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Jankovic J, Carruthers J, Naumann M, Ogilvie P, Boodhoo T, Attar M, Gupta S, Singh R, Soliman J, Yushmanova I, Brin MF, Shen J. Neutralizing Antibody Formation with OnabotulinumtoxinA (BOTOX ®) Treatment from Global Registration Studies across Multiple Indications: A Meta-Analysis. Toxins (Basel) 2023; 15:toxins15050342. [PMID: 37235376 DOI: 10.3390/toxins15050342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 05/10/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
Though the formation of neutralizing antibodies (NAbs) during treatment with botulinum neurotoxin is rare, their presence may nonetheless affect the biological activity of botulinum toxin and negatively impact clinical response. The goal of this updated meta-analysis was to evaluate and characterize the rate of NAb formation using an expanded dataset composed of 33 prospective placebo-controlled and open-label clinical trials with nearly 30,000 longitudinal subject records prior to and following onabotulinumtoxinA treatment in 10 therapeutic and aesthetic indications. Total onabotulinumtoxinA doses per treatment ranged from 10 U to 600 U administered in ≤15 treatment cycles. The NAb formation at baseline and post-treatment was tested and examined for impact on clinical safety and efficacy. Overall, 27 of the 5876 evaluable subjects (0.5%) developed NAbs after onabotulinumtoxinA treatment. At study exit, 16 of the 5876 subjects (0.3%) remained NAb positive. Due to the low incidence of NAb formation, no clear relationship was discernable between positive NAb results and gender, indication, dose level, dosing interval, treatment cycles, or the site of injection. Only five subjects who developed NAbs post-treatment were considered secondary nonresponders. Subjects who developed NAbs revealed no other evidence of immunological reactions or clinical disorders. This comprehensive meta-analysis confirms the low NAb formation rate following onabotulinumtoxinA treatment across multiple indications, and its limited clinical impact on treatment safety and efficacy.
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Affiliation(s)
| | - Jean Carruthers
- Department of Ophthalmology, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
- Jean Carruthers Cosmetic Surgery Inc., Vancouver, BC V5Z 4E1, Canada
| | - Markus Naumann
- Department of Neurology and Clinical Neurophysiology, University Hospital, 86156 Augsburg, Germany
| | | | | | | | | | | | | | | | - Mitchell F Brin
- AbbVie, Irvine, CA 92612, USA
- Department of Neurology, University of California, Irvine, CA 92697, USA
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Rahman E, Alhitmi HK, Mosahebi A. Immunogenicity to Botulinum Toxin Type A: A Systematic Review With Meta-Analysis Across Therapeutic Indications. Aesthet Surg J 2022; 42:106-120. [PMID: 33528495 DOI: 10.1093/asj/sjab058] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Botulinum toxin A (BTX-A) is commonly employed as a neuromodulator in several neurological diseases and aesthetic indications. Formation of neutralizing antibodies (NAbs) after BTX-A injections may be responsible for treatment failure. OBJECTIVES The authors sought to quantify the prevalence of NAbs following treatment with Abobotulinumtoxin A, Incobotulinumtoxin A, and Onabotulinumtoxin A for therapeutic indications. METHODS An electronic systematic search (2000-2020) of PubMed, Scopus, Web of Science, and Embase was conducted. Original studies reporting prevalence of NAbs were included. Data analysis was carried out through open meta-analysis softwares. RESULTS Forty-three studies involving 8833 patients were included in this meta-analysis. The incidence of NAbs was 1.8% (summary estimate = 0.018, 95% CI [0.012, 0.023]); a meta-regression analysis revealed that BTX-A duration was significantly associated with increased incidence of NAbs (P = 0.007). Patients with dystonia had the highest incidence (7.4%) of NAbs against BTX-A (summary estimate = 0.074, 95% CI = [0.045, 0.103], I2 = 93.%, P < 0.00) followed by patients with spasticity (6.7%) and urological indications (6.2%). Abobotulinumtoxin A was associated with the highest incidence of NAbs (7.4%) (summary estimate = 0.074, 95% CI = [0.053, 0.096], I2 = 97.24%, P < 0.00) by the Incobotulinumtoxin A and Onabotulinumtoxin A 0.3% (summary estimate <0.003%, 95% CI = [-0.001, 0.007], P < 0.003). CONCLUSIONS Although the overall incidence of NAbs following BTX-A injections is relatively low, patients with secondary nonresponse to BTX-A with no apparent causes should be investigated for NAbs. A consensus needs to be developed for the optimal management of such patients. LEVEL OF EVIDENCE: 2
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Affiliation(s)
- Eqram Rahman
- Department of Plastic and Reconstructive Surgery, Royal Free Hospital, University College London, London, Hampstead, United Kingdom
| | | | - Afshin Mosahebi
- Department of Plastic and Reconstructive Surgery, Royal Free Hospital, University College London, London, Hampstead, United Kingdom
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Walter U, Mühlenhoff C, Benecke R, Dressler D, Mix E, Alt J, Wittstock M, Dudesek A, Storch A, Kamm C. Frequency and risk factors of antibody-induced secondary failure of botulinum neurotoxin therapy. Neurology 2020; 94:e2109-e2120. [DOI: 10.1212/wnl.0000000000009444] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 11/21/2019] [Indexed: 11/15/2022] Open
Abstract
