Evidence for the Use of Intramuscular Injections in Outpatient Practice MARK SHATSKY, DO, Providence Medical Group, Portland, Oregon There are few studies comparing the outcomes of patients who are treated with oral versus intramuscular antibiotics, corticosteroids, nonsteroidal anti-inflammatory drugs, or vitamin B . This may lead to confusion about when the intramuscular route is indicated. For example, intramuscular ceftriaxone for Neisseria gonorrhoeae infection and intramuscular penicillin G benzathine for Treponema pallidum infection are the treatments of choice. However, oral anti- biotics are the treatment of choice for the outpatient treatment of pneumonia and most other outpatient bacterial infections. Oral corticosteroids are as effective as intramuscular cortico- steroids and are well-tolerated by most patients. High daily doses of oral vitamin B with ongo- ing clinical surveillance appear to be as effective as intramuscular treatment. Few data support choosing intramuscular ketorolac over an oral nonsteroidal anti-inflammatory drug unless the patient is unable to tolerate an oral medication. For other indications, the intramuscular route should be considered only when the delivery of a medication must be confirmed, such as when a patient cannot tolerate an oral medication, or when compliance is uncertain. (Am Fam Physi- cian. 2009;79(4):297-300. Copyright American Academy of Family Physicians.)
This is one in a series of “Clinical Pharmacology” articles coordinated by Al en F. Shaughnessy, PharmD, Tufts University Family Medicine Resi-
Family physicians may choose to vitamin B, although IM antibiotics are
treat common bacterial infections, indicated for some infections. asthma, musculoskeletal pain, and vitamin B deficiency with medica-
tions administered through the oral or intra-
After the discovery of penicillin in the early
muscular (IM) route. Because there are few 1940s, “the shot” became associated with a studies comparing the outcomes of patients dramatic reversal of illness. Since then, injec-who are treated with oral medications ver-
tions have continued to represent a powerful
sus IM medications, there may be confusion medical symbol.1 Physicians and patients about when the IM route is appropriate.
may perceive an injection as being more
In general, IM administration may be potent than standard oral treatment, and
appropriate for patients with nausea, vom-
physicians may favor this route when treat-
iting, diarrhea, or dehydration. It may also ing a sick patient.1 However, this approach is be appropriate when the physician needs to not supported by the literature.1,2confirm the delivery of medication, such as
The advantages of IM antibiotics are likely
when a patient has failed ongoing oral treat-
limited to situations when the delivery of a
ment, or when a patient is unreliable or unco-
medication must be confirmed. For example,
operative. The IM route is contraindicated the IM route may be appropriate if a patient when the medication is erratically absorbed, cannot tolerate an oral medication (e.g., when there is concern for allergic reaction, because of emesis or an inability to swallow), or when there is a danger to the patient. Oral or if the patient’s compliance is uncertain medications can be easier to administer than (e.g., because of forgetfulness or unwilling-IM injections and are equally effective for ness to take a medication). treating many conditions. Oral medications
The American Thoracic Society and the
do not cause pain or compromise the skin Infectious Diseases Society of America rec-barrier. For most patients, the evidence does ommend oral antibiotics for the outpatient not support the IM route over the oral route treatment of pneumonia.3 No IM antibiot-for antibiotics, corticosteroids, nonsteroi-
ics are approved by the U.S. Food and Drug
dal anti-inflammatory drugs (NSAIDs), or Administration or specifically recommended
Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright 2009 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. SORT: KEY RECOMMENDATIONS FOR PRACTICE
Oral antibiotics are recommended for the outpatient treatment of pneumonia.
Intramuscular penicil in G benzathine is the recommended treatment of choice for Treponema pal idum infections, and intramuscular ceftriaxone (Rocephin) is recommended for Neisseria gonorrhoeae infections and pelvic inflammatory disease.
Intramuscular penicil in is the recommended treatment for group A beta-hemolytic
streptococcal pharyngitis when the oral route cannot be used.
Intramuscular epinephrine is the recommended drug of choice for anaphylactic reactions.
