15 Peculiar Ways of Administering Medications

Many people--well, if we're honest, probably most--don't like taking medication. But the large majority of medicines are tablets, capsules, or pills, which can be swallowed, for most folks without too much trouble, if we're practiced at it.

Enter the well-known theory that things can always get worse. Just when you feel sorry for yourself for having to swallow a horse-sized pill that causes gagging, remember this theory--and feel grateful that your medicine isn't headed into your eye, your ear, your bone, your muscle--or up some very private spaces.

There are more ways of administering medicine than skinning a cat, some of them highly irregular--and not all of them completely pleasant. Here are 15 ways of administering medications, some very peculiar indeed.

1. Not Quite What I Meant by 'By Mouth': Sublabial Administration

Meaning, literally, 'under the lip' in Latin, a sublabial injection is given between the lip and the gums, where it enters directly into the blood stream.

It is used for the drug Glyceryl trinitrate, to treat angina, and can also be used to administer morphine to cancer patients.

Medicine administered via this method, like most of the rest we'll see below, enters the bloodstream directly, avoiding the metabolic process. The advantage over orally-administered medication is in avoiding the pass through the gastrointestinal tract  (known as the ‘first pass effect'), where stomach acid and bile might degrade it, as well as through the liver, which can alter its composition significantly.   Additionally, avoiding the GI tract can help avoid stomach irritation and other side effects.

2. Stick Out Your Tongue and. . : Sublingual Administration

Sublingual literally means 'under the tongue,' so this is a pretty self-evident means of administration. Because these drugs enter the blood stream through the mucus membrane of the tongue, they have a faster absorption into the blood stream than orally swallowed pills which must pass through the metabolic process.  The only downside may be the taste and aftertaste.

Many medications are now available for sublingual administration, including heart drugs, barbiturates, steroids, and even a relatively new atypical antipsychotic, not to mention nutritional supplements.

3. Inhaling Through Your Nose: Nasal Administration

Nasal administration isn't a personal favorite of mine, but it can be used to deliver drugs both locally (decongestants or allergy treatments) and also systemically, as in certain migraine medications and hormone treatments.

The lining of your nose is full of blood vessels, so a medicine can easily move directly into blood circulation rather than be metabolized through the digestive system.  This speeds up the process so that efficacy is often achieved within 5 minutes.

Thus nasal administration is quite useful if you need action fast, or if a medication is considerably degraded by traveling through the stomach, intestines, or liver.

According to WebMD, nasal administration is particularly effective for decongestants because these medications cause the blood vessels in the nose's lining to narrow, which reduces blood flow to the area.  The nose is thus less stuffed up--and produces less mucus.

Nasal migraine medications are beneficial both due to speedy effect, and because giving them orally can lead to nausea. Hormone treatments are sometimes given as nasal sprays, this time to avoid drug degradation in the gut and liver.

Other drugs that can be given via the nose includesedatives, anesthetics, and anti-nausea drugs that require fast onset of efficacy.

4. Now Breathe Deeply: Inhalation

So back to that inhaler I was so grateful for. Drugs given via inhalation by mouth must be atomized into small particles to pass through the windpipe and into the lungs. The smaller the droplets, the deeper into the lungs the med passes, which increases the amount of medication that gets absorbed.

Often such medication is given through a metered dose inhaler, which delivers a specific amount of medication directly into the lungs. This inhaler is the most common means of administration for treating respiratory diseases like asthma or COPD.

Aside from metered dose inhalers, there are also dry powder inhalers with powders broken into very fine particles drawn into the lungs when the patient inhales.

This administration is advantageous in that the medication is absorbed into the system quickly and can work both systemically and locally. On the downside, it can increase heart rate or cause tremors and hyperactivity.

Aside from respiratory issues, few drugs are given via inhalation because it's so hard to ensure the person receives the correct amount of the drug in the correct amount of time. This method is used, though, to administer gases in general anesthesia.

5. The 'Eyes' Have It: Opthalmic Administration

According to the medical component of The Free Dictionary, opthalmic administration of medication is "the administration of a drug by installation of a cream, an ointment, or a liquid drop preparation in the conjunctival sac." Drugs used to treat eye disorders such as glaucoma or conjunctivitis can be mixed with inactive substances to make a liquid, gel, or ointment appropriate for opthalmic administration.

