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Effect of Bladder Injection of OnabotulinumtoxinA on the Central Expression of Genes Associated with the Control of the Lower Urinary Tract: A Study in Normal Rats. Int J Mol Sci 2022; 23:ijms232214419. [PMID: 36430896 PMCID: PMC9694129 DOI: 10.3390/ijms232214419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/14/2022] [Accepted: 11/15/2022] [Indexed: 11/22/2022] Open
Abstract
To investigate a possible central mechanism of action of Botulinum toxin A (BoNT/A) following injection in the bladder, complementary to the acknowledged peripheral bladder effect, we studied changes in the expression of neuropeptides and receptors involved in lower urinary tract function in the spinal cord (SC) and dorsal root ganglia (DRG) of normal rats following BoNT/A bladder injection. Thirty-six Sprague-Dawley rats, divided into three groups of n = 12, received bladder injections of 2U or 5U OnabotulinumtoxinA (BOTOX®), or saline. Six animals from each group were sacrificed on days 7 and 14. Expression of Tachykinin 1 (Tac1), capsaicin receptor (TRPV1), neuropeptide Y (NPY), proenkephalin (PENK) and muscarinic receptors M1, M2, M3, was evaluated in the bladder, L6-S1 DRG, and SC segments using real-time PCR and Western blotting. Real-time PCR revealed increased expression of NPY in all tissues except for SC, and increased TRPV1 and PENK expression in DRG and SC, whereas expression of Tac1, M1 and M2 was decreased. Less significant changes were noted in protein levels. These findings suggest that bladder injections of OnabotulinumtoxinA may be followed by changes in the expression of sensory, sympathetic and cholinergic bladder function regulators at the DRG/SC level.
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Drinovac Vlah V, Bach-Rojecky L. What have we learned about antinociceptive effect of botulinum toxin type A from mirror-image pain models? Toxicon 2020; 185:164-173. [DOI: 10.1016/j.toxicon.2020.07.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 07/06/2020] [Accepted: 07/13/2020] [Indexed: 12/20/2022]
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Malde S, Apostilidis A, Selai C, Rahnama'i MS, Marcelissen T, Cardozo L, Lovick T. Botulinum toxin A for refractory OAB and idiopathic urinary retention: Can phenotyping improve outcome for patients: ICI-RS 2019? Neurourol Urodyn 2019; 39 Suppl 3:S104-S112. [PMID: 31692092 DOI: 10.1002/nau.24207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 10/20/2019] [Indexed: 12/17/2022]
Abstract
AIMS Botulinum toxin A (BTX-A) is a well-established treatment for refractory idiopathic overactive bladder (OAB). It has also been used with short-term success in treating idiopathic urinary retention. However, efficacy and complication rates are variable and predicting those likely to benefit most from treatment would enable personalization of therapy and optimization of outcomes. At the International Consultation on Incontinence-Research Society (ICI-RS) meeting in 2019 a Think Tank addressed the question of how we can improve the way we phenotype patients undergoing BTX-A treatment. METHODS The Think Tank conducted a literature review and expert consensus meeting focussing on how advances in basic science research of the mechanism of action of BTX-A, as well as assessment of psychological comorbidity, can be translated into clinical practice to improve patient selection for therapy. RESULTS Idiopathic OAB and idiopathic urinary retention are heterogenous conditions encompassing several phenotypes with multiple potential pathophysiological mechanisms. Animal models have demonstrated a central nervous system mechanism of action of intravesically injected BTX-A and this has been confirmed in human functional MRI studies, but whether this tool can be used to predict outcome from treatment remains to be determined. Phenotyping based on psychological comorbidity using validated screening tools should be studied as a way to potentially optimize patient selection for therapy. CONCLUSIONS Advances in basic science research into the mechanism of action of BTX-A have improved our understanding of the pathophysiology of OAB and may lead to novel ways to phenotype patients. Psychological assessment is another way in which phenotyping may be improved. Areas for further research are proposed.