Oral vitamin B at a dosage of 2,000 mcg per day is an effective treatment for B deficiency
Intramuscular ketorolac (Toradol, no longer available for injection) is no more effective for
pain syndromes than oral ibuprofen or other oral nonsteroidal anti-inflammatory agents. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp. org/afpsort.xml.
for acute sinusitis,4,5 and most community-acquired Corticosteroids methicillin-resistant Staphylococcus aureus skin infec-
For acute asthma exacerbation and croup, systemic
tions remain susceptible to oral trimethoprim/sulfa-
corticosteroids are the recommended treatment.18-27
methoxazole (Bactrim, Septra) and tetracycline.6
Corticosteroids have been shown to lead to symptom
One systematic review found that there is no evi-
improvement, fewer hospitalizations, and fewer return
dence that oral antibiotic therapy is less effective or visits for both conditions.18-27 Although much of the slower than parenteral treatment for severe urinary data regarding the treatment of asthma and croup are tract infection in children and adults.7 Other studies based on emergency department and hospital encoun-have shown similar clinical effectiveness for a single ters, there is a growing body of evidence indicating dose of IM ceftriaxone (Rocephin) or 10 days of oral tri-
that oral treatment and IM treatment are equally effec-
methoprim/sulfamethoxazole for urinary tract infec-
tive.22-27 One study also found that oral prednisolone
tions in febrile children.8-10 Several studies have shown (Prelone) is not inferior to IM prednisolone (Pred-that for children with otitis media, a single dose of IM alone; brand no longer available in the United States) ceftriaxone is no more effective in regard to rates of in treatment for exacerbations of chronic obstructive improvement, failure, or relapse than 10 days of oral pulmonary disease.28 amoxicillin, amoxicillin/clavulanate (Augmentin), or
Multiple studies comparing IM administration of cor-
ticosteroids with oral administration have found no sig-
Although IM antibiotics have not been shown to be nificant differences in outcomes between groups.20,22-26
more effective or to lead to faster recovery, they are appro-
Despite numerous trials evaluating doses, dosing fre-
priate for specific indications. For example, IM penicillin quencies, and routes of administration of various cor-G benzathine (Bicillin L-A) is the medication of choice ticosteroids, there is no clear evidence for a superior to treat Treponema pallidum.14 IM penicillin G benza-
formulation or administration route.20,22-26
thine alone or in combination with penicillin G pro-
For children who are not able to swallow pills or who
caine (Bicillin C-R) is an effective treatment for group A refuse a bad-tasting medication, a single long-acting IM-beta-hemolytic streptococcal pharyngitis when the oral administered corticosteroid such as dexamethasone or route cannot be used.15 The Centers for Disease Control methylprednisolone acetate (Depo-Medrol) eliminates and Prevention recommends 125 mg of IM ceftriaxone nonadherence.24 If the tolerability or compliance with a to treat Neisseria gonorrhoeae infections,16 and 250 mg of tapering dose of oral steroids are issues, the IM route is IM ceftriaxone plus seven to 14 days of oral doxycycline reasonable.23,29 However, oral corticosteroids eliminate (Vibramycin) at a dosage of 100 mg twice daily to treat the pain, anxiety, side effects, and costs associated with pelvic inflammatory disease and epididymitis.17
injections, and are generally well-tolerated by patients of
The perception that IM injections are more powerful all ages.22,25,26
or have an added psychologic effect is unproven and is an
Some physicians believe that corticosteroids are the
inadequate reason to choose injection when oral antibi-
treatment of choice in acute anaphylaxis, although epi-
otics are less expensive, less painful, and have fewer seri-
nephrine is the recommended medication for anaphy-
lactic reactons.30 Epinephrine is absorbed more rapidly
298 American Family Physician Volume 79, Number 4 ◆ February 15, 2009Intramuscular Injections
intramuscularly than subcutaneously.30 Corticosteroids
Additionally, the evidence does not support the notion
may have some benefit in decreasing the uncommon that IM ketorolac is more effective than oral NSAIDs for occurrence of a protracted or biphasic reaction.30 Whether pain relief in patients with acute renal colic.44,45 Limited delivered parenterally or orally, the effectiveness of admin-
studies have shown that ketorolac is as effective as cer-
istering corticosteroids for anaphylaxis is unclear.
