Pregnancy outcomes following exposure to onabotulinumtoxinA

Safety and tolerability of onabotulinumtoxinA in the treatment of upper facial lines from global registration studies in 5298 participants: A meta-analysis

Background

Since its discovery as a facial aesthetic treatment >30 years ago, onabotulinumtoxinA has received worldwide approval for dynamic upper facial line treatment.

Objective

Meta-analysis examining the safety of onabotulinumtoxinA for treatment of glabellar lines (GL), crow's feet lines (CFL), and forehead lines (FHL).

Methods

Participants (N = 5298) with moderate to severe GL, CFL, or FHL at maximum contraction received onabotulinumtoxinA or placebo in 1 of 18 registration studies (14 double-blind, placebo-controlled [DBPC]; 1 double-blind; 3 open-label). Adverse events (AEs) were analyzed by descriptive statistics and fixed-effects meta-analysis.

Results

In the overall double-blind placebo-controlled (DBPC) population, AEs were reported in 1443 (42.1%) and 486 (35.8%) participants in the onabotulinumtoxinA (n = 3431) and placebo (n = 1359) groups, respectively. Serious AEs were reported in 54 (1.6%) and 17 (1.3%) participants; 1 (spontaneous abortion) was considered possibly treatment related by the investigator. Using fixed-effects statistical meta-analysis, AEs of interest that were found to be statistically higher for onabotulinumtoxinA than placebo in the DBPC population were eyelid ptosis, eyelid sensory disorder, skin tightness, brow ptosis, eyelid edema, and facial pain (P ≤ .05).

Limitations

Retrospective, ad hoc analysis.

Conclusion

This meta-analysis confirms the onabotulinumtoxinA safety profile for GL, CFL, and FHL treatment, with no new onabotulinumtoxinA-associated AEs.

Efficacy and Safety Analysis of Botox Application and Iatrogenic Botulism: Panacea or Peril?

Clostridium botulinum toxin-A (BoNT-A) creates temporary paralysis in the muscles by acting on the muscle-nerve junction. It is injected into the mimic muscles when a decrease in the movements of the mimic muscles is desired. Despite many favorable applications, the use of BoNT-A is not without drawbacks. Although there is no expected serious side effect on health in BoNT-A treatments, various problems can be encountered in patients treated for aesthetic purposes. Botulism is a rare but potentially life-threatening syndrome, which is caused by the toxin produced by the bacterium Clostridium botulinum, which acts on the nervous system, vegetative forms of C. botulinum can only survive in anaerobic conditions, while spore forms are common in nature and can withstand harsh conditions. Botulism can stem from bacterial spores which release toxin in the body; in the form of enteric botulism, and wound botulism. The cases that develop 'iatrogenic botulism' after such procedures are usually those receiving high-dose toxin for therapeutic purposes. The treatment of botulism mainly consists of anti-toxin therapy and, if necessary, intensive care to prevent organ failures, including respiratory support. This article aims to cover all these issues related to botulism and other adverse outcomes related to BoNT-A injection in light of the most recent literature.

Supporting the Young Adulthood Transitions in Women With Migraine

Migraine is a painful neurological disorder that disproportionately affects women and has a significant impact on quality of life. This article summarizes the critical role of women's health nurses in supporting young adult women with migraine during major life transitions. Nurses can advocate for workplace or school disability accommodations for women with migraine. Nurses can also support young adult women with migraine by providing education about available treatment that becomes available after an individual's 18th birthday. Women's health nurses can also provide counseling on healthy lifestyle habits to sustain through life transitions, such as guidance on safe alcohol consumption and wellness approaches to migraine management. Through these interventions, women's health nurses can help women with migraine to succeed personally, professionally, and academically while effectively managing migraine symptoms.

The Association of Coloproctology of Great Britain and Ireland guideline on the management of anal fissure

AIM

The management of anal fissure: ACPGBI position statement was written 15 years ago. [KLR Cross et al., Colorectal Dis, 2008]. Our aim was to update the guideline and provide recommendations on the most effective treatment for patients with anal fissures utilising a multidisciplinary, rigorous guideline methodology.

METHODS

The development process consisted of six phases. In phase 1 we defined the scope of the guideline. The patient population included patients with acute and chronic anal fissure. The target group was all practitioners (primary and secondary care) treating patients with fissures and, in addition, healthcare workers and patients who desired information regarding fissure management. In phase 2 we formed a guideline development group (GDG) including a methodologist. In phase 3 review questions were formulated, using a reversed PICO process, starting with possible recommendations based on the GDG's knowledge. In phase 4 a comprehensive literature search focused on existing systematic reviews addressing each review question, supplemented by more recent studies if appropriate. In phase 5 data were extracted from the included papers and checked by the GDG. If indicated, meta-analysis of systematic review data was updated by the GDG. During phase 6 the GDG members decided what recommendations could be made based on the evidence in the literature and strength of the recommendation was assessed using 'grade'.