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Affiliation(s)
- Sachin Malde
- Department of Urology, Guy's Hospital, London, UK
| | - Apostolos Apostilidis
- 2nd Department of Urology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Caroline Selai
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK
| | - Mohammad Sajjad Rahnama'i
- Department of Urology, Uniklinik Aachen RWTH, Aachen, Germany.,Department of Urology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Tom Marcelissen
- Department of Urology, Uniklinik Aachen RWTH, Aachen, Germany
| | - Linda Cardozo
- Department of Urogynaecology, King's College Hospital, London, UK
| | - Thelma Lovick
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, UK
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Kim YS, Hong ES, Kim HS. Botulinum Toxin in the Field of Dermatology: Novel Indications. Toxins (Basel) 2017; 9:toxins9120403. [PMID: 29258169 PMCID: PMC5744123 DOI: 10.3390/toxins9120403] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 12/13/2017] [Accepted: 12/14/2017] [Indexed: 12/20/2022] Open
Abstract
Since its approval by the US Food and Drug Administration in 2002 for glabellar wrinkles, botulinum toxin (BTX) has been widely used to correct facial wrinkles. As a result, many consider BTX synonymous with cosmetic dermatology. Recent studies indicate that BTX elicits biological effects on various skin cell types via the modulation of neurotransmitter release, and it seems that BTX has a wider zone of dermatologic influence than originally understood. Clinicians and researchers are now beginning to explore the potential of BTX beyond the amelioration of facial lines and encouraging results are seen with BTX in a variety of skin conditions. In this paper, we review novel dermatological indications of BTX which includes (but not limited to) scar prevention, facial flushing, post-herpetic neuralgia and itch. These areas show great promise, but there is definite need for larger, double-blinded, randomized control trials against established treatments before BTX becomes a clinical reality.
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Affiliation(s)
- Yoon Seob Kim
- Department of Dermatology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea.
| | - Eun Sun Hong
- Department of Dermatology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea.
| | - Hei Sung Kim
- Department of Dermatology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea.
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Matak I, Lacković Z, Relja M. Botulinum toxin type A in motor nervous system: unexplained observations and new challenges. J Neural Transm (Vienna) 2016; 123:1415-1421. [PMID: 27586162 DOI: 10.1007/s00702-016-1611-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 08/25/2016] [Indexed: 12/16/2022]
Abstract
In the motor system, botulinum toxin type A (BoNT/A) actions were classically attributed to its well-known peripheral anticholinergic actions in neuromuscular junctions. However, the enzymatic activity of BoNT/A, assessed by the detection of cleaved synaptosomal-associated protein 25 (SNAP-25), was recently detected in motor and sensory regions of the brainstem and spinal cord after toxin peripheral injection in rodents. In sensory regions, the function of BoNT/A activity is associated with its antinociceptive effects, while in motor regions we only know that BoNT/A activity is present. Is it possible that BoNT/A presence in central motor nuclei is without any function? In this brief review, we analyze this question. Limited data available in the literature warrant further investigations of BoNT/A actions in motor nervous system.
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Affiliation(s)
- I Matak
- Department of Pharmacology, University of Zagreb School of Medicine, Šalata 11, 10000, Zagreb, Croatia.
| | - Z Lacković
- Department of Pharmacology, University of Zagreb School of Medicine, Šalata 11, 10000, Zagreb, Croatia
| | - M Relja
- Department of Neurology, Movement Disorders Centre, Clinical Medical Centre, University of Zagreb School of Medicine, Zagreb, Croatia
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Matak I, Lacković Z. Botulinum neurotoxin type A: Actions beyond SNAP-25? Toxicology 2015; 335:79-84. [PMID: 26169827 DOI: 10.1016/j.tox.2015.07.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 07/01/2015] [Accepted: 07/04/2015] [Indexed: 01/29/2023]
Abstract
Botulinum neurotoxin type A (BoNT/A), the most potent toxin known in nature which causes botulism, is a commonly used therapeutic protein. It prevents synaptic vesicle neuroexocytosis by proteolytic cleavage of synaptosomal-associated protein of 25 kDa (SNAP-25). It is widely believed that BoNT/A therapeutic or toxic actions are exclusively mediated by SNAP-25 cleavage. On the other hand, in vitro and in vivo findings suggest that several BoNT/A actions related to neuroexocytosis, cell cycle and apoptosis, neuritogenesis and gene expression are not necessarily mediated by this widely accepted mechanism of action. In present review we summarize the literature evidence which point to the existence of unknown BoNT/A molecular target(s) and modulation of unknown signaling pathways. The effects of BoNT/A apparently independent of SNAP-25 occur at similar doses/concentrations known to induce SNAP-25 cleavage and prevention of neurotransmitter release. Accordingly, these effects might be pharmacologically significant. Potentially the most interesting are observations of antimitotic and antitumor activity of BoNT/A. However, the exact mechanisms require further studies.
