotrexate injections for at least 4 weeks were invited to participate in the study. Patients and families underwent a focused interview, conducted by one interviewer, exploring their experience with methotrexate injections. Thereafter, they were trained to use the Faces Pain Scale\NRevised (FPS‐R) tool to be able rate pain associated with future methotrexate injections. Associations between pain scores and age, duration of therapy, and presence of side effects were tested using simple and multiple linear regression.Results:41 out of 42 eligible patients consented to the study. Four patients were switched from subcutaneous to oral route of methotrexate at the time of study enrolment. Of the remaining 37 patients, 29 (78%) returned the completed pain scales. The mean age was 11.2 years (SD = 3.9 years) and 68% were female. Most of these patients were diagnosed with JIA (73%). Mean duration of therapy with subcutaneous injections of methotrexate was 2.5 years (SD = 2.1 yrs) and the dosing range was 0.3–1 mg/kg/week (maximum 25 mg/week). The upper arm was the preferred injection site in 71% of patients. Median amount of pain in the subset of 29 patients was 2/10; 18 (62%) patients reported mild pain (FPS‐R score 0–2), 9 (31%) reported moderate pain (FPS‐R score 4–6) and 2 participants reported severe pain (FPS‐R 8–10). In univariate testing, higher intensity of pain was associated with presence of side effects (p = 0.004), but not duration of therapy (p = 0.20) or age (p = 0.24). Results were largely unchanged in multiple linear regression. Injection pain was successfully alleviated by ice in 10/14 patients (71%), comfort positions in 14/21 patients (67%), rewards in 13/20 patients (65%), reassurance in 11/22 patients (50%), distraction in 10/21 patients (48%), and analgesics in 4/9 patients (44%).Conclusion:While the average amount of pain associated with subcutaneous injections of methotrexate is mild, patients who suffer from methotrexate associated side‐effects report significantly higher levels of pain. Patients and families reported using various effective strategies to alleviate injection associated pain.