MEDICATION AND INJECTION ADMINISTRATION EDUCATIONAL BOOKLET FOR OVULATION INDUCTION

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1 MEDICATION AND INJECTION ADMINISTRATION EDUCATIONAL BOOKLET FOR OVULATION INDUCTION Comprehensive Guide to Understanding, Mixing, and Administering Fertility Medications IMPORTANT PHONE NUMBERS: WEEKEND NURSE LINE: , OPTION 5 ANSWERING SERVICE: FOR AFTER HOURS URGENT QUESTIONS AND EMERGENCIES ONLY

2 Table of Contents Menopur 75iu vials...3 Gonal F 75iu Vials...5 Gonal F Pen (300,450, 900iu)...6 Follistim Pen (300, 600, 900iu)...7 Mixing Half Vials (Half Dosing)...10 Ovidrel (Hcg)...11 Subcutaneous Injection Technique...12 CPD3.04a Ovulation Induction Injection Instruction REV. SEPTEMBER 2016 SHADY GROVE FERTILITY 2

Medications for Ovulation Induction FSH Medications: Menopur (75iu) SUPPLIES: Alcohol wipes, gauze pad, 3cc syringe, Q-Cap(s), 27g or 30g ½ inch needle, medication and diluent, sharps container. 1.

3 Medications for Ovulation Induction FSH Medications: Menopur (75iu) SUPPLIES: Alcohol wipes, gauze pad, 3cc syringe, Q-Cap(s), 27g or 30g ½ inch needle, medication and diluent, sharps container. 1. Note: You may choose not to use the Q-Cap and use a 21g or 22g, 1 ½ inch needle to mix and draw up the medication (old-fashioned way). Use a 27g or 30g ½ inch needle to administer the injection. 2. Keep in mind when mixing these medications, up to 6 vials of powdered medication may be mixed with 1cc/ml of diluent. 3. Gather supplies and wash your hands. 4. Remove the syringe from the wrapper. If there is a capped needle on the syringe, remove the needle by twisting it counter clock-wise. Open one Q-Cap by peeling back the label and set the blister pouch with the Q-Cap aside. Do not take the Q- Cap out of the blister pouch at this time. Do not touch the ends of the Q-Cap. 5. Remove the plastic caps from the tops of the vials of the sterile diluent and medication powder. 6. Wipe the tops of the vials with alcohol. Don t touch the tops of the vials once you have wiped them. 7. Place the sterile diluent vial on the counter. Remove the Q-Cap from the blister pouch by grasping its side. Carefully twist the syringe onto the Luer end (connector) of the Q-Cap until you feel a slight resistance. Do not touch the spike end of the Q- Cap. CPD3.04a Ovulation Induction Injection Instruction REV. SEPTEMBER 2016 SHADY GROVE FERTILITY 3

4 8. Withdraw the syringe plunger to the 1cc/ml mark to pull air into the syringe. Hold the syringe and place the spike end of the Q-Cap over the top of the sterile diluent vial. Push the tip of the Q-Cap into the rubber stopper of the vial until you feel a slight resistance. Be very careful not to push down on the syringe plunger during this step. 9. Push the syringe plunger down to transfer the air from the syringe into the vial. Keeping the syringe and Q-Cap together, turn the vial upside down and pull back on the syringe plunger to withdraw the 1cc/ml of diluent from the vial. 10. Place the vial on the counter. Remove the Q-Cap and syringe from the vial by pulling up on the syringe barrel. Discard the diluent vial (there will still be 1cc of diluent left in the vial). 11. Hold the powdered medication vial in one hand. Grasp the sides of the syringe with your other hand and place the tip of the Q-Cap into the rubber stopper of the vial until you feel a slight resistance. Be very careful not to push on the syringe plunger during this step. 12. Slowly inject the sterile diluent into the vial containing the powdered medication. Gently swirl until the powder is completely dissolved. Do not shake the vial because this will create bubbles. 13. As soon as the powder has completely dissolved, turn the vial upside down and withdraw all of the medication into the syringe. If you need to use more than one vial: The solution from above may be used to dissolve up to 5 additional vials, for a total of 6 vials in 1cc/ml. After reconstituting the first vial of medication with sterile diluent, use the solution already in the Q-Cap syringe to reconstitute the additional vials of medication. When reconstituting additional vials, follow steps 10 and 11 using the reconstituted medication until all the vials needed have been mixed. Helpful Hint: You may also choose to use more than one Q-Cap and put a Q-Cap on each vial (diluent and powder) and just twist the Q-Cap and vial on and off of your syringe as you mix the number of vials that you need. This may be easier for you to do. 14. When you have finished reconstituting the last vial necessary for your injection and have withdrawn all the medication into the syringe, twist the syringe counter clockwise while holding the Q-Cap steady to remove the syringe from the Q-Cap. Discard the Q-Cap with the attached medication vial. CPD3.04a Ovulation Induction Injection Instruction REV. SEPTEMBER 2016 SHADY GROVE FERTILITY 4