ObjectiveTo investigate the risk factors of neutralizing antibody (NAB)–induced complete secondary treatment failure (cSTF) during long-term botulinum neurotoxin (BoNT) treatment in various neurologic indications.MethodsThis monocenter retrospective cohort study analyzed the data of 471 patients started on BoNT therapy between 1995 and 2015. Blood samples of 173 patients were investigated for NABs using the mouse hemidiaphragm test (93 with suspected therapy failure, 80 prospective study participants). The frequency of NAB-cSTF was assessed for various indications: hemifacial spasm, blepharospasm, cervical dystonia, other dystonia, and spasticity. A priori defined potential risk factors for NAB-cSTF were evaluated, and a stepwise binary logistic regression analysis was performed to identify independent risk factors.ResultsTreatment duration was 9.8 ± 6.2 years (range, 0.5–30 years; adherence, 70.6%) and number of treatment cycles 31.2 ± 22.5 (3–112). Twenty-eight of 471 patients (5.9%) had NAB-cSTF at earliest after 3 and at latest after 103 treatment cycles. None of the 49 patients treated exclusively with incobotulinumtoxinA over 8.4 ± 4.2 (1–14) years developed NAB-cSTF. Independent risk factors for NAB-cSTF were high BoNT dose per treatment, switching between onabotulinumtoxinA and other BoNT formulations (except for switching to incobotulinumtoxinA), and treatment of neck muscles.ConclusionsWe present a follow-up study with the longest duration to date on the incidence of NAB-cSTF in patients treated with various BoNT formulations, including incobotulinumtoxinA. Whereas the overall risk of NAB-cSTF is low across indications and BoNT formulations, our findings underpin the recommendations to use the lowest possible dose particularly in cervical dystonia, and to avoid unnecessary switching between different formulations.
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Immunogenicity Associated with Botulinum Toxin Treatment. Toxins (Basel) 2019; 11:toxins11090491. [PMID: 31454941 PMCID: PMC6784164 DOI: 10.3390/toxins11090491] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 08/22/2019] [Indexed: 11/17/2022] Open
Abstract
Botulinum toxin (BoNT) has been used for the treatment of a variety of neurologic, medical and cosmetic conditions. Two serotypes, type A (BoNT-A) and type B (BoNT-B), are currently in clinical use. While considered safe and effective, their use has been rarely complicated by the development of antibodies that reduce or negate their therapeutic effect. The presence of antibodies has been attributed to shorter dosing intervals (and booster injections), higher doses per injection cycle, and higher amounts of antigenic protein. Other factors contributing to the immunogenicity of BoNT include properties of each serotype, such as formulation, manufacturing, and storage of the toxin. Some newer formulations with purified core neurotoxin devoid of accessory proteins may have lower overall immunogenicity. Several assays are available for the detection of antibodies, including both structural assays such as ELISA and mouse-based bioassays, but there is no consistent correlation between these antibodies and clinical response. Prevention and treatment of antibody-associated non-responsiveness is challenging and primarily involves the use of less immunogenic formulations of BoNT, waiting for the spontaneous disappearance of the neutralizing antibody, and switching to an immunologically alternate type of BoNT.
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Mathevon L, Declemy A, Laffont I, Perennou D. Immunogenicity induced by botulinum toxin injections for limb spasticity: A systematic review. Ann Phys Rehabil Med 2019; 62:241-251. [PMID: 30980953 DOI: 10.1016/j.rehab.2019.03.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 02/03/2019] [Accepted: 03/30/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND The imputability of neutralizing antibodies (NABs) in secondary non-response (SnR) to botulinum toxin (BoNT) injections for limb spasticity is still debated. OBJECTIVE This systematic literature review aimed to determine the prevalence of NABs after BoNT injections for limb spasticity and analyze their determinants and their causal role in SnR. METHODS We searched MEDLINE via PubMed, Cochrane and Embase databases for articles published during 1990-2018. Two independent reviewers extracted the data and assessed the quality of studies with a specific scale (according to PRISMA and STROBE guidelines). Because the techniques used to detect NABs did not influence the results, we calculated the global (all studies) sensitivity and specificity of NAB positivity to reveal SnR. RESULTS We included 14 articles published from 2002 to 2018 (including an epublication) describing 5 randomized controlled trials and 5 interventional and 4 observational studies. The quality was satisfactory (mean score 18/28 arbitrary units). NAB detection was the primary criterion in 5 studies and a secondary criterion in 9. In total, 1234 serum samples for 1234 participants (91% with stroke) were tested after injection. NAB prevalence was about 1%, with no significant difference among formulations. NAB positivity seemed favoured by long-duration therapy with high doses and a short interval between injections. The identification of non-response by NAB positivity had poor global sensitivity (56%) but very high specificity (99.6%). No consensual criteria were used to diagnose non-response to BoNT injection. CONCLUSIONS NAB prevalence is much lower after BoNT treatment for limb spasticity than cervical dystonia. Consensual criteria must be defined to diagnose non-response to BoNT injection. Because immunogenicity is not the most common cause of non-response to BoNT injection, NABs should be sought in individuals with SnR with no other cause explaining the treatment inefficacy. A test with 100% specificity is recommended. In cases for which immunogenicity is the most likely cause of non-response to BoNT injections, some biological arguments suggest trying another BoNT, but no clinical evidence supports this strategy.