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Affiliation(s)
- Ivica Matak
- Laboratory of Molecular Neuropharmacology, Department of Pharmacology and Croatian Brain Research Institute, University of Zagreb School of Medicine, Šalata 11, 10000 Zagreb, Croatia
| | - Zdravko Lacković
- Laboratory of Molecular Neuropharmacology, Department of Pharmacology and Croatian Brain Research Institute, University of Zagreb School of Medicine, Šalata 11, 10000 Zagreb, Croatia.
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Papagiannopoulou D, Vardouli L, Dimitriadis F, Apostolidis A. Retrograde transport of radiolabelled botulinum neurotoxin type A to the CNS after intradetrusor injection in rats. BJU Int 2015; 117:697-704. [PMID: 25912438 DOI: 10.1111/bju.13163] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To investigate the potential distribution of radiolabelled botulinum neurotoxin type A (BoNT/A) in the CNS after bladder injection in normal rats, by using the gamma-emitting radionuclide technetium-99 m ((99m) Tc). MATERIALS AND METHODS BoNT/A was radiolabelled by pretreatment with 2-iminothiolane and incubation with (99m) Tc-gluconate. The labelled toxin (99m) Tc-BoNT/A was purified using size exclusion HPLC. Twenty-four female Wistar rats were evenly injected in the bladder wall with either (99m) Tc-ΒοΝΤ/Α (n = 12) or free (99m) Tc (n = 12). Four rats from each group were killed at 1, 3 and 6 h after injection, respectively. The bladder, L6-S1 spinal cord segment and L6-S1 dorsal root ganglia (DRG) were harvested and their radioactivity counted in a gamma scintillation detector. Results were calculated as % injected dose (I.D.) per gram of tissue. The paired t-test was used for comparison of means of (99m) Tc-ΒοΝΤ/Α radioactivity vs free (99m) Tc in the tissues of interest. RESULTS Radiolabelled BoNT/A had a high radiochemical stability of 70% after 24 h. Gradual accumulation of (99m) Tc-ΒοΝΤ/Α was observed in the DRG up to 6 h after injection (P = 0.04 and P = 0.029 compared with 1 h and 3 h, respectively), while no accumulation was detected for free (99m) Tc. Consequently, (99m) Tc-ΒοΝΤ/Α radioactivity in the DRG was higher than free (99m) Tc radioactivity (3.18 ± 0.67% I.D./g vs 0.19 ± 0.10% I.D./g [P = 0.002] 6 h after injection). Values for (99m) Tc-ΒοΝΤ/Α radioactivity in the spinal cord were higher than those for free (99m) Tc, but not significantly. The bladder retained higher dosages of (99m) Tc-ΒοΝΤ/Α than free (99m) Tc at all time points. CONCLUSIONS Significant accumulation of the radiolabelled toxin in the lumbosacral DRG, together with a less significant uptake in the respective spinal cord segment as opposed to free radioactivity provide first evidence of the retrograde transport of BoNT/A to the CNS after bladder injection in rats.
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Affiliation(s)
- Dionysia Papagiannopoulou
- Department of Medicinal Chemistry, School of Pharmacy, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Lina Vardouli
- Department of Pharmacology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Fotios Dimitriadis
- Department of Pharmacology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Apostolos Apostolidis
- 2nd Department of Urology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Apostolidis A. Words of wisdom. Re: Intrathecal administration of botulinum toxin type a improves urinary bladder function and reduces pain in rats with cystitis. Eur Urol 2015; 67:816. [PMID: 25765213 DOI: 10.1016/j.eururo.2014.12.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Apostolos Apostolidis
- Aristotle University of Thessaloniki, 2nd Department of Urology, Papageorgiou General Hospital, 54629 Thessaloniki, Greece.