The Merck Manual Home Health Handbook notes that liquid drops are simpler to use but may run out of the eye so quickly that they're not well absorbed. Gel and ointments keep the drug in contact with the eye longer--but may blur vision. There are even solid inserts--but these are both difficult to put in and hard to keep in place.

The prescription for such an administration will usually say 'O.D.' if the medication is for the right eye. O.S. for the left ye, and O.U. for both eyes.

6. Did You Say to Stick it in My Ear?: Otic Administration

Otic medications are mainly ear drops.

After placing the correct number of drops in the ear, the patient presses the small flap of skin over the ear to help push the drops into the ear canal.

The advantage in delivering drops this way is that it's a local effect--the drug doesn't have to navigate too many other systems before it reaches its intended target.

On the downside, the person often has to wait, head tilted to the side, for 3-5 minutes while the drops penetrate the ear--a pain in the neck.  If drops in the both ears are required, the patient has to wait 5 minutes at a minimum before repeating the process.

7. Medicine in a Patch: Transdermal Administration

Medication delivered directly through the skin is often delivered in a transdermal patch.

One side of an adhesive patch has medication, and this is the side that patients place on their skin. (This comes under the category of 'You have to tell some people everything.")  The skin absorbs the medication, which then enters the bloodstream.  Patches have the advantage of releasing medications gradually, rather than a large jolt at one time

Patches don't require injections, and they do allow doctors to titrate the doses more precisely. They also, like so many of these other routes, are not broken down by the digestive tract or live enzymes, thereby limiting efficacy.

Some disadvantages are that the patches might irritate the skin, and the dose absorbed can be affected by both the condition of the skin and the health of the circulatory system.

In a 2008 article entitled "Transdermal drug delivery"  published in Nature Biotechnology ,Mark R. Prausnitz and Robert Langer point out the following interesting 'transdermal trivia':

• The first transdermal medicine for systemic rather than local delivery was a three-day patch that delivered scopolamine to treat motion sickness. It was approved for use in the U.S. in 1979.
• 10 years later, nicotine patches became the first 'transdermal blockbusters'
• Between 1979 and 2002, a new patch was approved every 2.2 years, but between 2003 and 2007 that rate more than tripled to 7.5 months.
• More than 1 billion transdermal patches are made every year.

8. Under My Skin: Subcutaneous

Subcutaneous injections are given in the fatty layer of tissue just under the skin.

According to the National Institutes of Health, such injections are given because there is little blood flow the fatty tissue, and thus the medicine is absorbed more slowly, sometimes over the course of the day.

Growth hormones, insulin, and epinephrine are usually delivered subcutaneously. Drugs with protein benefit by this administration, as the medication would be destroyed by the digestive tract if taken orally.

9. Show Me Your Muscles: Intramuscular

Intramuscular (IM) injections are shots delivered into the muscle, and thus are deeper than subcutaneous injections. They are usually injected into the muscles of the upper arm, thigh or buttock.

There are several reasons for giving IM injections. Some medicines simply work better if delivered directly into the muscle. Others indications are if the person is incapable of swallowing, or is refusing court-ordered medications.

Some contraceptive hormones are delivered this way, as are most vaccines, and epinephrine injections for severe allergic reactions.

Sometimes drug companies that already have a successful oral treatment will be able to earn a new patent on a drug that administered via IM. For example, Johnson and Johnson lost patent on its antipsychotic Risperdal in 2008, but its long-acting Consta, administered as an intramuscular injection once every two weeks, received its own approval, and was J&J's cash flow for the antipsychotic significant through the present.

10. Into My Skin: Intradermal Injections

Far more infrequent than subcutaneous or IM administrations, in intradermal injections tiny amounts of fluid are injected directly into the skin. They're often used to check for allergies, but medications given this way are limited mainly to treatments for rabies.

wiseGEEK makes the interesting point that, while most shots are delivered perpendicular to the body part being injected, the needle in these injections is almost parallel to the body part, in order to better ensure the medicine gets in between the layers of skin.