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Affiliation(s)
- Laure Mathevon
- Department of Physical and Rehabilitation Medicine, Institute of Rehabilitation, South Hospital-University Hospital Grenoble-Alpes, 38130 Grenoble, France.
| | - Arnaud Declemy
- Department of Physical and Rehabilitation Medicine, University Hospital Nice, 06000 Nice, France
| | - Isabelle Laffont
- Department of Physical and Rehabilitation Medicine, Euromov, IFRH, Montpellier University Hospital, Montpellier University, 34090 Montpellier, France
| | - Dominic Perennou
- Department of Physical and Rehabilitation Medicine, Institute of Rehabilitation, South Hospital-University Hospital Grenoble-Alpes, 38130 Grenoble, France; University Hospital Grenoble-Alpes, CNRS, LPNC, 38000 Grenoble, France
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Eivazzadeh-Keihan R, Pashazadeh-Panahi P, Baradaran B, Guardia MDL, Hejazi M, Sohrabi H, Mokhtarzadeh A, Maleki A. Recent progress in optical and electrochemical biosensors for sensing of Clostridium botulinum neurotoxin. Trends Analyt Chem 2018. [DOI: 10.1016/j.trac.2018.03.019] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Residual Limb Hyperhidrosis and RimabotulinumtoxinB: A Randomized Placebo-Controlled Study. Arch Phys Med Rehabil 2016; 97:659-664.e2. [DOI: 10.1016/j.apmr.2015.12.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 12/18/2015] [Indexed: 11/18/2022]
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Bentivoglio AR, Del Grande A, Petracca M, Ialongo T, Ricciardi L. Clinical differences between botulinum neurotoxin type A and B. Toxicon 2015; 107:77-84. [PMID: 26260691 DOI: 10.1016/j.toxicon.2015.08.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Accepted: 08/04/2015] [Indexed: 12/23/2022]
Abstract
In humans, the therapeutic use of botulinum neurotoxin A (BoNT/A) is well recognized and continuously expanding. Four BoNTs are widely available for clinical practice: three are serotype A and one is serotype B: onabotulinumtoxinA (A/Ona), abobotulinumtoxinA (A/Abo) and incobotulinumtoxinA (A/Inco), rimabotulinumtoxinB (B/Rima). A/Abo, A/Inco, A/Ona and B/Rima are all licensed worldwide for cervical dystonia. In addition, the three BoNT/A products are approved for blepharospasm and focal dystonias, spasticity, hemifacial spasm, hyperhidrosis and facial lines, with remarkable regional differences. These toxin brands differ for specific activity, packaging, constituents, excipient, and storage. Comparative literature assessing the relative safety and efficacy of different BoNT products is limited, most data come from reports on small samples, and only a few studies meet criteria of evidence-based medicine. One study compared the effects of BoNT/A and BoNT/B on muscle activity of healthy volunteers, showing similar neurophysiological effects with a dose ratio of 1:100. In cervical dystonia, when comparing the effects of BoNT/A and BoNT/B, results are more variable, some studies reporting roughly similar peak effect and overall duration (at a ratio of 1:66, others reporting substantially shorter duration of BoNT/B than BoNT/A (at a ratio 1/24). Although the results of clinical studies are difficult to compare for methodological differences (dose ratio, study design, outcome measures), it is widely accepted that: BoNT/B is clinically effective using appropriate doses as BoNT/A (1:40-50), injections are generally more painful, in most of the studies on muscular conditions, efficacy is shorter, and immunogenicity higher. Since the earliest clinical trials, it has been reported that autonomic side effects are more frequent after BoNT/B injections, and this observation encouraged the use of BoNT/B for sialorrhea, hyperhidrosis and other non-motor symptoms. In these indications the efficacy of toxins A and B are comparable and dose ratio is 1:25-30.
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Affiliation(s)
| | | | - Martina Petracca
- Institute of Neurology, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Tamara Ialongo
- Institute of Neurology, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Lucia Ricciardi
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, University College London, London, UK
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Hefter H, Spiess C, Rosenthal D. Very early reduction in efficacy of botulinum toxin therapy for cervical dystonia in patients with subsequent secondary treatment failure: a retrospective analysis. J Neural Transm (Vienna) 2013; 121:513-9. [PMID: 24311063 PMCID: PMC3996372 DOI: 10.1007/s00702-013-1127-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 11/21/2013] [Indexed: 12/01/2022]
Abstract
The objective of this study was to estimate the probability of development of partial secondary treatment failure (PSTF) in patients with cervical dystonia (CD) who had been treated over up to 9 years with repetitive intramuscular injections of botulinum neurotoxin type A (BoNT/A). The temporal course of treatment response in patients in whom PSTF was detected retrospectively was compared to patients with a normal clinical response. For this purpose, charts of all CD patients treated in our outpatient clinic between 1988 and 2001 were retrospectively analyzed. Extracted data included time of all injections, dose per visit, disease severity measured by TSUI scores, and time of determination of neutralizing antibodies. Final data analysis using a special formal definition of PSTF was based on charts of 568 patients having exclusively been treated with abobotulinumtoxinA. PSTF onset was observed in our CD cohort during the entire treatment period analyzed, with no clustering at any time point. Probability to develop PSTF was 14.5 % in 9 years. Thus, mean PSTF incidence was 1.6 % per year. The mean TSUI score of patients with retrospectively defined PSTF (n = 33) became already significantly worse after the second injection when compared with the group without PSTF (n = 535). Our data indicate that clinical response in patients developing PSTF later on differs from that of patients without PSTF already very early in the course of botulinum neurotoxin type A treatment, and that PSTF remains undetected at this early stage. Reduced response may therefore be present in a number of CD patients who think they still respond normally to continuous BoNT/A treatment.
