“Switching adalimumab from syringe to pen. Expected outcomes”

Dear Editor,

We have read the original article entitled “Acceptability of switching adalimumab from prefilled syringe to an autoinjection pen” published by Borras-Blasco et al. in your journal [1]. First of all, we are glad with the interest focusing in the switching profile of biological therapies in patients with inflammatory diseases. Their results suggest (as it should be initially expected) that the self-administered pen device (with a safety profile) is preferred to the syringe [2]. They included 55 patients who reported 100% adherence to treatment with the autoinjection pen, and due to their information/educational sessions, the percentage of patients self-administering medication increased from 51 to 84% and the percentage attending primary care for injection decreased from 33 to 2%.

According to their results, our group performed a nurse-led educational program to analyze patients' opinion concerning the role played by our nurse specialist in rheumatology and to evaluate patients' preference after having used both devices: syringe and pen [3]. Taking into account that our sample of patients (16 patients: 9 rheumatoid arthritis and 7 psoriatic arthritis) was smaller with a similar mean age 53.8 versus 50.0, we analyzed facts related to the nurse-led educational programs, such as self-administration and self-injections after receiving the training, transport and management of the drug. We also measured the degree of pain while and 15 min after the self-injection, difficulties managing the syringe versus pen, global assessment and finally their preferences. Surprisingly, we detected that 85% of our patients self-administered the medication even with the syringe (compared with the initial syringe results of Borras-Blasco et al.). With regard to tolerance to the new device, their results considered that 39% of patients thought that the new device was excellent, 13.7% very good, 31% good and 15.7% poor; on the other hand, compared with our results, 54% of patients preferred the pen, 13% the syringe but 38% did not refer any device preference. The possible explanation for that would be that the time between the educational program and the reevaluation was too short to obtain a sustained satisfaction. In agreement with the results from the TOUCH study [4], our results suggest a better profile of pain when the drug is administered with the new device. The data comparing pain in VAS with syringe (2.15) versus pen (2.0) (p value 0.4) were similar to those from Borras-Blasco et al. and the TOUCH study.

Finally, we would like to mention that we were surprised about who performed the teaching of the use of the new device in Borras-Blasco et al. study as it seems that there was a lack of nursing input (their study mentions that the educational strategy was given by a rheumatologist or a specialist pharmacist). As you may know, according to the royal college of nursing guidance, practitioners who are going to administer biologic therapies using subcutaneous routes should have received specific training on the administration of biologic therapies and be competent in the education and training of patients in self-administration of subcutaneous injections [5], as there is evidence in the literature confirming that the administration (and the teaching) of subcutaneous injections is an important part of a common nursing intervention in clinical practice [6].

To summarize, we consider that the pen as a new device for administration of adalimumab is widely accepted and preferred in all the studies performed up to date, and we would like to emphasize the importance of the role that specialist nurses may play in those educational programs in patients with inflammatory diseases.

Declaration of interest

The authors state no conflict of interest and have received no payment in preparation of this manuscript.