RESULTS

This guideline is divided into two sections: Primary care which includes (i) diagnosis; (ii) basic treatment; (iii) topical treatment; and secondary care which includes (iv) botulinum toxin therapy; (v) surgical intervention and (vi) special situations (including pregnancy and breast-feeding patients, children, receptive anal intercourse and low-pressure fissures). A total of 23 recommendations were formulated. A new term clinically healed was described by the GDG.

CONCLUSION

This guideline provides an up-to-date evidence-based summary of the current knowledge of the management of anal fissure and may serve as a useful guide for clinicians as well as a potential reference for patients.

Bladder pain syndrome and pregnancy

Bladder pain syndrome (BPS) is a poorly understood condition. In pregnancy, lower urinary tract symptoms and pain are common, but the possibility of BPS is rarely considered and almost never explored. The consequences of BPS on pregnancy and vice versa are poorly understood, and management options appear to be limited. This article reviews the current evidence to allow us to better counsel, investigate, diagnose and manage patients with suspected or known BPS who fall pregnant or who are considering pregnancy. MEDLINE, EMBASE and PubMed were searched for a combination of mesh terms of keywords: 'cystitis', 'interstitial', 'bladder', 'pain' and 'pregnancy'. Relevant articles were identified, reviewed and further relevant articles identified from the references. CONCLUSION: BPS symptoms are very common in pregnancy, with limited data suggesting significant negative effects on the woman and pregnancy. There are safe options for investigation, diagnosis and management in pregnancy. There is a need to raise awareness of the impact of BPS symptoms in pregnancy and the available options for diagnoses and management, improving patient experience and outcomes. PATIENT SUMMARY: Patients with BPS or symptoms akin to BPS need not be abandoned in pregnancy. There is data to support them in making decisions around investigation and management in pregnancy.

Obstetric and Gynecologic Disorders and the Nervous System

OBJECTIVE

This article discusses obstetric and gynecologic associations with common neurologic disorders.

LATEST DEVELOPMENTS

Neurologic complications of obstetric and gynecologic disorders can arise throughout the lifespan. Caution should be exercised when prescribing fingolimod and natalizumab to patients with multiple sclerosis who are of childbearing potential because of the risk of disease rebound when they are discontinued. OnabotulinumtoxinA is considered safe in pregnancy and lactation based on long-term observational data. Hypertensive disorders of pregnancy are associated with higher subsequent cerebrovascular risk, likely via multiple mechanisms.

ESSENTIAL POINTS

Neurologic disorders may present in a variety of obstetric and gynecologic contexts, with meaningful implications for recognition and treatment. These interactions must be considered when treating women with neurologic conditions.

Migraine and the Gender Divide

Migraine is a global neurologic disease that is highly prevalent, especially in women. Studies have observed a predisposition for the development of migraine in women, although the mechanisms involved have yet to be fully elucidated. This review aimed to summarize the recent evidence regarding the epidemiology, pathophysiology, and treatment of migraine and highlight key sex differences. We also identify gaps in care for both women and men living with migraine and discuss the presence of migraine-related stigma and how this may impact the efficacy of clinical care.

Safety of drugs used for the treatment of migraine during pregnancy: a narrative review

INTRODUCTION

Migraine is common in females of childbearing age and negatively impacts quality of life. The majority of those with migraine who become pregnant see an improvement in their condition but not all do. Providing evidence-based recommendations for the pharmacological management of migraine in pregnancy is challenging.

AREAS COVERED

This narrative review provides an update on the safety of drugs used for migraine in pregnancy. National and international guidelines on the management of episodic migraine in adults were used to select the drugs of relevance to pregnant women. The final list of drugs was chosen by a pain specialist who categorized them according to drug class and use in acute management or prevention. PubMed was searched from inception to 31st July 2022 for evidence on drug safety.

EXPERT OPINION

Obtaining high-quality drug safety data in pregnant migraineurs is difficult not least because exposing a fetus to research-related risks is often considered unethical. There is reliance on observational studies which often group drugs together and lack specificities pertinent to drug prescribing like timing, dosing and duration. Improved statistical tools, study designs and the creation of international collaborative frameworks are ways to advance knowledge on drug safety in pregnancy.

Migraine treatment in pregnancy: A survey of comfort and treatment practices of women's healthcare providers

OBJECTIVE

The objective of this study was to assess women's healthcare providers' treatment practices for pregnant women with migraine.

BACKGROUND

Migraine is associated with several maternal and fetal complications during pregnancy, including preeclampsia and preterm birth. Migraine treatment during pregnancy can present significant challenges due to lack of controlled clinical trials and risks associated with specific medications.

METHODS

Women's healthcare providers were queried regarding practice patterns and comfort with use of acute and preventive migraine treatments during pregnancy. The survey was distributed online.