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Affiliation(s)
- Harald Hefter
- Department of Neurology, University of Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany,
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Jankovic J. Medical treatment of dystonia. Mov Disord 2013; 28:1001-12. [DOI: 10.1002/mds.25552] [Citation(s) in RCA: 119] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Revised: 05/03/2013] [Accepted: 05/10/2013] [Indexed: 01/21/2023] Open
Affiliation(s)
- Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine; Houston Texas USA
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Efficacy, tolerability, and immunogenicity of onabotulinumtoxina in a randomized, double-blind, placebo-controlled trial for cervical dystonia. Clin Neuropharmacol 2013; 35:208-14. [PMID: 22948497 DOI: 10.1097/wnf.0b013e31826538c7] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To evaluate the efficacy, tolerability, and neutralizing antibodies in the treatment of cervical dystonia with onabotulinumtoxinA (BOTOX). METHODS Subjects received onabotulinumtoxinA (containing original bulk toxin) treatment in a 10-week open-label period (period 1). Eligible subjects who completed this period were randomized to onabotulinumtoxinA or placebo in a 10-week double-blind period (period 2). The primary outcome measures were the Cervical Dystonia Severity Scale and the physician Global Assessment Scale at week 6 in period 2. Serum samples for immunogenicity tests were taken at baseline and study exit. The potential impact of preexisting neutralizing antibodies (nAbs) was examined across subgroups for period 1 and by analysis of covariance for period 2. RESULTS Of 214 subjects enrolled in period 1, 170 enrolled in period 2 and received placebo (n = 82) or onabotulinumtoxinA (n = 88). In period 1, subjects with preexisting nAbs responded similarly to those without preexisting nAbs. In period 2, onabotulinumtoxinA produced significantly greater improvements than placebo on the Cervical Dystonia Severity Scale (-1.81 vs -0.31 points; P = 0.012) and physician Global Assessment Scale (61.7% vs. 41.6% improved; P = 0.022) at the primary time point week 6, using baseline severity and neutralizing antibody (nAb) status at study entry as covariates. Two subjects seroconverted from nAb negative at baseline to nAb positive at study exit but remained responsive to onabotulinumtoxinA during both the open and blinded treatment periods. Rhinitis and treatment-related dysphagia were reported significantly more frequently with onabotulinumtoxinA than placebo. CONCLUSION OnabotulinumtoxinA was well tolerated and more effective than placebo for the treatment of cervical dystonia. Subject nAb status at baseline was not a clear predictor of response to onabotulinumtoxinA.
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Carruthers A, Kane MAC, Flynn TC, Huang P, Kim SD, Solish N, Kaeuper G. The Convergence of Medicine and Neurotoxins: A Focus on Botulinum Toxin Type A and Its Application in Aesthetic Medicine—A Global, Evidence-Based Botulinum Toxin Consensus Education Initiative. Dermatol Surg 2013; 39:493-509. [DOI: 10.1111/dsu.12147] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wheeler A, Smith HS. Botulinum toxins: mechanisms of action, antinociception and clinical applications. Toxicology 2013; 306:124-46. [PMID: 23435179 DOI: 10.1016/j.tox.2013.02.006] [Citation(s) in RCA: 103] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Revised: 02/07/2013] [Accepted: 02/10/2013] [Indexed: 10/27/2022]
Abstract
Botulinum toxin (BoNT) is a potent neurotoxin that is produced by the gram-positive, spore-forming, anaerobic bacterium, Clostridum botulinum. There are 7 known immunologically distinct serotypes of BoNT: types A, B, C1, D, E, F, and G. Clostridum neurotoxins are produced as a single inactive polypeptide chain of 150kDa, which is cleaved by tissue proteinases into an active di-chain molecule: a heavy chain (H) of ∼100 kDa and a light chain (L) of ∼50 kDa held together by a single disulfide bond. Each serotype demonstrates its own varied mechanisms of action and duration of effect. The heavy chain of each BoNT serotype binds to its specific neuronal ecto-acceptor, whereby, membrane translocation and endocytosis by intracellular synaptic vesicles occurs. The light chain acts to cleave SNAP-25, which inhibits synaptic exocytosis, and therefore, disables neural transmission. The action of BoNT to block the release of acetylcholine botulinum toxin at the neuromuscular junction is best understood, however, most experts acknowledge that this effect alone appears inadequate to explain the entirety of the neurotoxin's apparent analgesic activity. Consequently, scientific and clinical evidence has emerged that suggests multiple antinociceptive mechanisms for botulinum toxins in a variety of painful disorders, including: chronic musculoskeletal, neurological, pelvic, perineal, osteoarticular, and some headache conditions.
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Affiliation(s)
- Anthony Wheeler
- The Neurological Institute, 2219 East 7th Street, Charlotte, NC 28204, United States.