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Blockade of glutamate release by botulinum neurotoxin type A in humans: a dermal microdialysis study. Pain Res Manag 2015; 19:126-32. [PMID: 24851237 DOI: 10.1155/2014/410415] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND The analgesic action of botulinum neurotoxin type A (BoNTA) has been linked to the blockade of peripheral release of neuropeptides and neurotransmitters in animal models; however, there is no direct evidence of this in humans. OBJECTIVES To investigate the effect of BoNTA on glutamate release in humans, using an experimental model of pain and sensitization provoked by capsaicin plus mild heat. METHODS Twelve healthy volunteers (six men, six women) were pretreated with BoNTA (10 U) on the volar forearm and with a saline control on the contralateral side. Dermal microdialysis was applied one week later to collect interstitial samples before and after the application of a capsaicin patch (8%) plus mild heat (40°C⁄60 min) to provoke glutamate release, pain and vasodilation. Samples were collected every hour for 3 h using linear microdialysis probes (10 mm, 100 kD). Dialysate was analyzed for glutamate concentration. Pain intensity and skin vasomotor reactions (temperature and blood flow changes) were also recorded. RESULTS BoNTA significantly reduced glutamate release compared with saline (P<0.05). The provoked pain intensity was lower in the BoNTA-pretreated arm (P<0.01). The reduction in pain scores was not correlated with glutamate level. Cutaneous blood flow (P<0.05), but not cutaneous temperature (P≥0.05), was significantly reduced by BoNTA. There was a correlation between glutamate level and skin blood flow (r=0.58⁄P<0.05) but not skin temperature (P≥0.05). No differences according to sex were observed in any response. CONCLUSIONS The present study provided the first direct evidence supporting the inhibitory effect of BoNTA on glutamate release in human skin, which is potentially responsible for some of the analgesic action of BoNTA.
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Matak I, Lacković Z. Botulinum toxin A, brain and pain. Prog Neurobiol 2014; 119-120:39-59. [PMID: 24915026 DOI: 10.1016/j.pneurobio.2014.06.001] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Revised: 05/25/2014] [Accepted: 06/03/2014] [Indexed: 10/25/2022]
Abstract
Botulinum neurotoxin type A (BoNT/A) is one of the most potent toxins known and a potential biological threat. At the same time, it is among the most widely used therapeutic proteins used yearly by millions of people, especially for cosmetic purposes. Currently, its clinical use in certain types of pain is increasing, and its long-term duration of effects represents a special clinical value. Efficacy of BoNT/A in different types of pain has been found in numerous clinical trials and case reports, as well as in animal pain models. However, sites and mechanisms of BoNT/A actions involved in nociception are a matter of controversy. In analogy with well known neuroparalytic effects in peripheral cholinergic synapses, presently dominant opinion is that BoNT/A exerts pain reduction by inhibiting peripheral neurotransmitter/inflammatory mediator release from sensory nerves. On the other hand, growing number of behavioral and immunohistochemical studies demonstrated the requirement of axonal transport for BoNT/A's antinociceptive action. In addition, toxin's enzymatic activity in central sensory regions was clearly identified after its peripheral application. Apart from general pharmacology, this review summarizes the clinical and experimental evidence for BoNT/A antinociceptive activity and compares the data in favor of peripheral vs. central site and mechanism of action. Based on literature review and published results from our laboratory we propose that the hypothesis of peripheral site of BoNT/A action is not sufficient to explain the experimental data collected up to now.
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Affiliation(s)
- Ivica Matak
- Laboratory of Molecular Neuropharmacology, Department of Pharmacology and Croatian Brain Research Institute, University of Zagreb School of Medicine, Šalata 11, 10000 Zagreb, Croatia
| | - Zdravko Lacković
- Laboratory of Molecular Neuropharmacology, Department of Pharmacology and Croatian Brain Research Institute, University of Zagreb School of Medicine, Šalata 11, 10000 Zagreb, Croatia.
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Abstract
The use of botulinum toxin type A continues to be investigated by the US FDA for potential use in the treatment of headache. As part of this process there has been extensive research conducted by individual study sites as well as multicenter trials. To date, the majority of the focus has been on migraine headache as well as on tension-type headache. The results of these studies have been mixed. A variety of issues may contribute to the mixed results, including difference in the dose of toxin used, the number of injection sites utilized, the treatment paradigm itself, confounding medications, high and prolonged placebo response, as well as patient selection issues. Currently, the focus on botulinum toxin type A is on those patients who have chronic daily headache with a migraine component to their clinical picture. The results of two large trials in this population produced positive findings, especially when consideration is given to the a priori additional analyses of this complex patient population. The results of these studies have allowed a more focused program to be undertaken in the Phase III evaluation. At the same time, additional work has been performed to understand the mechanism by which botulinum toxin type A may work to alleviate migraine. This work may contribute substantially to improving outcomes with botulinum toxin type A. Characterization of the mechanism of action in pain may be crucial to outcomes because many issues are related to central sensitization.