11. A Pain in the Vein: Intravenous

Intravenous medications are delivered through an intravenous line directly into a vein. This is one of the fastest ways to administer medications (and often fluids as well) throughout the system, as the drug is being delivered directly into the blood stream. However, this also means that the effects tend to wear off sooner. Thus many drugs are given via continuous infusion.

All IV injections must be sterile.  That necessitates having new or sterilized equipment each time an IV is administered.

IV medications are mixed with a solution, and the size of the needle is based on the thickness of the medication and the depth of the injection (not to mention the size of the vein).

Today 80% of hospitalized patients receive IV therapy and a large number of medications are given via IV.  IV therapy has become its own subspecialty in nursing.

12. Ah, My Aching Bones: Intraosseous Infusion

Intraosseous administration involves injecting medications directly into the soft marrow of a bone, as a non-collapsible, immediate point of entry into the vascular system. It is normally used in situations when intravenous administration is not an option [or when 3 attempts at venous access fail, or 90 seconds pass without successfully tapping the vein].  Speed is vital, but because the injection can only be maintained for 24-48 hours before an alternative method must quickly be found.

This is a relatively new technique, first described in humans in 1934.

Rates of efficacy are similar to those found in IV administration.

13. Suppositories

(Warning to the very delicate: The words 'vaginal' and 'rectal' will appear in this section. If that's not to your liking, skip ahead.)

Probably pushing the ick factor, suppositories are solid, cone-shaped medications that are inserted into the rectum, vagina, or urethra to dissolve.

Rectal

For a delectable piece of trivia, rectal suppositories are mixed with cocoa butter which melts at body temperature for better absorption.  The rectal wall is thin and richly supplied with blood, so that absorption is relatively quick.

Aside from suppositories, enemas, in which the medication is suspended in a solution, are also administered via the rectum.

One of the obvious advantages to rectal suppositories or enemas is that they can be administered to people who are unconscious, vomiting, or otherwise unable to swallow. The disadvantages seem patently obvious.

Vaginal

Yeast-infected women of the world unite. Ye of all people well understand the ins and outs of this means of administration.

Larger than rectal suppositories, vaginal ones are generally cone-  or wedge-shaped, for better insertion into the vagina. This route doesn't serve general health purposes particularly well, but is quite effective in the treatment of gynecological ailments, particularly those stubborn yeast infections.

Anyone who takes an over-the-counter approach to yeast-infection treatment must be prepared for the insertion of just such a suppository--or a cream--into the vagina, but the world of big pharma came to women's aid, and our debt of gratitude is great to gratitude to Pfizer for its Diflucan (fluconazole), approved in January 1990, which treats the unpleasant infections with one small, pink pill.

Urethral

Urethral suppositories are quite rare, and are used only to treat severe erectile dysfunction. In fact, the only one currently on the market is MUSE, an alprostadil suppository.

Muse is a medicated micro-suppository 1.4mm in diameter by 3mm or 6 mm in lengths and is administered by inserting the applicator into the urethra right after urination.

The medication is absorbed from the urethra by the surrounding tissues where it increases blood flow into the penis, causing an erection.

The use of Muse has decreased considerably with the development of oral medications for ED. No surprise.

14. Oh My Aching Back: Intrathecal Administration

Intrathecal administration is the injection of medication into the spinal cord. The needle is inserted between two vertebrae in the lower spine and into the space around the spinal cord.  The drugs can work rapidly on the brain, spinal cord, or meninges (the layers of tissue covering the brain and spinal cord).

This method is used mainly for anesthesia and for management of pain (morphine is sometimes given this way) and to treat brain or spinal infections.

Medication that is administered intrathecally must be made specially by a pharmacist because preservatives or other inactive ingredients usually found in other drug preparations would be harmful.

15. Traveling the Other Way: Intravesical Administration

For intravesical administration a medication is injected directed into the bladder through a urethral catheter, usually to treat local diseases, most often bladder cancer.  Introducing the medication this way will often reduce systemic side effects.

Biological therapy for bladder cancer is often adminstered this way, including Bacille Calmette-Guerin (BCG), an immune-stimulating bacterium.

In Closing

Fundamentally, the route of administration for a medication is determined by the type of medication and the absorption requirements.

Unfortunately it's not determined by your personal preference. Unless, of course, your personal preference is for the peculiar.