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Abstract
Botulinum neurotoxins are formulated biologic pharmaceuticals used therapeutically to treat a wide variety of chronic conditions, with varying governmental approvals by country. Some of these disorders include cervical dystonia, post-stroke spasticity, blepharospasm, migraine, and hyperhidrosis. Botulinum neurotoxins also have varying governmental approvals for cosmetic applications. As botulinum neurotoxin therapy is often continued over many years, some patients may develop detectable antibodies that may or may not affect their biological activity. Although botulinum neurotoxins are considered "lower risk" biologics since antibodies that may develop are not likely to cross react with endogenous proteins, it is possible that patients may lose their therapeutic response. Various factors impact the immunogenicity of botulinum neurotoxins, including product-related factors such as the manufacturing process, the antigenic protein load, and the presence of accessory proteins, as well as treatment-related factors such as the overall toxin dose, booster injections, and prior vaccination or exposure. Detection of antibodies by laboratory tests does not necessarily predict the clinical success or failure of treatment. Overall, botulinum neurotoxin type A products exhibit low clinically detectable levels of antibodies when compared with other approved biologic products. This review provides an overview of all current botulinum neurotoxin products available commercially, with respect to the development of neutralizing antibodies and clinical response.
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Affiliation(s)
- Markus Naumann
- Department of Neurology, Klinikum Augsburg, Augsburg, Germany
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Naumann M, Boo LM, Ackerman AH, Gallagher CJ. Immunogenicity of botulinum toxins. J Neural Transm (Vienna) 2013; 120:275-90. [PMID: 23008029 PMCID: PMC3555308 DOI: 10.1007/s00702-012-0893-9] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Accepted: 08/21/2012] [Indexed: 12/01/2022]
Abstract
Botulinum neurotoxins are formulated biologic pharmaceuticals used therapeutically to treat a wide variety of chronic conditions, with varying governmental approvals by country. Some of these disorders include cervical dystonia, post-stroke spasticity, blepharospasm, migraine, and hyperhidrosis. Botulinum neurotoxins also have varying governmental approvals for cosmetic applications. As botulinum neurotoxin therapy is often continued over many years, some patients may develop detectable antibodies that may or may not affect their biological activity. Although botulinum neurotoxins are considered "lower risk" biologics since antibodies that may develop are not likely to cross react with endogenous proteins, it is possible that patients may lose their therapeutic response. Various factors impact the immunogenicity of botulinum neurotoxins, including product-related factors such as the manufacturing process, the antigenic protein load, and the presence of accessory proteins, as well as treatment-related factors such as the overall toxin dose, booster injections, and prior vaccination or exposure. Detection of antibodies by laboratory tests does not necessarily predict the clinical success or failure of treatment. Overall, botulinum neurotoxin type A products exhibit low clinically detectable levels of antibodies when compared with other approved biologic products. This review provides an overview of all current botulinum neurotoxin products available commercially, with respect to the development of neutralizing antibodies and clinical response.
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Affiliation(s)
- Markus Naumann
- Department of Neurology, Klinikum Augsburg, Augsburg, Germany
| | - Lee Ming Boo
- Medical Affairs, Allergan, Inc., 2525 Dupont Drive, Irvine, CA 92612 USA
| | - Alan H. Ackerman
- Medical Affairs, Allergan, Inc., 2525 Dupont Drive, Irvine, CA 92612 USA
| | - Conor J. Gallagher
- Medical Affairs, Allergan, Inc., 2525 Dupont Drive, Irvine, CA 92612 USA
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Thenganatt MA, Fahn S. Botulinum toxin for the treatment of movement disorders. Curr Neurol Neurosci Rep 2012; 12:399-409. [PMID: 22661378 DOI: 10.1007/s11910-012-0286-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
After botulinum toxin was initially used to treat strabismus in the 1970s, others started using it to treat movement disorders including blepharospasm, hemifacial spasm, cervical dystonia, spasmodic dysphonia, and oromandibular dystonia. It was discovered that botulinum toxin can be an effective treatment for focal movement disorders with limited side effects. Over the past three decades, various formulations of botulinum toxin have been developed and the therapeutic use of these toxins has expanded in movement disorders and beyond. We review the history and mechanism of action of botulinum toxin, as well as describe different formulations available and their potential therapeutic uses in movement disorders.
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Affiliation(s)
- Mary Ann Thenganatt
- Department of Neurology, College of Physicians and Surgeons, Columbia University, 710 West 168th Street, New York, NY 10032, USA.
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Naumann M, Boo LM, Ackerman AH, Gallagher CJ. Immunogenicity of botulinum toxins. JOURNAL OF NEURAL TRANSMISSION (VIENNA, AUSTRIA : 1996) 2012. [PMID: 23008029 DOI: 10.1007/500702-012-0893-9].] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Botulinum neurotoxins are formulated biologic pharmaceuticals used therapeutically to treat a wide variety of chronic conditions, with varying governmental approvals by country. Some of these disorders include cervical dystonia, post-stroke spasticity, blepharospasm, migraine, and hyperhidrosis. Botulinum neurotoxins also have varying governmental approvals for cosmetic applications. As botulinum neurotoxin therapy is often continued over many years, some patients may develop detectable antibodies that may or may not affect their biological activity. Although botulinum neurotoxins are considered "lower risk" biologics since antibodies that may develop are not likely to cross react with endogenous proteins, it is possible that patients may lose their therapeutic response. Various factors impact the immunogenicity of botulinum neurotoxins, including product-related factors such as the manufacturing process, the antigenic protein load, and the presence of accessory proteins, as well as treatment-related factors such as the overall toxin dose, booster injections, and prior vaccination or exposure. Detection of antibodies by laboratory tests does not necessarily predict the clinical success or failure of treatment. Overall, botulinum neurotoxin type A products exhibit low clinically detectable levels of antibodies when compared with other approved biologic products. This review provides an overview of all current botulinum neurotoxin products available commercially, with respect to the development of neutralizing antibodies and clinical response.