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Affiliation(s)
- Frederick G Freitag
- The Chicago Medical School at Rosalind Franklin University of Medicine and Science, Department of Family Medicine, North Chicago, IL, USA.
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Involvement of μ-opioid receptors in antinociceptive action of botulinum toxin type A. Neuropharmacology 2013; 70:331-7. [PMID: 23499661 DOI: 10.1016/j.neuropharm.2013.02.011] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Revised: 01/08/2013] [Accepted: 02/08/2013] [Indexed: 11/22/2022]
Abstract
Botulinum toxin A (BTX-A) is approved for treatment of chronic migraine and has been investigated in various other painful conditions. Recent evidence demonstrated retrograde axonal transport and suggested the involvement of CNS in antinociceptive effect of BTX-A. However, the mechanism of BTX-A central antinociceptive action is unknown. In this study we investigated the potential role of opioid receptors in BTX-A's antinociceptive activity. In formalin-induced inflammatory pain we assessed the effect of opioid antagonists on antinociceptive activity of BTX-A. Naltrexone was injected subcutaneously (0.02-2 mg/kg) or intrathecally (0.07 μg/10 μl-350 μg/10 μl), while selective μ-antagonist naloxonazine was administered intraperitoneally (5 mg/kg) prior to nociceptive testing. The influence of naltrexone (2 mg/kg s.c.) on BTX-A antinociceptive activity was examined additionally in an experimental neuropathy induced by partial sciatic nerve transection. To investigate the effects of naltrexone and BTX-A on neuronal activation in spinal cord, c-Fos expression was immunohistochemically examined in a model of formalin-induced pain. Antinociceptive effects of BTX-A in formalin and sciatic nerve transection-induced pain were prevented by non-selective opioid antagonist naltrexone. Similarly, BTX-A-induced pain reduction was abolished by low dose of intrathecal naltrexone and by selective μ-antagonist naloxonazine. BTX-A-induced decrease in dorsal horn c-Fos expression was prevented by naltrexone. Prevention of BTX-A effects on pain and c-Fos expression by opioid antagonists suggest that the central antinociceptive action of BTX-A might be associated with the activity of endogenous opioid system (involving μ-opioid receptor). These results provide first insights into the mechanism of BTX-A's central antinociceptive activity.
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Abstract
Botulinum toxin (BTX) has gained a great interest in cosmetic dermatology for its effects on hyperkinetic facial lines. Understanding the basic research and analysis of effects of this potent drug can lead to other possible indications of interest for dermatologists. The use of BTX in focal hyperhidrosis is well established, but BTX has also effects on pain perception, itch and inflammation as discussed in this review.
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Affiliation(s)
- Uwe Wollina
- Department of Dermatology and Allergology, Hospital Dresden-Friedrichstadt, Academic Teaching Hospital of the University of Dresden, Friedrichstrasse 41, 01067 Dresden, Germany
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Lee JH, Lee SH, Song SH. Clinical Effectiveness of Botulinum Toxin A Compared to a Mixture of Steroid and Local Anesthetics as a Treatment for Sacroiliac Joint Pain. PAIN MEDICINE 2010; 11:692-700. [DOI: 10.1111/j.1526-4637.2010.00838.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Effective Pain Palliation in Fibromyalgia Syndrome Patients with Botulinum Toxin Type-A: Case Series of 25. ACTA ACUST UNITED AC 2010. [DOI: 10.1300/j094v15n04_07] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Monnier G, Tatu L, Michel F. New indications for botulinum toxin in rheumatology. Joint Bone Spine 2006; 73:667-71. [PMID: 16997603 DOI: 10.1016/j.jbspin.2006.03.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2005] [Accepted: 03/21/2006] [Indexed: 11/29/2022]
Abstract
Previously known only as a deadly bacterial poison responsible for severe paralysis, botulinum toxin is now a well-recognized therapeutic agent used to relieve involuntary movements, dystonia-related functional impairments, spasticity, and autonomic disorders such as hyperhidrosis. Musculoskeletal pain in patients with rheumatic disorders is among the emerging indications for botulinum toxin therapy. Preliminary data have been obtained in patients with cervical or thoracolumbar myofascial pain syndrome, chronic low back pain, piriformis muscle syndrome, tennis elbow, and stiff person syndrome. At present, the effects of botulinum toxin and its use for pain relief remain controversial. Carefully designed prospective trials are needed to investigate the efficacy and safety of botulinum toxin in pain disorders.
