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McGarey PO, Simpson CB, Daniero JJ. Practice Patterns and Barriers in Botulinum Toxin Injection for the Treatment of Voice Disorders. J Voice 2020; 36:113-118. [PMID: 32467003 DOI: 10.1016/j.jvoice.2020.04.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/27/2020] [Accepted: 04/28/2020] [Indexed: 10/24/2022]
Abstract
Laryngeal botulinum toxin injection is an important treatment modality for spasmodic dysphonia and other laryngeal disorders. We sought to compare usage patterns of laryngeal botulinum toxin injections for voice disorders and to identify and quantify inefficiencies and barriers in providing this treatment. A 26 item survey was written and approved for distribution by the American Academy of Otolaryngology-Head and Neck Surgery and the National Spasmodic Dysphonia Association. It was distributed to Otolaryngologists who perform laryngeal botulinum toxin injections via the e-mail lists of the National Spasmodic Dysphonia Association provider database, American Academy of Otolaryngology-Head and Neck Surgery Voice Committee and the American Laryngological Association Neurolaryngology Study Group. There were 81 survey participants who collectively reported performing >1700 laryngeal botulinum toxin injections for voice disorders monthly (Mean = 21.5 pts/month). Regarding botulinum toxin A (BtxA) vial use, 54% of participants reported using multiple doses per vial for different patients during a single clinic day, while 14% reported using pharmacy predrawn single use aliquots. A combination of usage practices was reported by 7% of participants. Using an individual vial per patient and discarding the unused remainder was reported by 26% of participants with an associated annual cost in wasted BtxA of $84,300 per physician. There is wide variation in injection practices regarding management of BtxA vials and adherence to an individual vial per patient policy is associated with significant waste of health care resources. Alternative approaches to BtxA vial use could positively impact health care resource utilization.
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Affiliation(s)
- Patrick O McGarey
- Department of Otolaryngology - Head and Neck Surgery, University of Virginia Health System, Charlottesville, Virginia.
| | - C Blake Simpson
- Department of Otolaryngology - Head and Neck Surgery, University of Alabama - Birmingham, Birmingham, Alabama
| | - James J Daniero
- Department of Otolaryngology - Head and Neck Surgery, University of Virginia Health System, Charlottesville, Virginia
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Giordano CN, Matarasso SL, Ozog DM. Injectable and topical neurotoxins in dermatology: Basic science, anatomy, and therapeutic agents. J Am Acad Dermatol 2017; 76:1013-1024. [PMID: 28522038 DOI: 10.1016/j.jaad.2016.11.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 11/03/2016] [Accepted: 11/06/2016] [Indexed: 11/24/2022]
Abstract
Botulinum toxin is a potentially deadly anaerobic bacterial toxin that acts by inhibiting release of acetylcholine at the neuromuscular junction, thereby inhibiting contraction of the exposed striated muscle. There are currently 4 botulinum toxin preparations approved by the US Food and Drug Administration (FDA): onabotulinumtoxin, abobotulinumtoxin, incobotulinumtoxin and rimabotulinumtoxin. While significant overlap exists, each product has unique properties and specifications, including dosing, diffusion, and storage. Extensive physician knowledge of facial anatomy, coupled with key differences of the various neurotoxin types, is essential for safe and successful treatments. The first article in this continuing medical education series reviews key characteristics of each neurotoxin, including new and upcoming agents, and provides an anatomic overview of the most commonly injected cosmetic sites.
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Affiliation(s)
| | - Seth L Matarasso
- Department of Dermatology, University of California, San Francisco School of Medicine, San Francisco, California
| | - David M Ozog
- Department of Dermatology, Henry Ford Hospital, Detroit, Michigan.