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Affiliation(s)
- Markus Naumann
- Department of Neurology, Klinikum Augsburg, Augsburg, Germany
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Abstract
Botulinum toxin type A is a 150 kD protein produced by Clostridium botulinum, which exists in a complex with up to six additional proteins. The ability of botulinum toxin to inhibit acetylcholine release at the neuromuscular junction has been exploited for use in medical conditions characterized by muscle hyperactivity. As such, botulinum toxin is widely recommended by international treatment guidelines for movement disorders and it has a plethora of other clinical and cosmetic indications. The chronic nature of these conditions requires repeated injections of botulinum toxin, usually every few months. Multiple injections can lead to secondary treatment failure in some patients that may be associated with the production of neutralizing antibodies directed specifically against the neurotoxin. However, the presence of such antibodies does not always render patients non-responsive. The reported prevalence of immunoresistance varies greatly, depending on factors such as study design and treated indication. This review presents what is currently known about the immunogenicity of botulinum toxin and how this impacts upon patient non-response to treatment. The complexing proteins may act as adjuvants and stimulate the immune response. Their role and that of neutralizing and non-neutralizing antibodies in the response to botulinum toxin is discussed, together with an assessment of current neutralizing antibody measurement techniques. Botulinum toxin preparations with different compositions and excipients have been developed. The major commercially available preparations of botulinum toxin are Botox® (onabotulinumtoxinA; Allergan, Inc., Ireland), Dysport® (abobotulinumtoxinA; Ipsen Ltd, UK), and Xeomin® (incobotulinumtoxinA; botulinum toxin type A [150 kD], free from complexing proteins; NT 201; Merz Pharmaceuticals GmbH, Germany). The new preparations of botulinum toxin aim to minimize the risk of immunoresistance in patients being treated for chronic clinical conditions.
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Affiliation(s)
- Reiner Benecke
- Department of Neurology, University of Rostock, Rostock, Germany.
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Jankovic J, Adler CH, Charles PD, Comella C, Stacy M, Schwartz M, Sutch SM, Brin MF, Papapetropoulos S. Rationale and design of a prospective study: Cervical Dystonia Patient Registry for Observation of OnaBotulinumtoxinA Efficacy (CD PROBE). BMC Neurol 2011; 11:140. [PMID: 22054223 PMCID: PMC3220636 DOI: 10.1186/1471-2377-11-140] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Accepted: 11/04/2011] [Indexed: 12/31/2022] Open
Abstract
Background A registry of patients with cervical dystonia (Cervical Dystonia Patient Registry for Observation of onaBotulinumtoxinA Efficacy [CD PROBE]) was initiated to capture data regarding physician practices and patient outcomes with onabotulinumtoxinA (BOTOX®, Allergan, Inc., Irvine, CA, USA). Methods and baseline demographics from an interim analysis are provided. Methods/Design This is a prospective, multicenter, clinical registry in the United States enrolling subjects with cervical dystonia (CD) who are toxin naïve and/or new to the physicians' practices, or who had been in a clinical trial but received their last injection ≥ 16 weeks prior to enrollment. Subjects are followed over 3 injection cycles of onabotulinumtoxinA, with assessments at time of injection and 4-6 weeks later. Information on physician's practice, patient demographics, CD disease history, duration of treatment intervals and neurotoxin dose, dilution, use of electromyography, and muscles injected are collected. Outcomes are assessed by physicians and subjects using various questionnaires. Discussion This ongoing registry includes 609 subjects with the following baseline data: 75.9% female, 93.6% Caucasian, mean age 57.6 ± 14.3, age at symptom onset 48.3 ± 16.2, and time to diagnosis 5.4 ± 8.6 years, with an additional 1.0 ± 3.5 years before treatment. Of those employed at the time of diagnosis, 36.6% stopped working as a result of CD. CD PROBE, the largest clinical registry of CD treatment, will provide useful data on current treatment practices with onabotulinumtoxinA, potentially leading to refinements for optimization of outcomes. Trial registration NCT00836017
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Affiliation(s)
- Joseph Jankovic
- Baylor College of Medicine, Department of Neurology, Houston, TX, USA.
