During SC administration, a needle is inserted through the epidermal and dermal layers of the skin and into the fatty subcutaneous tissue. Also, the rate may be unpredictable in infants because of insufficient muscle tone and vascularity of muscle tissue. Although several studies have shown that there are no substantial differences between IM and SC injections in terms of absorption and drug efficacy (2), the absorption rate from an IM injection does depend on blood flow at the injection site and the muscle mass. Less common side effects can include intramuscular hemorrhage, cellulitis, tissue necrosis, and gangrene (7, 8). Other complications of IM injections include local induration, erythema, hematoma, persistent bleeding, and ultimately, drug discontinuation. Infection is a risk with any parenteral injection because of the risk of bacteria being introduced into the tissue (2, 4–6), which in turn can lead to abscesses and infections in the skin or soft tissue. IM injections, therefore, are best performed by trained personnel who are familiar with anatomical landmarks, which may be difficult to identify in obese or emaciated patients. Because of the needle length and bore size required, IM injections are painful and can temporarily result in limited mobility, an issue of particular concern in older patients (2). There is a possibility of hitting a nerve or blood vessel, leading to muscle contractures and nerve injury (3). Because of the distance from the skin surface into a muscle, IM injections require a relatively long needle (1–2 in.). Volumes of 2–5 mL can be administered, and this route is particularly suited for drugs that are not readily soluble, as a sustained depot action is possible (2, 3). IM injections are given deep into skeletal muscle and usually involve the gluteal, deltoid, rectus femoris, or vastus lateralis muscles. When therapeutic regimens require injection volumes in excess of 1 mL, intramuscular (IM) injections are generally chosen. This entire process occupies both space in an office and specialized nursing time (1). IV drugs are administered by trained medical personnel in a hospital or physician's office and, because of the rapid effects achieved, patients are typically observed for undesired side effects following injection. Direct IV access also carries a risk of systemic infection. IV dosing requires the skilled insertion of a needle or catheter directly into a vein, a process that can be challenging, especially in certain patient types such as obese, palliative-care, and neonate patients. IV dosing is also typical when administering irritating agents such as cytotoxics that would otherwise cause tissue damage and pain if given by alternative routes. IV injections are given either as a 1-to-2-min-bolus or an infusion with a longer duration to facilitate administering precise doses in a controlled manner or in providing a rapid response. For many drugs, including biologics and anticancer agents, the traditional route of administration is intravenous (IV). Therapeutic agents can be introduced into the body by several routes of administration with each having specific advantages and disadvantages (see Table I). Intravenous, intramuscular, and subcutaneous delivery
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