Acromegaly Shots

What is this about?

After being diagnosed with Acromegaly and being prescribed Pegvisomant, I searched a lot for a resource or people that could share their experience with how to give yourself the shots. While the manufacturer does provide a complete kit for the shot, I found it painful and I could never get over my internal resistance to stick a needle into myself. Unfortunately, I was not able to find a concise resource on how to handle these challenges so this is why I created this page. I hope this is helpful to you.

Now the standard disclaimer that this is not medical advice to you, the reader, but it is a sharing of my experiences. I hope that this is helpful to you in some way, but I'm not liable for any issue that you may experience if you choose to use it personally.

I have a lot to share, so let's get organized and break this into sections. Please click on the section you want to go to or just navigate to the page.

My goal in creating this process

Supply List for a painless self shot

The Autoject 2 Applicator

Minimizing Medication Waste

Pegvisomant Mixing

Painless Needles and Autoject Adjustment

Painless Self Shot

Tracking Shots

A message to Pfizer

My goal in creating this process

While developing this process of taking my Pegvisomant shots my goals were:

Make it painless. The 27G 1/2" needle that came in the package was very painful to me. I was sure that there is a way to make this less painful by using smaller needles.
Find a way to get over my hesitance to stick a needle into myself. I struggled with self inflicted pain. Giving myself a painful shot was a tough task.
Reduce medication waste: With the cost of the medication, it seems that it is vital to make the most of it and not waste any. The process of pulling the mixed medication out of the vial using the provided syringes would waste a part of the medication, so I thought I could improve on that.
Improve the mixing process. When following the manufacturer process to mix Pegvisomant it always (for me) formed some clumps that took a while to be fully dissolved. One of my smaller goals was to work on a better way to mix it that didn't generate clumps of the foaming.
Tracking shots: I take my shots every other day and I need to rotate the location of the shot. I needed a way to track the day of the shot and the last location of the shot in a seamless and easy way.

Supply List for a painless self shot

I tested two self injectors, several needles and syringes to get to this combination that I think works best. The easiest and safest way would be to ask your provider to give you a prescription for the needles and syringes as the law varies by state on the legality of having syringes in your possession without a prescription.

Here is the list of items that I use:

Owen Munford Autoject 2 - Standard Removable AJ1311. I make sure to get the one for removable needles and not for the fixed needles. Possible source for purchase (I take no commissions)
Low dead space Tuberculin 1ml Syringe: these are low dead space and have a tip that push the medication from the tip of the syringe. Some brands:
- Norm-Ject 1m Luer slip Syringe
- Exel 1ml Tuberculin Luer slip
30G x 1/2" Needles: these are thinner needles that are painless. Some brands and sources:
- BD PrecisonGlide 305106
- Nipro 30G 1/2"
22G x 2" Needles: these needles are a used on a different way of withdrawing the medication. It does take some more skill, but you are able to retrieve almost all the medication from the vial, by sucking it with a long needle from the bottom of the vial. Check my details below on the section on minimizing medication waste. This is an optional step to reduce medication waste. Here is a brand and source:
- HSW Fine-Ject Standard Hypodermic Needle 2"

The Autoject 2 Applicator

The Autoject 2 is a very well engineered applicator. It has the following features:

It hides the needles so there is no anxiety about the shot
The button is only activate when you press the Autoject against the skin and apply a certain amount of pressure.
It will slowing push the handle of the syringe until all the medication is pushed out.

The video clip on the side explains how the applicator works. There are 3 models of the injector and two are for the fixed needle syringes. The third one that I will be using is for removable needles and is not the focus of this video, so the syringe looks a little different.

Minimizing Medication Waste

One of my goals as I mentioned above was to minimize the waste of medication. I approached that from two directions:

Reduce the dead space on the syringe: as you can see the syringe that I'm recommending above has a very small dead space in the tip.
Improve the process of filling the syringe from the vial, to minimize medication left in the vial.