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Naumann M, Carruthers A, Carruthers J, Aurora SK, Zafonte R, Abu-Shakra S, Boodhoo T, Miller-Messana MA, Demos G, James L, Beddingfield F, VanDenburgh A, Chapman MA, Brin MF. Meta-analysis of neutralizing antibody conversion with onabotulinumtoxinA (BOTOX®) across multiple indications. Mov Disord 2011; 25:2211-8. [PMID: 20737546 DOI: 10.1002/mds.23254] [Citation(s) in RCA: 122] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
This meta-analysis evaluated the frequency of neutralizing antibody (nAb) conversion with onabotulinumtoxinA (BOTOX®; Allergan) across five studied indications. The analysis was based on large, controlled or prospective, open-label trials (durations 4 months to ≥2 years). Serum samples were analyzed for nAbs using the Mouse Protection Assay. Subjects who were antibody negative at baseline and had at least one analyzable postbaseline antibody assay result were included. The 16 clinical studies included 3,006 subjects; of these, 2,240 met the inclusion criteria for this analysis. Subjects received 1-15 treatments (mean 3.8 treatments) with onabotulinumtoxinA. Total doses per treatment cycle ranged from 10 or 20 units in glabellar lines to 20-500 units in cervical dystonia. The numbers of subjects who converted from an antibody-negative status at baseline to antibody-positive status at any post-treatment time point were: cervical dystonia 4/312 (1.28%), glabellar lines 2/718 (0.28%), overactive bladder 0/22 (0%), post-stroke spasticity 1/317 (0.32%), and primary axillary hyperhidrosis 4/871 (0.46%). Across all indications, 11/2,240 subjects (0.49%) converted from antibody negative at baseline to positive at one or more post-treatment time points, but only three subjects became clinically unresponsive to onabotulinumtoxinA at some point following a positive assay. Based on these large trials, the frequency of antibody conversion after onabotulinumtoxinA treatment is very low, and infrequently leads to loss of efficacy. © 2010 Movement Disorder Society.
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Affiliation(s)
- Markus Naumann
- Department of Neurology, Klinikum Augsburg Neurologische Klinik, Augsburg, Germany.
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Dodick DW, Turkel CC, DeGryse RE, Aurora SK, Silberstein SD, Lipton RB, Diener HC, Brin MF. OnabotulinumtoxinA for treatment of chronic migraine: pooled results from the double-blind, randomized, placebo-controlled phases of the PREEMPT clinical program. Headache 2010; 50:921-36. [PMID: 20487038 DOI: 10.1111/j.1526-4610.2010.01678.x] [Citation(s) in RCA: 578] [Impact Index Per Article: 41.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the efficacy, safety, and tolerability of onabotulinumtoxinA (BOTOX) as headache prophylaxis in adults with chronic migraine. BACKGROUND Chronic migraine is a prevalent, disabling, and undertreated neurological disorder. Few preventive treatments have been investigated and none is specifically indicated for chronic migraine. METHODS The 2 multicenter, pivotal trials in the PREEMPT: Phase 3 REsearch Evaluating Migraine Prophylaxis Therapy clinical program each included a 24-week randomized, double-blind phase followed by a 32-week open-label phase (ClinicalTrials.gov identifiers NCT00156910, NCT00168428). Qualified patients were randomized (1:1) to onabotulinumtoxinA (155-195 U) or placebo injections every 12 weeks. Study visits occurred every 4 weeks. These studies were identical in design (eg, inclusion/exclusion criteria, randomization, visits, double-blind phase, open-label phase, safety assessments, treatment), with the only exception being the designation of the primary and secondary endpoints. Therefore, the predefined pooling of the results was justified and performed to provide a complete overview of between-group differences in efficacy, safety, and tolerability that may not have been evident in individual studies. The primary endpoint for the pooled analysis was mean change from baseline in frequency of headache days at 24 weeks. Secondary endpoints were mean change from baseline to week 24 in frequency of migraine/probable migraine days, frequency of moderate/severe headache days, total cumulative hours of headache on headache days, frequency of headache episodes, frequency of migraine/probable migraine episodes, frequency of acute headache pain medication intakes, and the proportion of patients with severe (> or =60) Headache Impact Test-6 score at week 24. Results of the pooled analyses of the 2 PREEMPT double-blind phases are presented. RESULTS A total of 1384 adults were randomized to onabotulinumtoxinA (n = 688) or placebo (n = 696). Pooled analyses demonstrated a large mean decrease from baseline in frequency of headache days, with statistically significant between-group differences favoring onabotulinumtoxinA over placebo at week 24 (-8.4 vs -6.6; P < .001) and at all other time points. Significant differences favoring onabotulinumtoxinA were also observed for all secondary efficacy variables at all time points, with the exception of frequency of acute headache pain medication intakes. Adverse events occurred in 62.4% of onabotulinumtoxinA patients and 51.7% of placebo patients. Most patients reported adverse events that were mild to moderate in severity and few discontinued (onabotulinumtoxinA, 3.8%; placebo, 1.2%) due to adverse events. No unexpected treatment-related adverse events were identified. CONCLUSIONS The pooled PREEMPT results demonstrate that onabotulinumtoxinA is an effective prophylactic treatment for chronic migraine. OnabotulinumtoxinA resulted in significant improvements compared with placebo in multiple headache symptom measures, and significantly reduced headache-related disability and improved functioning, vitality, and overall health-related quality of life. Repeat treatments with onabotulinumtoxinA were safe and well tolerated.