RESULTS

The survey was completed by 92 women's healthcare providers (response rate 22.9% [92/402]), with most specializing in general obstetrics and gynecology (91% [83/92]). Approximately one-fourth (26% [24/92]) of respondents indicated they counseled women on migraine treatment in pregnancy as early as before pregnancy contemplation, while over one-third (35% [32/92]) counseled on migraine treatment once the patient became pregnant. The majority of respondents reported feeling somewhat or very comfortable with recommending (63% [58/92]) or continuing (64% [59/92]) acute treatments for pregnant patients with migraine, with highest comfort levels for acetaminophen (100% [92/92] for prescribing or continuing) and caffeine (94% [85/90] prescribing, 91% [82/90] continuing). Higher levels of discomfort were reported with triptans (88% [80/91] rarely or never prescribe during pregnancy). Survey respondents felt less comfortable with recommending preventive migraine treatments to pregnant patients (40% [37/92] somewhat or very comfortable), compared with a higher comfort level with continuing preventive medications (63% [58/92] somewhat or very comfortable). Highest comfort levels were reported with use of magnesium (69% [63/91] comfortable prescribing, 82% [75/92] comfortable continuing) and non-pharmacologic approaches (70% [62/89] comfortable prescribing, 84% [75/89] comfortable continuing). Nearly 40% (35/92) of respondents reported that they typically refer to neurologists or headache specialists for migraine treatment during pregnancy.

CONCLUSION

This survey of women's healthcare providers revealed varying levels of comfort regarding migraine management during pregnancy, and highlights the need for additional education regarding migraine treatment safety data during pregnancy.

Reproduction, skin aging, and sleep in middle-aged women

There is a growing trend for women to delay having children, with a significant number of women postponing motherhood until the third or fourth decade of life. At the same time, these middle-aged women may be more concerned about skin aging and use dermatologic procedures to delay or repair the effects of aging, environmental factors, and oxidative stress on the skin. It has been suggested that the use of skin cosmetics and procedures may play a role in the reproductive system, although their possible effects have not yet been clearly elucidated. Another crucial factor that needs to be raised in this context is poor sleep, which seems to have an important relationship with both reduced fertility and accelerated skin aging, especially when it is associated with greater oxidative stress and hormonal imbalance. This review discusses the important triad of sleep, dermatology, and reproduction, a subject that has received relatively little attention; and, given its potentially wide-ranging implications, one that deserves more frequent and detailed consideration in future studies. Understanding this complex web of interactions could help to provide outcomes that include healthier skin, safety, improved self-esteem, and successful fertility treatments, all of which can directly affect quality of life.

Integrative, Interventional, and Non-invasive Approaches for the Treatment for Migraine During Pregnancy

PURPOSE OF REVIEW

While most women with migraine improve during pregnancy, a subset may remain unchanged or even become more severe. Given the limited evidence for the use of prescription medications during pregnancy, many look to other treatment modalities. We seek to review complementary and integrative medicine, procedural interventions, and neurostimulation to empower women with safe and effective treatment options during pregnancy.

RECENT FINDINGS

Migraine treatment during pregnancy remains controversial. While evidence is limited, prospective and retrospective reviews, as well as clinical experience support the use of nutraceuticals, procedural interventions, and neurostimulation during pregnancy when the appropriate risks and benefits are weighed. Empowering patients with information on complementary and integrative medicine, as well as non-systemic and interventional treatments, may help to reduce anxiety and headache burden during pregnancy. Various nutraceuticals have shown promise for the preventive management of migraine. Non-systemic interventions such as trigger point injections and peripheral and sphenopalatine nerve blocks offer effective treatment options with minimal side-effects. Options for neurostimulation have expanded in recent years and may offer safe and effective non-pharmacologic options for the management of migraine. It is imperative that providers do not minimize migraine during pregnancy and become aware of the treatment modalities available to help guide women through this experience.

Headache: pregnancy and breastfeeding Recommendations of the Spanish Society of Neurology's Headache Study Group

INTRODUCTION

Headache is one of the most common neurological complaints, and is most frequent during reproductive age. As a result, we are routinely faced with pregnant or breastfeeding women with this symptom in clinical practice. It is important to know which pharmacological choices are the safest, which should not be used, and when we should suspect secondary headache. To this end, the Spanish Society of Neurology's Headache Study Grouphas prepared a series of consensus recommendations on the diagnostic and therapeutic algorithms that should be followed during pregnancy and breastfeeding.

DEVELOPMENT

This guide was prepared by a group of young neurologists with special interest and experience in headache, in collaboration with the Group's Executive Committee. Recommendations focus on which drugs should be used for the most frequent primary headaches, both during the acute phase and for prevention. The second part addresses when secondary headache should be suspected and which diagnostic tests should be performed in the event of possible secondary headache during pregnancy and breastfeeding.

CONCLUSIONS

We hope this guide will be practical and useful in daily clinical practice and that it will help update and improve understanding of headache management during pregnancy and breastfeeding, enabling physicians to more confidently treat these patients.