The method that has worked best for me is to:

Insert the 2" needle on the Tuberculin 1 ml syringe.
Fill the syringe with air. This air will be injected in the vial to make it easier to pull out the medication.
Insert the needle in the vial. Inject the air, making sure the needle is not submerged in the medication, as this will cause bubbles.
Tilt the vial about 20 degrees and position the needle tip on the bottom of the vial.
Pull the medication from the vial. I sometimes have to pull the handle past the first stop at the bottom of the syringe. This is safe as there is a second stop that will prevent the medication from leaking and the handle from leaving the syringe.
When the liquid is almost gone, I make sure the needle tip is flat against the side of the glass as that allows me to pull all the remaining medication.

Pegvisomant Mixing

As I mentioned before, if I follow the manufacturer instructions and drip the sterile water slowing on the side of the vial, it seems that it forms clumps of medication. I think this is probably caused by the slow introduction of water in the vial and the slow mixing process. My alternate approach is to tip the vial upside down (like if you are withdrawing the medication), slowing inject the water and then slowing tip the vial the right side up. A few turns of the vial will finish the mixing without clump formation.

In more detail:

First make sure the Sterile water vial has no air on it. This uses the syringe that is included in the package.
Using the 2" needle or the 1/2" that included with the package, insert the needle in the vial, with it upside down or at a 50 degree angle.
Slowly inject the sterile water and let it poll on the bottom of the vial
Remove the needle.
Slowly turn the vial the right side up letting the powder mix with the water.
Holding the vial on one hand, use the finger from the other hand to turn it in circles until there is no powder clump left.
Optionally let it rest for a few minutes, so the liquid dissolves and settles down.

Painless Needles and Autoject Adjustment

The pain aspect of the shot has a lot to do with the size and length of the needle. I do believe that the 27G 1/2" needles sent with the Pegvisomant carton is a compromise between being sturdy enough to use it on the vial and small enough not to be too painful. I tried some shots using insulin syringes and while they were painless, it was really hard not to bend the needle while pulling the medication from the vial. So the 27G 1/2" needle fulfills both functions, but doesn't do them as well as it could if we used dedicated needles for each process.

Another argument for using a smaller needles are the current recommendations for insulin needle sizes, like the "New injection recommendations for patients with diabetes" that advocate for shorter and smaller needles like 5 or 6 mm. Both Insulin and Pegvisomant shots are subcutaneous, should be applied on the same body region and have about the same viscosity.

While I'm using 30G x 1/2" needle, i,e 12.7 mm , the applicator has the capability to make a shallower shot, so I have been actually using it with a depth of 8 mm.

Painless Self Shot

So now I have the all the materials I need and the Pegvisomant is mixed and is loaded into the syringe. The next steps are:

Insert the 30G x 1/2" needle into the syringe. Push all the air out.
Load the syringe on the applicator.
Chose an injection site and disinfect it using an alcohol pad. Let it dry.
Pinch the skin to form a fold.
Touch the applicator to the area and apply pressure until the bottom section touches the middle section. This step unlocks the shot button at the top.
Click the button at the top of the applicator and pay attention to the window in the middle of the applicator. It will show a series of black lines in a yellow background. When the lines stop moving the shot is complete.

The videos below illustrates the steps.

Tracking Shots

I take my Pegvisomant every other day and I make sure to rotate the injection site, as recommended. But it is hard to remenber the date and location of my last day. To address that I found a very good phone application that addresses both issues very well.

The application is called MyTheraphy and is available for Android and Apple phones. Again, I take no commissions and I actually pay for the application.

Some features:

Free! It is funded by working with manufacturers and being a platform to reach patients.
It can remind users when they need to take their shot.
It can track the amount of medication and let users know when you reach a certain number of doses left.
It lets users graphically pick the location of the shot on the body.
It shows users a history of shots and locations.
Users don't need to register for an cloud account to use it.

My schedule and number of shots left

Selecting the location of shot

Checking history of shots

Shot Reminder and options

A message to Pfizer

I would love if Pfizer would send an automatic applicator like the Autoject 2 with their medication. Several manufacturers already do this, for example Copaxone for MS will ship with an auto injector as described in this blog .

Just having an applicator that would take the syringe that is shipped with Pegvisomant would be a great simplification already.

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What is this about?

Contents

My goal in creating this process

Supply List for a painless self shot

The Autoject 2 Applicator

Minimizing Medication Waste

Pegvisomant Mixing

Painless Needles and Autoject Adjustment

Painless Self Shot

Tracking Shots

A message to Pfizer