15. You are now ready to attach the 27g or 30g ½ inch needle to the syringe. While holding the syringe pointing upward, twist the small needle clockwise onto the syringe. 16.

5 15. You are now ready to attach the 27g or 30g ½ inch needle to the syringe. While holding the syringe pointing upward, twist the small needle clockwise onto the syringe. 16. Hold the syringe straight up. Draw back slightly on the plunger and tap the syringe so that any air bubbles rise to the top. Slowly press the plunger until all the air is out of the syringe and a small drop of solution forms at the tip of the needle. 17. Tap the syringe to remove the drop of solution at the tip of the needle. 18. Carefully recap the needle (using the scoop method) to keep it sterile. The solution is now ready for injection. 19. Please refer to the SQ injection instructions at this point to administer the injection. 20. Be sure to rotate injection sites, and to take the medication at approximately the same time each day give or take 1 hour. Gonal F 75iu Vials SUPPLIES: Alcohol wipes, Gonal-F 75 IU RFF vial, prefilled syringe of Sterile Water for Injection (1 cc/ml), 27g ½ inch injection needle, 18g 1 ½ inch mixing needle. 1. Gather your supplies and wash your hands. 2. Flip the protective plastic cap off of the vial. 3. Wipe the top of the vial with an alcohol swab. 4. Hold the barrel of the prefilled syringe of Sterile Water in one hand. Firmly hold the plastic cap between the thumb and forefinger of the other hand and with a downward motion, gently snap and pull off the cap. If the gray cap remains, simply remove. 5. Remove the wrapper of the 18g 1 ½ inch needle. Twist the needle on the prefilled syringe until it is tightened (clockwise). Holding the hub, or base, of the needle, secure the needle on the tip of the prefilled syringe and remove the needle cap. CPD3.04a Ovulation Induction Injection Instruction REV. SEPTEMBER 2016 SHADY GROVE FERTILITY 5

6. With the vial of Gonal-F powder on a flat surface, insert the needle of the prefilled syringe straight down through the marked center circle of the rubber stopper.

6 6. With the vial of Gonal-F powder on a flat surface, insert the needle of the prefilled syringe straight down through the marked center circle of the rubber stopper. Slowly inject the water into the vial. DO NOT shake. 7. Invert the vial and pull back the needle as far as needed and withdraw the entire contents of the vial. Remove the syringe from the vial. 8. If your dose requires more than one vial, use the mixture in the syringe to reconstitute the next vial of medication. Use the same 18g 1 ½ inch needle and syringe to reconstitute additional vials. 9. Gently pull the plunger back to allow a small air space. Recap the needle. Twist and pull off the needle from the syringe and discard in a sharps container. 10. Remove the wrapper of the 27g ½ inch needle for injection. Twist the needle on the prefilled syringe until it is tightened (clockwise). Holding the hub, or base, of the needle, secure the needle on the tip of the prefilled syringe and remove the needle cap. 11. With the syringe pointing upward, gently tap on the syringe and slowly push the plunger until all air bubbles are gone and a drop of liquid appears on the tip of the needle. 12. Recap the needle. The administration syringe is now filled and ready for injection. 13. Please refer to the SQ injection instructions at this point to administer the injection. 14. Be sure to rotate injection sites, and to take the medication at approximately the same time each day give or take 1 hour. 15. Dispose of the used syringe in the sharps container. Gonal F RFF Redi-ject Pen (300, 450, 900iu) SUPPLIES: Alcohol wipes, gauze pad, Gonal-F pen, outer needle cap, sharps container. Using the Pen: 1. Remove pen cap and wipe threaded tip with alcohol wipe. Remove peel tab from CPD3.04a Ovulation Induction Injection Instruction REV. SEPTEMBER 2016 SHADY GROVE FERTILITY 6

outer needle cap. Press threaded tip of pen into open end of outer needle cap. Twist pen clockwise until needle is securely attached. Remove outer needle cap.