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Alam M, Bolotin D, Carruthers J, Hexsel D, Lawrence N, Minkis K, Ross EV. Consensus statement regarding storage and reuse of previously reconstituted neuromodulators. Dermatol Surg 2015; 41:321-6. [PMID: 25705950 DOI: 10.1097/dss.0000000000000303] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Legacy recommendations suggest that vials of botulinum toxin be used within 24 hours of reconstitution and in a single patient. Current standard of care is consistent with storage after reconstitution and use of a single vial for several patients. OBJECTIVE To develop expert consensus regarding the effectiveness and safety of storage and reuse of botulinum toxin. MATERIALS AND METHODS The American Society for Dermatologic Surgery authorized a task force of content experts to review the literature and provide guidance. Data extraction was followed by clinical question review, a consensus Delphi process, and validation of the results by peer review. RESULTS After 2 rounds of Delphi process, the task force concluded by unanimous consensus and with the highest level of confidence that a vial of toxin reconstituted appropriately can, for facial muscle indications, be (1) refrigerated or refrozen for at least 4 weeks before injection without significant risk for contamination or decreased effectiveness and (2) used to treat multiple patients, assuming appropriate handling. CONCLUSION The standard of care, which allows for use of botulinum toxin more than 24 hours after reconstitution and in more than 1 patient per vial, is appropriate and consistent with the safe and effective practice of medicine.
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Affiliation(s)
- Murad Alam
- Departments of *Dermatology, †Otolaryngology, and ‡Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; §Section of Dermatology, University of Chicago Medicine, Chicago, Illinois; ‖Department of Ophthalmology, University of British Columbia, Vancouver, BC, Canada; ¶Department of Dermatology, Pontificia Universidade Catolica do Rio Grande do Sul, Porto Alegre, Brazil; #Brazilian Center for Studies in Dermatology, Porto Alegre, Brazil; **Division of Dermatology, Cooper University Hospital Medical Center, Marlton, New Jersey; ††Department of Dermatology, Weill Cornell Medical College, Cornell University, New York, New York; ‡‡Division of Dermatology, Scripps Clinic, San Diego, California
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Osaki T, Osaki MH, Osaki TH, Sant'Anna AE, Yu MCZ, Hofling-Lima AL. Absence of bacterial or fungal growth in vials of reconstituted botulinum toxin type A after storage. Aesthet Surg J 2015; 35:189-93. [PMID: 25717119 DOI: 10.1093/asj/sju072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Botulinum toxin type A (BTX-A; Botox) is supplied as individual freeze-dried preparations that should be administered within 24 hours after reconstitution. To avoid wasting this expensive drug, some physicians have resorted to storing vials of reconstituted BTX-A beyond the recommended duration. However, there is insufficient evidence to indicate that the sterility of previously reconstituted BTX-A is maintained during storage. OBJECTIVES The authors sought to determine whether bacterial and/or fungal proliferation occurred in vials of reconstituted BTX-A and subsequent storage of the remaining solution under refrigeration for 4 weeks. METHODS A portion of the contents of 88 consecutive 100-U vials of BTX-A was administered aseptically to 108 patients for essential blepharospasm, hemifacial spasm, or facial rejuvenation. The vials were then stored for 4 weeks in a refrigerator, after which the contents were transferred to various media (blood agar, chocolate agar, Sabouraud agar, brain-heart infusion medium, and thioglycolate broth) and assessed for bacterial and/or fungal growth by standard methods. RESULTS None of the BTX-A vials contained detectable bacterial or fungal contamination after 4 weeks of storage. CONCLUSIONS Storing vials of reconstituted BTX-A for 4 weeks after administration to patients was not associated with detectable growth of bacteria or fungi.