The problem of diagnosis and differential diagnosis of botulism in pregnant women. Case report

The article describes a clinical observation of a severe course of a sporadic case of foodborne botulism in a woman at 32 weeks gestation with a successful resolution of pregnancy by independent childbirth. No adverse effects of botulism on pregnancy, delivery, and fetal development were noted. Anti-botulinum serum was administered to the patient no earlier than 96 hours from the onset of the disease. The paper analyzes the clinical picture of botulism, on the basis of which it is necessary to carry out a differential diagnosis.

Headache: pregnancy and breastfeeding. Recommendations of the Spanish Society of Neurology's Headache Study Group

INTRODUCTION

Headache is one of the most common neurological complaints, and is most frequent during reproductive age. As a result, we are routinely faced with pregnant or breastfeeding women with this symptom in clinical practice. It is important to know which pharmacological choices are the safest, which should not be used, and when we should suspect secondary headache. To this end, the Spanish Society of Neurology's Headache Study Group has prepared a series of consensus recommendations on the diagnostic and therapeutic algorithms that should be followed during pregnancy and breastfeeding.

DEVELOPMENT

This guide was prepared by a group of young neurologists with special interest and experience in headache, in collaboration with the Group's Executive Committee. Recommendations focus on which drugs should be used for the most frequent primary headaches, both during the acute phase and for prevention. The second part addresses when secondary headache should be suspected and which diagnostic tests should be performed in the event of possible secondary headache during pregnancy and breastfeeding.

CONCLUSIONS

We hope this guide will be practical and useful in daily clinical practice and that it will help update and improve understanding of headache management during pregnancy and breastfeeding, enabling physicians to more confidently treat these patients.

Comprehensive management of adults with chronic migraine: Clinical practice guidelines in Mexico

Introduction:

Migraine is a polygenic multifactorial disorder with a neuronal initiation of a cascade of neurochemical processes leading to incapacitating headaches. Headaches are generally unilateral, throbbing, 4–72 h in duration, and associated with nausea, vomiting, photophobia, and sonophobia. Chronic migraine (CM) is the presence of a headache at least 15 days per month for ≥3 months and has a high global impact on health and economy, and therapeutic guidelines are lacking.

Methods:

Using the Grading of Recommendations, Assessment, Development, and Evaluations system, we conducted a search in MEDLINE and Cochrane to investigate the current evidence and generate recommendations of clinical practice on the identification of risk factors and treatment of CM in adults.

Results:

We recommend avoiding overmedication of non-steroidal anti-inflammatory drugs (NSAIDs); ergotamine; caffeine; opioids; barbiturates; and initiating individualized prophylactic treatment with topiramate eptinezumab, galcanezumab, erenumab, fremanezumab, or botulinum toxin. We highlight the necessity of managing comorbidities initially. In the acute management, we recommend NSAIDs, triptans, lasmiditan, and gepants alone or with metoclopramide if nausea or vomiting. Non-pharmacological measures include neurostimulation.

Conclusions:

We have identified the risk factors and treatments available for the management of CM based on a grading system, which facilitates selection for individualized management.

OnabotulinumtoxinA for the prophylactic treatment of headaches in adult patients with chronic migraine: a safety evaluation

Introduction: Existing oral prophylaxis for chronic migraine (CM) are often ineffective or poorly tolerated. OnabotulinumtoxinA (onabotA) is approved for headache prophylaxis in CM and ameliorates headaches in patients refractory to multiple preventatives.Areas covered: We appraise evidence regarding action mechanisms, pharmacodynamics, and pharmacokinetics of onabotA in CM prophylaxis. We critically evaluate salient clinical and real-world studies demonstrating its efficacy in improving multiple aspects of CM. We discuss onabotA safety, tolerability, and adverse events (AEs) for CM prophylaxis from clinical trials, post-authorization studies and meta-analyses, including novel pregnancy safety data and comparisons with oral prophylactics. We explore areas of future interest, particularly onabotA safety and efficacy in the context of novel antibody-based prophylaxis.Expert opinion: Clinical and real-world evidence demonstrate onabotA safety, tolerability and efficacy for CM prophylaxis. Most AEs are mild/moderate and self-limiting, with few serious AEs and no treatment-related deaths. Common AEs include neck pain, ptosis, muscle weakness, and stiffness. Modifying existing responder-criteria enables more patients to benefit from onabotA. OnabotA shows superior safety and efficacy to oral preventatives, and appears safe in pregnancy. Future pregnancy-risk register will clarify pregnancy and lactation safety further. Future research comparing onabotA safety and efficacy with newly emergent antibody-based prophylaxis is keenly awaited.