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Affiliation(s)
- Guy Monnier
- Neuromuscular Diseases and Investigations, Jean-Minjoz Teaching Hospital, 3, boulevard Fleming, 25030 Besancon cedex, France.
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Abstract
Dyshidrosis is a common chronic dermatitis of the hands and feet that may cause significant physical discomfort, psychological distress, and occupational impairment. Topics reviewed in this article include epidemiology, clinical findings, quality of life, and therapeutic considerations. Dyshidrosis is often difficult to manage; therefore, extra attention is given in this review article to current treatment options.
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Allam N, Brasil-Neto JP, Brown G, Tomaz C. Injections of botulinum toxin type a produce pain alleviation in intractable trigeminal neuralgia. Clin J Pain 2005; 21:182-4. [PMID: 15722812 DOI: 10.1097/00002508-200503000-00010] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
To report the effects of local injections of botulinum toxin type A regarding pain relief and long-term control in a patient with intractable trigeminal neuralgia. The patient was a 75-year-old man with trigeminal neuralgia in the left hemifacial region. His pain was unbearable and could not be controlled by carbamazepine, amitriptyline, or blocked by infiltration of a glycerol solution or phenol. The authors evaluated pain intensity, quality, and location using a Visual Analog Scale to establish the efficacy of botulinum toxin type A injections. Two units of botulinum toxin type A (Botox) were subcutaneously injected once in eight points distributed along the territory of V1 and V2. Visual Analog Scores were measured at baseline and at 7, 30, 60, and 90 days after treatment. The authors also examined the patient's general condition and daily life activities. The Visual Analog values were, respectively, 82, 54, 25, 25, and 45 mm at each follow-up examination. No side effects were observed on the site of injection and on the patient's clinical state. The authors have been able to reduce trigeminal neuralgia pain with botulinum toxin type A injections in the V1, V2 territory during all the period of study, as well as to withdraw all medication. Interestingly, there was concomitant reduction of pain also in V3, which was not injected.
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Affiliation(s)
- Nasser Allam
- Graduate Program in Health Sciences and Department of Physiological Sciences, University of Brasília, Brasília, Brazil
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Kern U, Martin C, Scheicher S, Müller H. Effects of Botulinum Toxin Type B on Stump Pain and Involuntary Movements of the Stump. Am J Phys Med Rehabil 2004; 83:396-9. [PMID: 15100632 DOI: 10.1097/01.phm.0000124444.32257.04] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patients who had previously undergone amputation of the arm (n = 2) or leg (n = 2) were treated with botulinum toxin type B injections at several trigger points of their stump musculature. We administered a total dose of 2500 IU of botulinum toxin type B (Neurobloc, Elan Pharma, Munich, Germany) to the arm amputation stumps, 5000 IU for one amputation of the lower leg, and 2500 IU to the other lower leg amputation of a patient with a very low baseline body weight. Two patients reported that the injection was very painful. All patients experienced a reduction in stump pain, which lasted for many weeks. Other reports included a reduction in the frequency of pain attacks, cessation of "balloon feelings," improvement in stump allodynia, and decreased occurrence of involuntary stump movements. In addition, quality of sleep at night significantly improved in one patient. Botulinum toxin type B can therefore be regarded as a new treatment option for possible improvements in the rehabilitation of amputees.
