Cost-Effectiveness of Incobotulinumtoxin-A with Flexible Treatment Intervals Compared to Onabotulinumtoxin-A in the Management of Blepharospasm and Cervical Dystonia

Incobotulinum toxin type A for treatment of chronic myofascial pain

PURPOSE

This study assessed the effectiveness of incobotulinum toxin type A (IBTx) for chronic myofascial pain affecting the masseter and temporal muscles.

METHODS

Twenty two patients who received a diagnosis of chronic masseter and temporalis myofascial pain were evaluated by using a visual analog pain scale (VAS), digital pressure algometry, and the SF-36 Health Survey at baseline (T0), before IBTx injection. Patients were again evaluated at 2 months (T1) and 7 months (T2) after IBTx injection.

RESULTS

VAS scores for pain significantly differed (P = 0.029, Friedman test). Post-hoc tests showed a significant reduction in pain at 2 months (T0-T1) and 7 months (T0-T2) (P = 0.011 and P = 0.028, respectively; Wilcoxon test) but not between 2 and 7 months (P = 0.676; Wilcoxon test). There was no significant difference in pressure algometry values (P = 0.385, Friedman test). Quality of life (QOL) assessment showed a significant difference (P = 0.002, Friedman test). Post-hoc tests showed a significant improvement in QOLat 2 months, but no significant difference at 7 months (P = 0.004 and P = 0.260, Wilcoxon test).

CONCLUSION

IBTx injection resulted in safe, effective short-term pain relief for patients with chronic facial pain affecting the masseter and temporalis muscles.

The intravesical injection of highly purified botulinum toxin for the treatment of neurogenic detrusor overactivity

INTRODUCTION

We aimed to assess safety and efficacy of incobotulinumtoxinA for the treatment of neurogenic detrusor overactivity (NDO).

METHODS

We identified patients with NDO confirmed on urodynamics (UDS) and reported urgency incontinence (UI) in those who received intravesical incobotulinumtoxin A injection for neurogenic bladder between November 2013 and May 2017. Parameters studied were daytime frequency, daily incontinence episodes, daily pad use, clean intermittent catheterization (CIC) volumes, symptom scores (UDI6, IIQ7, PGII), and complications.

RESULTS

We examined 17 male patients who met inclusion criteria and underwent incobotulinumtoxinA injection. Mean age was 61.2±15.4 years. Fourteen patients (82%) were taking oral antimuscarinics prior to the incobotulinumtoxin A injection. There were improvements in the following parameters: average daily pads (4.5 to 3.3, p=0.465), daily urinary frequency (9.4 to 4.6, p=0.048), daily incontinent episodes (2.5 to 0.4, p=0.033), CIC volumes (400 to 550 mL, p=0.356), hours in between CIC (3.6 to 5.2, p=0.127), and the validated questionnaires UDI6 (30.6 to 7.4, p=0.543) and IIQ7 (52.4 to 6.8, p=0.029). There were no documented symptomatic urinary tract infections (UTIs) within 30 days of injection or reports of de novo urinary retention. Nine of 17 patients (53%) reported being dry at their first postoperative visit.

CONCLUSIONS

In this preliminary pilot study of a small cohort of males with NDO and UI, significant improvements were seen following incobotulinumtoxinA injection in daily frequency, incontinence episodes, hours in between CIC, and quality of life. Larger-scale and long-term studies are required to confirm these results, but initial findings are promising for wider use of this formulation.

Quantifying and Reducing Retained Botulinum Toxin Postinjection

BACKGROUND

Retained botulinum toxin solution may be visible in vials and syringe tips after mixing and presumed complete injections, leaving patients without the full prescribed dose.

OBJECTIVE

To quantify the mean amount of retained toxin within vials, syringes, and needles following spasticity injections (phase 1) and to design/test a targeted intervention for reduced retained toxin (phase 2).

DESIGN

Prospective cohort quality assurance study.

SETTING

Outpatient spasticity program in a rehabilitation facility.

PARTICIPANTS

Nine physicians specializing in physical medicine and rehabilitation, performing successive mixing and injections for spasticity with onabotulinumtoxinA or incobotulinumtoxinA.

METHODS

After initial review (phase 1), recommendations were made (phase 2) including not inverting the vial to withdraw medication unless needed, favoring 2-mL dilutions when possible, and decapping of vials for more complete medication withdrawal.

MAIN OUTCOME MEASUREMENTS

Retained volume of toxin solution that was not injected and estimated retained units of toxin.

RESULTS

A total of 157 vials of botulinum toxin A were tested. Of the 82 initial, phase 1, preintervention vials (8200 units), 5.5% (∼452 units) of toxin solution was retained following mixing and injections. One and 3-mL syringe tips contained a mean of 3.32 and 1.44 units of toxin respectively. Within vials, saline dilutions with 2 mL contained less mean retained toxin (1.89 vs 3.31 units) relative to 1-mL dilution. Awareness of monitoring significantly decreased retained solution in vials (0.035 mL vs 0.069 mL for naïve group, P = .002). Phase 2, postintervention testing of 75 vials demonstrated that withdrawing toxin from the inferior edge from a non-inverted vial reduced the retained toxin by 32.8% (P < .001). Decapping the vial further reduced the mean retained toxin to 0.42 units per vial (81.9% reduction, P < .001).

CONCLUSIONS

A potentially clinically significant amount of botulinum toxin solution is retained following mixing and injections. Implementation of guidelines significantly decreased wasted botulinum toxin.

LEVEL OF EVIDENCE

III.

Conversion Ratio between Botox®, Dysport®, and Xeomin® in Clinical Practice

Botulinum neurotoxin has revolutionized the treatment of spasticity and is now administered worldwide. There are currently three leading botulinum neurotoxin type A products available in the Western Hemisphere: onabotulinum toxin-A (ONA) Botox(®), abobotulinum toxin-A (ABO), Dysport(®), and incobotulinum toxin A (INCO, Xeomin(®)). Although the efficacies are similar, there is an intense debate regarding the comparability of various preparations. Here we will address the clinical issues of potency and conversion ratios, as well as safety issues such as toxin spread and immunogenicity, to provide guidance for BoNT-A use in clinical practice. INCO was shown to be as effective as ONA with a comparable adverse event profile when a clinical conversion ratio of 1:1 was used. The available clinical and preclinical data suggest that a conversion ratio ABO:ONA of 3:1-or even lower-could be appropriate for treating spasticity, cervical dystonia, and blepharospasm or hemifacial spasm. A higher conversion ratio may lead to an overdosing of ABO. While uncommon, distant spread may occur; however, several factors other than the pharmaceutical preparation are thought to affect spread. Finally, whereas the three products have similar efficacy when properly dosed, ABO has a better cost-efficacy profile.