Safety and tolerability of preventive treatment options for chronic migraine

INTRODUCTION

Relative to migraine generally, chronic migraine (CM) imposes greater disability, healthcare utilization and socioeconomic burden. Six therapies currently possess a credible evidence base for prevention/suppression of CM. This review is intended to provide an assessment of their relative utility, defined as a blend of safety, tolerability and efficacy, focusing in particular on their safety and tolerability.Areas Covered: We discuss all six medications currently FDA-approved for migraine prevention which also specifically possess credible evidence of efficacy in treating CM. While we do address the efficacy of each, our primary emphasis involves assessment of safety and tolerability data derived from clinical trials and post-marketing experience.Expert Opinion: Recent research involving CM has led to the identification of highly targeted and typically well-tolerated therapies. For patients who experience obstacles to accessing these newer therapies, topiramate is available as an evidence-based alternative, but contraindications, drug-drug interactions and poor tolerability may limit or prevent its use. Although data to support such intervention presently is limited, clinically challenging CM cases may benefit from combination therapy. 'Real world' studies are needed to evaluate such polytherapy, along with studies intended to assess the long-term safety of the individual therapies and their use during pregnancy and breast-feeding.

Headache in Women

PURPOSE OF REVIEW

Women are greatly overrepresented among patients seeking treatment for symptoms of headache pain in general and migraine in particular. Understanding the presentation of headache in women in relation to hormonal changes both during the menstrual cycle and throughout the life span is essential for appropriate diagnosis and treatment.

RECENT FINDINGS

Although perimenstrual migraine attacks are generally without aura, the diagnosis of migraine with aura has been added to the headache classification for menstrual migraine to account for women with the diagnosis of migraine with aura who experience menstrual migraine attacks. Emerging knowledge regarding the differences between menstrual and nonmenstrual attacks, the variability of attack triggering within and between women, and the response of women with menstrually related migraine to new migraine drug classes is contributing to better understanding and more effective treatment of these particularly burdensome and refractory attacks. Given the burden of migraine, almost one-fourth of women with migraine avoid or delay pregnancy. Women who experience migraine during pregnancy are more likely to have a hypertensive disorder and stroke during pregnancy and/or delivery and the postpartum period. Treatment of headache in general and migraine in particular in pregnancy is challenging because of fetal and maternal risks; however, a 2021 systematic review suggests that triptans and low-dose aspirin may not be associated with fetal/child adverse effects and could be more strongly considered for headache treatment in pregnancy.

SUMMARY

Headache in general and migraine in particular are extraordinarily common in women of reproductive age and fluctuate with hormonal changes and phases of life. Improved knowledge of the epidemiology, pathophysiology, and response to treatment of perimenstrual attacks is essential for more effective response to this most burdensome headache type. Treatment of headache in pregnancy remains challenging.

Clinic-based Procedures for Headache

PURPOSE OF REVIEW

Headache disorders are common and disabling, and many therapies that are effective and safe are procedural.

RECENT FINDINGS

After pivotal clinical trials, onabotulinumtoxinA has become an established preventive therapy for chronic migraine; it is better tolerated than many other treatments and may be useful for other headache disorders. Peripheral nerve blocks, especially greater occipital nerve blocks, have amassed evidence from randomized trials in the acute and short-term preventive treatment of migraine and cluster headache. Trigger point injections and sphenopalatine ganglion blocks have recent trials suggesting efficacy and safety in properly selected patients. Medical education initiatives are needed to train neurologists in these procedures to help manage the large population of patients with headache disorders who need them.

SUMMARY

Evidence exists for the efficacy and safety of procedural therapies to be incorporated into neurology practice for the management of patients with migraine, cluster headache, and other headache disorders.

Management of cluster headache and other trigeminal autonomic cephalalgias in pregnancy and breastfeeding

Many clinicians lack experience in managing trigeminal autonomic cephalalgias (TACs) in pregnancy and lactation. In addition to cluster headache, TACs include hemicrania continua, paroxysmal hemicrania, and short-lasting unilateral neuralgiform headache with conjunctival injection and tearing/autonomic symptoms (SUNCT/SUNA). Treating these rare, severe headache conditions often requires off-label drugs that have uncertain teratogenic potential. In the last few years, several new treatment options and safety documentation have emerged, but clinical guidelines are lacking. This narrative review aimed to provide an updated clinical guide and good clinical practice recommendations for the management of these debilitating headache disorders in pregnancy and lactation.

Women's and Fetal Issues in Neurotoxicology

Management of the pregnant patient with neurologic disease is challenging. Ideally, preconception planning can optimize the woman's neurologic condition before pregnancy. More than half of pregnancies are unplanned which makes careful consideration of medications vitally important. This article focuses on potential toxic risk to the fetus of medications deemed necessary to manage several common maternal neurologic issues: multiple sclerosis, epilepsy, and headache during pregnancy and postpartum. It is important for the practitioner to have an understanding beyond the category system to understand the potential toxic risks to the infant.

