Procedural pain and patient-reported side effects with weekly injections of subcutaneous methotrexate in children with rheumatic disorders.

Karen Watanabe Duffy,Johannes Roth,Julie Rachelle Lemieux,Melanie Anne Bechard,Mary Ombac Aglipay,Ciaran Maire Duffy,Roman Jurencak

doi:10.1186/1546-0096-12-54

Abstract

BackgroundDespite the widespread use of subcutaneous methotrexate in treating pediatric rheumatic disorders, the amount of pain associated with the injections has not been quantified. Our study aims 1) to quantify the amount of pain associated with subcutaneous injections of methotrexate, 2) to explore predictors of pain, 3) to determine the frequency of patient-reported clinical adverse effects of methotrexate, and 4) identify coping strategies of patients and caregivers.MethodsPatients aged 4–17 years with rheumatologic diseases who were receiving weekly subcutaneous methotrexate injections for at least 4 weeks were invited to participate in this prospective cohort study. They were trained to use the Faces Pain Scale – Revised (FPS-R) and Faces, Legs, Arms, Cry, Consolability (FLACC) tools to rate pain associated with the injections. All patients underwent focused interviews exploring their experiences with methotrexate injections.ResultsForty-one patients consented to the study. The mean age was 11.2 years (SD = 3.9 years) and 68% were female. Most patients were diagnosed with JIA (73%). Mean duration of methotrexate therapy was 2.5 years (SD = 2.1 yrs). All but one of the patients used methotrexate 25 mg/ml solution for injection in 1 cc or 3 cc syringe with 30 gauge ½” needle. Median amount of pain was 2/10 on the FPS-R and 1/10 on the FLACC. Higher intensity of pain was significantly associated with presence of side effects (p = 0.004), but not duration of therapy (p = 0.20) or age (p = 0.24). Most participants (61%) experienced at least one adverse effect; nausea (56%) and vomiting (34%) were the most common symptoms reported. Patients and caregivers reported using ice (34%), comfort positions (51%), rewards (49%), reassurance (54%), distraction (51%), and analgesic medications (22%) to cope with the injections.ConclusionSubcutaneous injections of methotrexate are associated with a mild amount of pain. Presence of side effects may amplify the amount of perceived pain. Clinicians can apply this knowledge when counseling patients and family members about methotrexate therapy.

Highlights

Despite the widespread use of subcutaneous methotrexate in treating pediatric rheumatic disorders, the amount of pain associated with the injections has not been quantified
Given the negative long-term effects of repeated exposure to procedural pain and the vulnerability of the paediatric rheumatology population using subcutaneous methotrexate, our study aimed to address gaps in the existing literature by investigating the following objectives: 1) quantify the amount of pain associated with subcutaneous methotrexate injections, 2) investigate the factors that influence the amount of perceived pain and identify effective pain management strategies used by patients and families, and
Study population All patients at the Children's Hospital of Eastern Ontario Rheumatology Clinic with appointments scheduled between June and August 2013 were screened for their eligibility to participate in this study

Summary

Introduction

Despite the widespread use of subcutaneous methotrexate in treating pediatric rheumatic disorders, the amount of pain associated with the injections has not been quantified. Weisman et al [6] have shown that children who do not receive proper pain control during lumbar punctures and bone marrow aspiration report higher amounts of pain for subsequent procedures, even when adequate analgesia has been provided. There has not yet been a formal attempt to quantify and reduce the amount of pain associated with subcutaneous methotrexate injections in the paediatric rheumatology population. These patients may be vulnerable to the long-term consequences of uncontrolled procedural pain due to their young ages and relatively long duration of therapy. Measuring the amount of pain associated with methotrexate provides a baseline for determining the efficacy of interventions and can aid clinicians in counseling patients and families about to begin therapy

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Discussion

Conclusion