7 outer needle cap. Press threaded tip of pen into open end of outer needle cap. Twist pen clockwise until needle is securely attached. Remove outer needle cap. Leave the blue inner shield on the needle 2. Turn dose knob clockwise until your prescribed dose shows in the dose display window. Do not push or pull the dose knob while you turn it. If you pass your dose, turn the dose knob back to the correct dose. 3. If loaded dose is lower than set dose, there is not enough drug to complete the dose. Use a new Gonal-F Pen to complete the dose. 4. Refer to the Subcutaneous Injection section. 5. Clean your site with alcohol and let air dry. 6. Remove the blue inner needle shield. Do not touch needle or allow it to touch any surface. 7. Inject the needle into the skin at a 90 degree angle and press down on the dose knob with your thumb as far as it will go. 8. Keep needle in the skin for at least 5 seconds. 9. Remove needle and apply pressure as needed with the gauze pad. 10. Be sure to rotate injection sites, and to take the medication at approximately the same time each day give or take 1 hour. 11. After the injection, hold the pen firmly by the drug reservoir and replace outer needle cap. Grip outer needle cap firmly and unscrew pen from the needle by turning pen counter-clockwise. Dispose of needle in sharps container. 12. Replace pen cap and store pen at room temperature or in refrigerator for up to 28 days. Follistim Pen (300, 600, 900iu) SUPPLIES: Alcohol wipes, Follistim AQ cartridge(s) for injection (300IU/600IU/900 IU), Follistim Pen, BD Microfine 29g needles (designed for the Follistim Pen), Pen injection instructions and patient kit. 1. Gather your supplies and wash your hands. 2. Remove the pen injector s protective cap and set aside. CPD3.04a Ovulation Induction Injection Instruction REV. SEPTEMBER 2016 SHADY GROVE FERTILITY 7

8 3. Unscrew the pen body (blue) from the cartridge holder (yellow). 4. Take the Follistim AQ cartridge from the sealed package. Wipe the rubber stopper top with alcohol. Place metal/rubber end down into the yellow cartridge holder. 5. Screw the pen body onto the cartridge holder. Align the blue arrow and yellow rectangle on the pen. 6. Clean the open end of the pen with alcohol. 7. Peel off the seal of the BD microfine needle and screw the needle onto the end of the yellow cartridge holder. Pull off the outer needle shield. DO NOT throw away the OUTER SHIELD. Remove the inner needle shield and discard. 8. Hold the pen with the needle pointing upwards and check for a drop of liquid on the tip of the needle. If a drop is seen, proceed to the next step. If no drop is seen, turn the dial 1 click and press the end button to prime the pen. You should see a drop at the end of the needle. Priming your pen will not decrease the amount of your medication that is available for your use the cartridges have a little extra medication for this primary purpose. 9. Dial your pen to the dose that your physician prescribed (between 50 to 450 IU per day). 10. If you make a MISTAKE DIALING THE DOSE, continue dialing the dosage knob in the same direction up past the 450 IU mark until you feel the dosage scale release and move freely. DO NOT try to dial backwards as you will lose medicine. Push the button in all the way to 0 after you feel the dosage scale ratchet release. Dial up your correct dose as previously instructed. 11. Follow the instructions for subcutaneous (SQ) injections. After pushing the dosage button in all the way, hold the needle in place for 5 seconds before removing. 12. If you see a number other than 0 after your injection, this means there was not enough medication left in the cartridge for your dose. The number in the Dosage Window will give you the amount of medicine needed to complete your dose. Write this number down as it will be the amount of medicine needed to complete your dose. Dispose of the cartridge and insert a new Follistim cartridge and needle. Dial the dose you wrote down. Clean a new, different injection site and inject the medication. You should see 0 now which means you have injected your correct dose. CPD3.04a Ovulation Induction Injection Instruction REV. SEPTEMBER 2016 SHADY GROVE FERTILITY 8