Treatment of acute dysmenorrhoea and pelvic pain syndrome of uterine origin with myometrial botulinum toxin injections under hysteroscopy: A pilot study

BACKGROUND

Acute dysmenorrhoea in women which has been shown to be anatomically negative for endometriosis is a very common condition. It is frequently associated with Chronic Pelvic Pain (CPP) from uterine origin, including painful uterine contractions and deep dyspareunia. We call this association Painful Uterine Syndrome (PUS).

SEARCH STRATEGY

In these women in failure of the usual treatments, we proposed a new treatment, with Uterine Toxin Botulinic injections (BTX) under hysteroscopy, as a compassionate option, among women in severe pain and therapeutic failure. Indeed, increased uterine contractility has been confirmed using cine magnetic resonance imaging in patients with acute dysmenorrhea and PUS. These findings, associated with the hypothesis of a possible uterine sensitization on the same model as irritable bowel syndrome (IBS) or painful bladder syndrome (PBS), led to the application of botulinum toxin (BTX) injections under hysteroscopy of the uterine myometrium in this indication.

MATERIAL AND METHODS

In 2018, we conducted an open-label non comparative study, on 30 patients, with severe dysmenorrhea and PUS in therapeutic failure situation. All women had failure of usual treatments, with painkillers, anti-inflammatory drugs, contraceptive pill, menstrual suppressant therapy and a negative MRI and laparoscopy. The BTX units (200 IU of Incobotulinum-toxin A) were evenly distributed in the anterior and posterior myometrial wall under hysteroscopic control. Patients were reviewed between 8 and 12 weeks after BTX injections and then, at 6 months.

MAIN RESULTS

Median VAS scores were significantly improved at 8-12 weeks follow up for dysmenorrhoea, deep dyspareunia, and pelvic pain outside of menstruation. Quality of life scores all improved dramatically. No major side effect has been reported in this pilot study. At 6 months, 12 patients (40 %), were given new injections for pain reccurence. But 14 patients (47 %), were still improved and did not require repeat injection at that time. 4 patients, were improvement was not significant, did not ask for repat BTX injections. These patients were all positive for Pelvic Sensitization criteria.

CONCLUSIONS

Uterine BTX injection could be a very interesting therapeutic option in women with acute dysmenorrheoa and PUS in therapeutic failure. Only long-term randomised studies will be able to confirm that BTX injections are useful as a treatment for this condition. The randomised long-term study, Uteroxine, will shortly release its results.

OnabotulinumtoxinA for chronic migraine during pregnancy: a real world experience on 45 patients

OBJECTIVE

To report the pregnancy outcomes on patients with chronic migraine exposed to onabotulinumtoxinA from Hull Headache Clinic.

BACKGROUND

Migraines are common in women of reproductive age and those with chronic migraine have a major impact on their activities of daily living and health-related quality of life. Apart from low dose amitriptyline and beta-blockers all other prophylactic agents have proven teratogenic effects. OnabotulinumtoxinA is approved as preventive treatment for adult patients with chronic migraine, although its impact on pregnancy is unknown.

METHODS

We prospectively collected data for efficacy and safety on all patients treated with onabotulinumtoxinA at the Hull Headache Clinic. The toxin is administered as per PREEMPT paradigm. Female patients of reproductive age group receiving onabotulinumtoxinA are given advice on contraception and the unknown impact of the toxin on pregnancy. They are asked to report pregnancy when they are appraised on the risk/benefit of treatment continuation. All patients are consented for access to their medical records and pregnancy outcome and those who wished to continue are asked to sign a disclaimer. Pregnancy outcome data was collected on all patients for the mode of delivery, birth weight and congenital malformation and any other unexpected outcomes.

RESULTS

Over 9 years period 45 patients reported pregnancy while receiving onabotulinumtoxinA. All patients had received onabotulinumtoxinA within 3 months prior to the date of conception. 32 patients wished to continue treatment during pregnancy while the remaining 13 stopped treatment. Apart from 1 miscarriage in the treatment group, all patients had full term healthy babies of normal birth weight and no congenital malformations.

CONCLUSION

We report our experience of 45 patients exposed to onabotulinumtoxinA during pregnancy. Although the numbers are small, there was no impact of the toxin found on the pregnancy outcomes.

Managing migraine in pregnancy and breastfeeding

The disproportionate prevalence of migraine among women in their reproductive years underscores the clinical significance of migraine during pregnancy. This paper discusses how migraine evolves during pregnancy, secondary headache disorders presenting in pregnancy and puerperium, and acute and preventive options for migraine management during pregnancy and lactation. Migraine is influenced by rising estrogen levels during pregnancy and their sharp decline in puerperium. Migraine, and migraine aura, can present for the first time during pregnancy and puerperium. There is also a higher risk for the development of preeclampsia and cerebrovascular headache during these periods. New or refractory headache, hypertension, and abnormal neurological signs are important "red flags" to consider. This paper reviews the diagnostic utility of neuroimaging studies and the risks of each during pregnancy. Untreated migraine can itself lead to preterm delivery, preeclampsia, and low birth weight infants. Behavioral interventions and lifestyle modifications are the cornerstone for migraine treatment during pregnancy. In addition, one should consider the risks and efficacy of each treatment during pregnancy on an individual basis. The protective nature of breastfeeding for migraine is debated, but there is no evidence to suggest breastfeeding worsens migraine. Acute and preventive migraine treatment options are available for nursing mothers. Neuromodulation and neurostimulation devices are additional options for treatment during pregnancy and lactation, while the safety of using calcitonin gene-related peptide receptor antagonists during these times remains to be determined.