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Affiliation(s)
- Teissy Osaki
- Drs T. Osaki, M.H. Osaki, T.H. Osaki and A.E. Sant'Anna are from Division of Ophthalmic Plastic Surgery, Department of Ophthalmology and Visual Sciences, Federal University of São Paulo, São Paulo, Brazil. Drs M. Cecilia and A.L. Hofling-Lima are from Department of Ophthalmology and Visual Sciences, Federal University of São Paulo, São Paulo, Brazil
| | - Midori H Osaki
- Drs T. Osaki, M.H. Osaki, T.H. Osaki and A.E. Sant'Anna are from Division of Ophthalmic Plastic Surgery, Department of Ophthalmology and Visual Sciences, Federal University of São Paulo, São Paulo, Brazil. Drs M. Cecilia and A.L. Hofling-Lima are from Department of Ophthalmology and Visual Sciences, Federal University of São Paulo, São Paulo, Brazil
| | - Tammy H Osaki
- Drs T. Osaki, M.H. Osaki, T.H. Osaki and A.E. Sant'Anna are from Division of Ophthalmic Plastic Surgery, Department of Ophthalmology and Visual Sciences, Federal University of São Paulo, São Paulo, Brazil. Drs M. Cecilia and A.L. Hofling-Lima are from Department of Ophthalmology and Visual Sciences, Federal University of São Paulo, São Paulo, Brazil
| | - Ana Estela Sant'Anna
- Drs T. Osaki, M.H. Osaki, T.H. Osaki and A.E. Sant'Anna are from Division of Ophthalmic Plastic Surgery, Department of Ophthalmology and Visual Sciences, Federal University of São Paulo, São Paulo, Brazil. Drs M. Cecilia and A.L. Hofling-Lima are from Department of Ophthalmology and Visual Sciences, Federal University of São Paulo, São Paulo, Brazil
| | - Maria Cecilia Z Yu
- Drs T. Osaki, M.H. Osaki, T.H. Osaki and A.E. Sant'Anna are from Division of Ophthalmic Plastic Surgery, Department of Ophthalmology and Visual Sciences, Federal University of São Paulo, São Paulo, Brazil. Drs M. Cecilia and A.L. Hofling-Lima are from Department of Ophthalmology and Visual Sciences, Federal University of São Paulo, São Paulo, Brazil
| | - Ana Luisa Hofling-Lima
- Drs T. Osaki, M.H. Osaki, T.H. Osaki and A.E. Sant'Anna are from Division of Ophthalmic Plastic Surgery, Department of Ophthalmology and Visual Sciences, Federal University of São Paulo, São Paulo, Brazil. Drs M. Cecilia and A.L. Hofling-Lima are from Department of Ophthalmology and Visual Sciences, Federal University of São Paulo, São Paulo, Brazil
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Barrow EM, Rosen CA, Hapner ER, Smith S, Hatcher JL, Simpson B, Johns MM. Safety and efficacy of multiuse botulinum toxin vials for intralaryngeal injection. Laryngoscope 2014; 125:1149-54. [DOI: 10.1002/lary.25068] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2014] [Indexed: 11/05/2022]
Affiliation(s)
- Emily M. Barrow
- Department of Otolaryngology-Head and Neck Surgery; Emory University School of Medicine; Atlanta Georgia
| | - Clark A. Rosen
- Department of Otolaryngology-Head and Neck Surgery; University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania
| | - Edie R. Hapner
- Department of Otolaryngology-Head and Neck Surgery; Emory University School of Medicine; Atlanta Georgia
| | - Sarah Smith
- Department of Otolaryngology-Head and Neck Surgery; University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania
| | - Jeanne L. Hatcher
- Department of Otolaryngology-Head and Neck Surgery; University of Texas Health Science Center at San Antonio; San Antonio Texas U.S.A
| | - Blake Simpson
- Department of Otolaryngology-Head and Neck Surgery; University of Texas Health Science Center at San Antonio; San Antonio Texas U.S.A
| | - Michael M. Johns
- Department of Otolaryngology-Head and Neck Surgery; Emory University School of Medicine; Atlanta Georgia
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Liu A, Carruthers A, Cohen JL, Coleman WP, Dover JS, Hanke CW, Moy RL, Ozog DM. Recommendations and current practices for the reconstitution and storage of botulinum toxin type A. J Am Acad Dermatol 2012; 67:373-8. [DOI: 10.1016/j.jaad.2011.10.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2011] [Revised: 06/28/2011] [Accepted: 10/06/2011] [Indexed: 11/29/2022]
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