9 13. Place your OUTER NEEDLE SHIELD on a flat surface with the opening pointing upwards. Bring your pen needle down into the needle shield until you feel them attach together. Unscrew your BD Microfine needle and dispose of it in a sharps container. 14. Place your pen cap onto the pen and store in the pen patient kit. 15. You should store the opened unused (leftover medication) portion of the medication cartridge in the pen in the refrigerator. CPD3.04a Ovulation Induction Injection Instruction REV. SEPTEMBER 2016 SHADY GROVE FERTILITY 9

10 Mixing Half Vials (Half Dosing) FOR THE FIRST EVENING: Prepare all of your supplies. Withdraw twice the usual amount of diluent from the vial of diluent (2cc instead of 1cc) IF YOUR DOSE IS 37.5 IU, mix the 2cc of diluent into one 75 IU vial of medication and draw back half (1cc) into the syringe to give injection and put the remainder of the mixed medication (the other half dose or 37.5 IU) into the refrigerator for the next day s dose. IF YOUR DOSE IS IU, mix the 2cc of diluent like you were mixing up a total of three 75 IU vials of medication (total of 225 IU). After reconstituting or concentrating the three vials together, draw back half (1cc) into the syringe to give injection (112.5 IU) and put the remainder of the mixed medication (the other half dose or IU) into the refrigerator for the next day s dose. FOR THE SECOND EVENING: Take the previously prepared half dose out of the refrigerator, draw up the already mixed solution into the syringes, and give the injection as directed. CPD3.04a Ovulation Induction Injection Instruction REV. SEPTEMBER 2016 SHADY GROVE FERTILITY 10

11 Trigger Medication Ovidrel (Hcg) SUPPLIES: Ovidrel Prefilled Syringe, alcohol swabs, gauze, sharps container. NOTE: MUST BE REFRIGERATED! Allow the pre-filled syringe to adjust to room temperature for 5 10 minutes before you administer your injection. 1. Gather supplies and wash your hands thoroughly. 2. Remove the pre-filled syringe from the box. 3. With the needle pointing upwards, carefully remove the needle cap from the syringe. Do not touch the needle or allow it to touch any surface. Keep materials sterile. 4. Pull back on the plunger to draw up a small amount of air. 5. To remove any air bubbles, keep the needle pointed upward and gently tap on the syringe until all the bubbles rise to the top. 6. Carefully push the plunger until a small drop of liquid begins to appear from the tip of the needle. 7. You are now ready to inject. Follow directions for SQ injections. CPD3.04a Ovulation Induction Injection Instruction REV. SEPTEMBER 2016 SHADY GROVE FERTILITY 11

12 Injection Technique Subcutaneous Injection Technique Subcutaneous injections (SQ) are injections given into fatty tissue under the skin. Some suggested sites are the upper outer arm, outer part of the thigh, and the abdomen. You should rotate sites if you are to receive more than one injection. Technique: 1. Swab the area to be injected with alcohol. Allow the area to dry for seconds before giving the injection. (Do not blow air on site). 2. Hold the needle at a 90-degree angle to the skin. 3. Hold the syringe like a pencil. Do not place your finger or thumb on the plunger. This will prevent you from accidentally pushing out the medication. 4. Pinch about an inch of tissue/skin, and then insert the needle gently into the skin with a quick forward motion all the way to the plastic hub of the needle. Release the pinch slightly prior to injecting the medication. 5. Push plunger in to inject the medication. 6. After giving the injection, release the pinch and keep your finger on the plunger as you carefully pull the needle out. 7. Dispose of the needle and syringe in a red sharps container. It is not necessary to recap the needle when putting it in the sharps container. 8. If you experience some discomfort during the injection, you may want to ice the area for a few minutes prior to injecting. 9. You might experience some swelling or a little tenderness around the injection site. To relieve any local discomfort or swelling, you may gently massage the injection site or apply warm moist heat. Please call us with questions. 10. Please return full sharps containers to our office for proper disposal. Do not discard in regular trash. 11. Site locations for SQ injections: CPD3.04a Ovulation Induction Injection Instruction REV. SEPTEMBER 2016 SHADY GROVE FERTILITY 12

Instructions for Use BYDUREON (by-dur-ee-on) Single-Dose Tray (exenatide extended-release) for injectable suspension

BYDUREON (exenatide extended-release) for injectable suspension 6 Instructions for Use BYDUREON (by-dur-ee-on) Single-Dose Tray (exenatide extended-release) for injectable suspension Before using Bydureon,