Long-Term Safety and Tolerability of OnabotulinumtoxinA Treatment in Patients with Chronic Migraine: Results of the COMPEL Study

Introduction

OnabotulinumtoxinA is approved in the USA for the prevention of headache in adults with chronic migraine, a debilitating neurologic disease characterized by headaches occurring on ≥ 15 days per month for > 3 months and including migraine features on ≥ 8 days per month.

Objective

The COMPEL Study (NCT01516892), a 108-week, multi-center, open-label study, evaluated the long-term efficacy and safety of onabotulinumtoxinA in adults with chronic migraine. The objective of this subanalysis was to examine the safety and tolerability of onabotulinumtoxinA after each of nine treatment cycles.

Methods

OnabotulinumtoxinA 155 U was administered every 12 weeks. Safety and tolerability, overall and by treatment cycle, were assessed. Treatment-emergent adverse events reported between successive treatments were attributed to the preceding treatment. The safety population received one or more doses of onabotulinumtoxinA. The primary efficacy outcome was the reduction in headache days at week 108 compared with baseline.

Results

Of 716 patients enrolled, 373 patients (52.1%) completed the study and 343 (47.9%) withdrew; 481 patients (67.2%) received 60 weeks of treatment and 402 (56.1%) received 108 weeks of treatment. In total, 436 (60.9%) patients reported treatment-emergent adverse events; most were mild/moderate in severity. Thirty-two patients (4.5%) discontinued the study after experiencing treatment-emergent adverse events. The incidence of treatment-emergent adverse events typically decreased with repeated onabotulinumtoxinA treatment: first cycle, 24.2%; fourth cycle, 18.4%; ninth cycle, 12.2%. Neck pain (2.7%), eyelid ptosis (1.8%), musculoskeletal stiffness (1.4%), injection-site pain (1.3%), and headache (1.3%) were the most common treatment-emergent adverse events after the first cycle. Seventy-five patients (10.5%) reported serious treatment-emergent adverse events, 13 (1.8%) withdrew. Treatment-related adverse events were reported by 131 patients (18.3%), one was considered serious. OnabotulinumtoxinA significantly reduced headache day frequency by 10.7 (6.4) days per 28-day period (p < 0.0001) at week 108.

Conclusions

OnabotulinumtoxinA treatment was well tolerated over 108 weeks; no new safety signals were identified. The overall incidence of treatment-emergent adverse events and the most common individual events decreased with repeated onabotulinumtoxinA administration.

Clinical Trial Registration

ClinicalTrials.gov; NCT01516892.

Electronic supplementary material

The online version of this article (10.1007/s40264-019-00824-3) contains supplementary material, which is available to authorized users.

Clinician-Patient Dialogue About Preventive Chronic Migraine Treatment

Many new medications for the treatment of migraine are now available on the market. In the current evolving migraine treatment landscape, an individualized treatment approach is needed. This review provides practical recommendations on how to obtain a correct diagnosis and then engage in a long-term partnership with patients with the most severe form of migraine: chronic migraine (CM). Given the need to effectively treat this complex neurological disease, clinicians in primary care, general neurologists, and headache specialists are at the forefront to ease the burden of this disease for their patients. This manuscript will review how to discuss the currently available treatment options to help control migraine attacks, manage expectations, and, together with the patient, determine the most effective and appropriate treatment. The goal is to create an environment where the clinician partners with the patient in shared decision-making to choose the most effective appropriate treatment for the individual patient.

Application of botulinum toxin in pregnancy and its impact on female reproductive health

Introduction: Botulinum toxin (BoNT) is a protein secreted by the anaerobic Gram-negative bacterium Clostridium botulinum. Among the seven known subtypes, type A is the most commonly used in women to treat diseases. It primarily blocks presynaptic release of acetylcholine at the neuromuscular junction, resulting in temporary muscle paralysis; thus, it is suitable for treating dystonia and other systemic diseases. BoNT is used widely for treating diseases that persist throughout, and may worsen during, pregnancy, such as cervical dystonia and achalasia. Thus, it is important to investigate whether BoNT injection during pregnancy causes side effects in pregnant women, fetuses, or newborns.Areas covered: This review highlights the efficiency and safety of BoNT injection in pregnancy. and assessed current literature with respect to the use of BoNT for disease treatment during pregnancy.Expert opinion: BoNT injection does not increase the risk of complications in pregnant women and fetuses. However, the use of BoNT to treat disease during pregnancy requires fully informed consent from patients. In addition, further research is needed to determine how to reduce the side effects of BoNT injection during pregnancy (e.g., by improving drug composition, or adjusting the amount of BoNT or the injection interval).