tain opioids for treating renal colic pain.40,41,44,45 However, data also indicate that oral NSAIDs generally offer at
least equal analgesia when compared with opioids.40,44,45
Until recently, the standard treatment for vitamin No randomized, double-blind studies are available that B deficiency has been IM vitamin B .31-35 However, directly compare oral NSAIDs with IM ketorolac. One
because evidence indicates that patients with vitamin study compared administration of a placebo injection to B malabsorption (intrinsic factor deficiency) absorb administration of a placebo oral agent and found that
only 1 to 2 percent of oral vitamin B ,32-35 high-dose oral injections did not confer a selective placebo effect.40
treatment has been investigated as an alternative to IM
The risks of administering IM ketorolac include
bruising, infection, hematoma, patient discomfort, and
Trials of oral versus IM vitamin B replacement needle-stick injury.38,39 In addition, IM administration
therapy have found that oral vitamin B in high doses is significantly more expensive than oral ibuprofen.39,42
appears to be as effective as IM administration in the Because there is no outcome-based evidence for choos-short-term.31-35 In one study, vitamin B was adminis-
ing IM ketorolac over an oral NSAID, and because there
tered orally at a dosage of 2,000 mcg per day for four are increased costs and potential hazards with injections, months.36 This resulted in a threefold increase in the IM ketorolac should be reserved for patients with acute level of serum vitamin B compared with the monthly pain who are unable to tolerate oral NSAIDs.39-42
IM injection group. Other trials using oral dosages of less than 500 mcg per day have not shown a consistent Final Comment response, which confirms the need for high-dose daily Because of the broad nature of this topic, modes of therapy.37,38 There have been no long-term outcome administration were limited to the IM and oral routes. studies evaluating the effectiveness in treating or pre-
Similarly, medications such as diphenhydramine (Bena-
dryl), opioid analgesics, ondansetron (Zofran), triptans,
There are several reasons to consider oral vitamin B and others were not included. Definitive guidelines for
administration instead of IM injection. An injection choosing the IM route or oral route are unlikely to be typically requires the patient to travel to a health care forthcoming. The decision-making process involves facility, which may be difficult for patients with disabili-
assessing the clinical picture, knowing medication
ties and for older patients. Additionally, injections are indications, and learning patient preferences. With few more expensive and painful, and place health care pro-
exceptions, there are no conclusive data that support the
fessionals at risk of needle-stick injuries.31-35 Although IM route as preferable to the oral route. The assumption large long-term trials are needed to determine whether that an IM injection is more powerful than the oral route oral vitamin B is as effective as IM treatment, high-dose is not supported by available data.
oral vitamin B treatment with ongoing clinical surveil-
lance appears to be painless, effective, safe, cost-efficient, The Author and convenient for most patients.31-33
MARK SHATSKY, DO, is a family physician at Providence Medical Group in Portland, Ore., and is in private neurointegrative practice. He received his
medical degree from Midwestern University’s Chicago Col ege of Osteo-
All NSAIDs have the same mechanism of action, regard-
pathic Medicine, Downers Grove, Il . He completed a family medicine resi-dency at Hinsdale Hospital, Hinsdale, Il ., and completed a primary care
less of the route of administration.39-41 The data do not fel owship at Michigan State University in East Lansing.
support the practice of administering IM ketorolac Address correspondence to Mark Shatsky, DO, 18168 Westminster Dr.,
(Toradol, no longer available for injection) for conditions Lake Oswego, OR 97034 (e-mail: [email protected]). Reprints
such as migraine, gout, and musculoskeletal pain when are not available from the author. oral NSAIDs are available and the patient can tolerate an Author disclosure: Nothing to disclose. oral medication.40-43 The few studies that have compared an oral NSAID such as ibuprofen to IM ketorolac have REFERENCES not demonstrated a significantly better response to the 1. Reeler AV. Anthropological perspectives on injections: a review. Bull World Health Organ. 2000;78(1):135-143. February 15, 2009 ◆ Volume 79, Number 4American Family Physician 299 Intramuscular Injections
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300 American Family Physician Volume 79, Number 4 ◆ February 15, 2009
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