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Affiliation(s)
- Uwe Kern
- Department of Neurology/Pain Management, Deutsche Klinik für Diagnostik, Wiesbaden, Germany, UK
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Kern U, Martin C, Scheicher S, Müller H. Botulinum toxin type A influences stump pain after limb amputations. J Pain Symptom Manage 2003; 26:1069-70. [PMID: 14654254 DOI: 10.1016/j.jpainsymman.2003.09.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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23
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Freitag FG. Preventative treatment for migraine and tension-type headaches : do drugs having effects on muscle spasm and tone have a role? CNS Drugs 2003; 17:373-81. [PMID: 12696998 DOI: 10.2165/00023210-200317060-00001] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Baclofen, tizanidine and botulinum toxin A, agents used to treat disorders of muscle tone, have been studied as potential preventative treatments for migraine, tension-type headache and other related disorders. The most extensive work has been completed with botulinum toxin A. However, there is still a paucity of well controlled, clinical trials with this agent, and overall there have been conflicting and oftentimes equivocal results: studies of its use in migraine headache have suggested efficacy, whereas those of tension-type headache have not shown significant evidence of efficacy. There were few significant adverse events associated with the use of botulinum toxin A in these trials. The mechanism by which botulinum toxin A may work to prevent headache is not clear. Although changes in muscle tone may play a role in the effect of the drug, central mechanisms such as effects on neuropeptides involved in the pathogenesis of migraine may also be relevant. Further clinical trial work is in progress to help determine optimal administration schedules and choice of injection locations with botulinum toxin A for specific headache disorders. There has been limited study of the use of baclofen, an agent that acts centrally via GABA(A) receptors, in migraine and cluster headache, with only two open trials conducted to date. Both of these studies support the use of baclofen in the preventive treatment of headache.Tizanidine, which may have both a peripheral and a central mechanism in the locus ceruleus in migraine headache, has been studied in several clinical trials. Although the primary mechanism of action of this agent is, like clonidine, as an alpha-adrenoceptor agonist, it has little antihypertensive effect. Open trials of tizanidine have shown it to be useful in chronic headache. One well controlled trial, conducted as a follow-up to an open-label trial in the preventive treatment of chronic daily headache, reported tizanidine as having a statistically significant benefit over placebo. Also of interest is its use in conjunction with a long-acting NSAID to aid in the treatment of rebound headache accompanying the discontinuation of overused acute migraine therapies. In conclusion, though limited, the studies suggest the efficacy of botulinum toxin A, baclofen and tizanidine in primary headache disorders.
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Affiliation(s)
- Frederick G Freitag
- Department of Family Medicine, Finch University of Health Sciences/Chicago Medical School, North Chicago, Illinois 60614, USA.
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Simon O, Raibaut P, Faucher M, Sheik-Ismael S, Amarenco G. [Botulinum toxin in headache]. ANNALES DE READAPTATION ET DE MEDECINE PHYSIQUE : REVUE SCIENTIFIQUE DE LA SOCIETE FRANCAISE DE REEDUCATION FONCTIONNELLE DE READAPTATION ET DE MEDECINE PHYSIQUE 2003; 46:312-8. [PMID: 12928136 DOI: 10.1016/s0168-6054(03)00104-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Use of botulinum toxin in headache is a recent method. More and more studies are dedicated to this method. However, despite the large number of published studies, results are contradictory. It is actually difficult to conclude that this therapy is effective or not due to the disparity of clinical studies. Nevertheless, some results are encouraging and studies with a large number of patients have to be done. Here, we take stock about pathophysiological data on the effect of botulinum toxin on pain. Then, we'll report a review of clinical studies available on literature.
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Affiliation(s)
- O Simon
- Service de rééducation neurologique et d'explorations périnéales, hôpital Rothschild, AP-HP, 33, boulevard de Picpus, 75571 Paris cedex 12, France
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Abstract
The impressive pain relief experienced by sufferers of dystonia and spasticity from intramuscular injections of botulinum toxin suggested that patients with other chronic, musculoskeletal pain conditions also may benefit. However, there have been relatively few placebo-controlled studies of botulinum toxin in such non-neurologic conditions as myofascial pain syndrome, chronic neck and low back pain, and fibromyalgia; the results of these studies have not been impressive. One explanation for the lack of positive findings may be the lack of clinically evident muscle spasms (overactivity), despite the presence of muscle tenderness, tightness, or trigger points. Clinical observations of pain relief from injections of botulinum toxin for dystonia and spasticity and its apparent efficacy in treating migraine suggest an anti-nociceptive action independent of its neuromuscular junction-blocking action. Evidence from animal experiments supports this notion, and other data provide plausible physiologic mechanisms in the periphery and central nervous systems. These involve modulation of the activity of the neurotransmitters glutamate, substance P, calcitonin gene-related peptide, enkephalins, and others. However, even if botulinum toxin is firmly established as an analgesic, there is insufficient clinical evidence of its efficacy in treating non-neurologic, chronic, musculoskeletal pain conditions.
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Affiliation(s)
- Geoffrey Sheean
- EMG and Neuromuscular Service, University of California, San Diego, 200 West Arbor Drive, San Diego 92103-8465, USA.