Migraine in Women

Migraine is a lifelong condition that disproportionately affects women and, if not effectively managed, can lead to significant disability. It is important for clinicians to have a good understanding of the impact of the hormonal fluctuations that occur throughout a female migraineur's life, so that appropriate, stratified therapies can be implemented. In doing so, whether it is migraine onset at menarche in an adolescent young woman, or migraine worsening in a perimenopausal female migraineur, quality of life can be ensured.

Safety issues associated with using medication to treat overactive bladder

INTRODUCTION

The mainstay of overactive bladder treatment is the use of anticholinergic medication with its common side effects well known. This review focused on three less well-known safety issues when treating OAB. Areas covered: Patients with increased anticholinergic load are at risk of cognitive decline, dementia or even death. The elderly are particularly at risk due to polypharmacy. Botulinum toxin carries the risk of high urinary residuals, urinary tract infection and need to self catheterise. The use of vaginal oestrogens may improve OAB symptoms, but there is concern in those with a history of breast cancer. Studies have shown that the systemic absorption is negligible and does not increase the risk of recurrence. Expert Opinion: Improvement in assessing anticholinergic load is needed with the development of a universal drug scale. To avoid increasing load, Mirabegron or botulinum toxin can be used instead. There is no consensus of the use of prophylactic antibiotics when injecting botulinum toxin and at what residual to initiate self catheterisation. Despite evidence showing that the use of vaginal oestrogens is safe in those with a history of cancer, it is not fully supported by any health body. Further work is needed in those using aromatase inhibitors.

Safety of available and emerging drug therapies for hyperhidrosis

INTRODUCTION

Hyperhidrosis affects 4.8% of the U.S. population and has been underestimated by physicians for long time despite considerable interference with quality of life. Many patients suffer from primary (idiopathic) hyperhidrosis which results from over-activity of sympathetic nerves and is restricted to specific body areas, mostly the axillae, palms, soles, or head. Secondary hyperhidrosis is caused by an underlying disease or the intake of medications and often involves large parts of the body. Numerous effective therapies with topical or systemic drugs and surgical options are available. Areas covered: Efficacy and safety data on aluminum salts, anticholinergic drugs for topical or systemic application, and on intradermal botulinum toxin injections used to treat hyperhidrosis are critically evaluated, including data from clinical trials with focus on possible side effects and long-term complications in dispute. Expert opinion: Hyperhidrosis often responds well to available therapies. Depending on the type of hyperhidrosis treatment should be topical/local or systemic. Most of the side effects are mild, transient and easily manageable. In case of systemic treatment with anticholinergics low dosing and up-titration of medication is necessary to avoid severe adverse effects. Concerns about the promotion of breast cancer and Alzheimer disease by topical aluminum salts are unsolved.

Pregnancy outcomes following exposure to onabotulinumtoxinA

PURPOSE

To evaluate pregnancy outcomes following onabotulinumtoxinA (US Food and Drug Administration pregnancy category C product) exposure using the Allergan safety database.

METHODS

The Allergan Global Safety Database contains reports of onabotulinumtoxinA administration before/during pregnancy, including both prospective (reported before outcome) and retrospective (outcome already known) cases. The database was searched from 1/1/90 to 12/31/13 for eligible cases where treatment occurred during pregnancy or ≤3 months before conception. To minimize reporting bias, prevalence rates were focused on prospective cases.

RESULTS

Of 574 pregnancies with maternal onabotulinumtoxinA exposure, 232 were eligible with known outcomes. Patients received onabotulinumtoxinA most frequently for cosmetic indications (50.5%), movement disorders (16.8%), and pain disorders (14.2%). Of the 137 with dose information, 40.1% received <50U, 14.6% 50U to <100U, 27.7% 100U to <200U, and 17.5% ≥200U. Among 146 cases with known maternal age, 47.9% were ≥35 years. Most (96.0%) fetal exposures occurred during/before the first trimester. Of the 137 prospective cases (139 fetuses), 110 (79.1%) were live births; 29 (20.9%; 95% CI, 14.0-30.0%) ended in fetal loss (21 spontaneous, 8 induced abortions). Among live births, 106 (96.4%) were normal, with four abnormal birth outcomes (1 major fetal defect, 2 minor fetal malformations, 1 birth complication), giving a 2.7% (3/110; 95% CI, 0.6-8.0%) prevalence rate for overall fetal defects.

CONCLUSIONS

A 24-year retrospective review of the Allergan safety database shows that the prevalence of fetal defects in onabotulinumtoxinA-exposed mothers before/during pregnancy (2.7%) is comparable with background rates in the general population. Pregnancy outcome monitoring in onabotulinumtoxinA-exposed women continues.