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26
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Nixdorf DR, Heo G, Major PW. Randomized controlled trial of botulinum toxin A for chronic myogenous orofacial pain. Pain 2002; 99:465-473. [PMID: 12406522 DOI: 10.1016/s0304-3959(02)00240-3] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The purpose of this study was to determine whether botulinum toxin A (BTX-A) was efficacious for the treatment of chronic moderate to severe jaw muscle pain in females. This was a randomized double-blind, placebo-controlled crossover trial of BTX-A. Twenty five units injected into each temporalis muscle and 50 U injected into each masseter muscle using three sites per muscle with 0.2 cm(3) per site. Data were collected at baseline, 8, 16, 24 weeks, with crossover occurring at 16 weeks. Primary outcome variables were pain intensity and unpleasantness, measured by horizontal visual analog scale (VAS). Secondary outcome variables were maximum interincisal opening without and irrespective of pain, muscle palpation tenderness (12 points), and four general questions. Fifteen female patients were enrolled (18-45 years), but only ten completed the trial. Of those who finished, no statistically significant difference was found in pain intensity (P=0.10), unpleasantness (P=0.40), palpation muscle tenderness (P=0.91), or the three general questions (P=0.64, P=0.66, P=0.67). Statistical significance was achieved for maximum opening without pain (P=0.02) and irrespective of pain (P=0.005) with the BTX-A arm having a relative decreased opening. No statistically significant difference was observed in any outcome measures except maximum opening, which showed BTX-A patient opening less wide than placebo. The results do not support the use of BTX-A in the treatment of moderate to severe jaw muscle pain in this patient population.
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Affiliation(s)
- Donald R Nixdorf
- Orofacial Pain Clinic, Department of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, 4048 Dentistry/Pharmacy Centre, Edmonton, Alberta, Canada T6G 2N8 Department of Mathematical and Statistical Sciences, Faculty of Science, University of Alberta, 487 Central Academic Building, Edmonton, Alberta, Canada T5G 2G1 Department of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, 1045 Dentistry/Pharmacy Centre, Edmonton, Alberta, Canada T6G 2N8
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Wollina U, Karamfilov T. Adjuvant botulinum toxin A in dyshidrotic hand eczema: a controlled prospective pilot study with left-right comparison. J Eur Acad Dermatol Venereol 2002; 16:40-2. [PMID: 11952288 DOI: 10.1046/j.1468-3083.2002.00361.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Dyshidrotic hand eczema is a therapeutic challenge. A prospective pilot study was performed with left-right comparison in order to investigate whether chemical de-innervation of sudoriferic nerves would be superior to standard therapy with topical corticosteroids. BACKGROUND Botulinum toxin A (BTXA) is a potent inhibitor of acetylcholine release, that induces eccrine sweat production and release. Inhibition of sweating by other measures such as tap water iontophoresis has been shown to be beneficial in dyshidrotic hand eczema. METHODS Eight adult patients suffering from dyshidrotic hand eczema (atopic type) were included in a prospective, side-by-side controlled clinical pilot study using topical corticosteroids on both hands in combination with intracutaneous injections of 100 units of BTXA (Botox) on the more severely affected hand on day 1. The dyshidrotic hand eczema was classified using the DASI (Dyshidrotic Eczema Area and Severity Index) before treatment (0), after 1 week, 4 weeks and 8 weeks. RESULTS Six patients completed the study, two dropped out because of social and personal reasons. The mean DASI score changed from 28 to17 with topical therapy alone and from 36 to 3 with adjuvant BTXA (P < 0.01). Itching and vesiculation were inhibited earlier when using the combination of corticosteroids and BTXA. There was one relapse in the corticosteroid group. Relapses have not been seen in the BTXA group. CONCLUSIONS Interruption of sweating by BTXA improves the outcome and reduces relapses in patients with dyshidrotic hand eczema. BTXA is antipruritic as well suggesting that it does not only interact with acetylcholine release but substance P.
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Affiliation(s)
- U Wollina
- Department of Dermatology and Allergology, the Friedrich-Schiller-University of Jena, Germany.
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Göbel H, Heinze A, Heinze-Kuhn K, Austermann K. Botulinum toxin A in the treatment of headache syndromes and pericranial pain syndromes. Pain 2001; 91:195-199. [PMID: 11275374 DOI: 10.1016/s0304-3959(01)00292-5] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Hartmut Göbel
- Kiel Pain Clinic, Heikendorfer Weg 9-27, D-24149 Kiel, Germany
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