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Affiliation(s)
- David W Dodick
- Department of Neurology, Mayo Clinic Arizona, Phoenix, AZ, USA
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Sławek J, Car H, Bonikowski M, Bogucki A, Koziorowski D, Potulska-Chromik A, Rudzińska M. Czy wszystkie preparaty toksyny botulinowej typu A są takie same? Porównanie trzech preparatów toksyny botulinowej typu A w zarejestrowanych wskazaniach w neurologii. Neurol Neurochir Pol 2010; 44:43-64. [DOI: 10.1016/s0028-3843(14)60406-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Discussion Regarding Botulinum Toxin, Immunologic Considerations with Long-term Repeated Use, with Emphasis on Cosmetic Applications. Facial Plast Surg Clin North Am 2009; 17:633-4; discussion 634-77, vii. [DOI: 10.1016/j.fsc.2009.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Müller K, Mix E, Adib Saberi F, Dressler D, Benecke R. Prevalence of neutralising antibodies in patients treated with botulinum toxin type A for spasticity. J Neural Transm (Vienna) 2009; 116:579-85. [PMID: 19352590 DOI: 10.1007/s00702-009-0223-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2008] [Accepted: 03/21/2009] [Indexed: 10/20/2022]
Abstract
Botulinum toxin (BT) has been used with great success to treat various muscle hyperactivity disorders. Occasionally, antibodies against BT (BT-AB) can be formed. When they are directed against the neurotoxin component of the BT drug, they are called neutralising antibodies. They can reduce the therapeutic effect partially or completely. We have measured neutralising BT-AB by use of the mouse diaphragm assay (MDA) in 42 adult patients with spasticity in the order of their appearance in the clinic. The patients had been treated for at least 2 years with BT type A (BT-A) and received on an average 14.2 +/- 6.1 BT-A injection series. BT-A was applied as Botox only, Dysport only or by sequential application of both preparations. The mean cumulative doses were 4,610 +/- 1,936 units Botox and 14,033 +/- 7,566 units Dysport, respectively. The mean treatment time was 4.5 +/- 1.8 (2-8) years. All patients were initially responsive to BT-A therapy. MDA detected BT-AB in 12% (5/42) of patients. However, in three patients the BT-AB titre was very low (<0.3 mIU/ml), in one it was intermediate (0.6 mIU/ml) and in one patient it was high (>1.0 mIU/ml). All BT-AB negative patients and also two of the patients with low BT-AB titre remained clinically responsive to BT therapy throughout the study. In conclusion, prevalence of BT-AB formation with clinical relevance (6%, 3/42) in adult patients with spasticity is not higher than that of BT-treated patients with cervical dystonia and much lower than that of BT-treated patients with infantile cerebral palsy.
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Affiliation(s)
- Kerstin Müller
- Department of Neurology, University of Rostock, Rostock, Germany
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Brashear A. Botulinum toxin type A in the treatment of patients with cervical dystonia. Biologics 2009; 3:1-7. [PMID: 19707390 PMCID: PMC2726049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Dystonia is an involuntary movement involving twisting and turning of agonist and antagonist muscles. Cervical dystonia is isolated to neck musculature. Botulinum toxin type A is a safe and effective treatment of this disabling and often painful syndrome. Three forms of botulinum toxin type A are available worldwide to treat patients with cervical dystonia. This is a review of the studies of botulinum toxin type A to treat cervical dystonia.
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Affiliation(s)
- Allison Brashear
- Correspondence: Allison Brashear, Dept of Neurology, Wake Forest University Baptist Medical Center, Medical Center Blvd, Winston Salem, NC 27157, USA, Tel +1 336 716 3545, Fax +1 335 716 9489, Email
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Repeated treatments with botulinum toxin type a produce sustained decreases in the limitations associated with focal upper-limb poststroke spasticity for caregivers and patients. Arch Phys Med Rehabil 2008; 89:799-806. [PMID: 18452724 DOI: 10.1016/j.apmr.2008.01.007] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2007] [Revised: 12/09/2007] [Accepted: 01/01/2008] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To assess the safety and evaluate the effects of repeated treatments with botulinum toxin type A (BTX-A) on functional disability, quality of life (QOL), and muscle tone of patients with upper-limb poststroke spasticity, as well as its effect on caregivers. DESIGN Multicenter, open-label, repeated-dose study. SETTING Thirty-five clinical sites in North America. PARTICIPANTS Patients (N=279) with upper-limb poststroke spasticity at 6 months or more poststroke. INTERVENTION Up to 5 intramuscular injections of BTX-A (200-400U) divided among the wrist, finger, thumb, and elbow flexors, with at least 200U in the wrist and finger flexors. Retreatment was permitted at 12 weeks or more after the last treatment. MAIN OUTCOME MEASURES Investigators rated disability using the Disability Assessment Scale and muscle tone using the Ashworth Scale. Each patient's health-related QOL was assessed by using the Stroke Adapted Sickness Impact Profile and the visual analog scale of the European Quality of Life-5 Dimensions questionnaires. RESULTS Patients treated with BTX-A reported improvements in muscle tone, disability, and ability to function that were statistically significant and clinically meaningful. Significant improvements were observed at week 30 and at subsequent time points in QOL in the overall group and the high-dose group. CONCLUSIONS Up to 5 treatments with BTX-A every 12 weeks for up to 56 weeks in patients with poststroke spasticity was well tolerated and significantly improved muscle tone, lessened disability, and improved patients' QOL. Further research is required to examine the effectiveness of repeated injections of BTX-A in patients with poststroke spasticity.
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Tamura BM, Cucé LC, Rodrigues CJ. Allergic reaction to botulinum toxin: positive intradermal test. Dermatol Surg 2008; 34:1117-9. [PMID: 18462430 DOI: 10.1111/j.1524-4725.2008.34223.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Bachhuber A, Wagner A, Reichel G, Doberenz M, Stenner A, Hermann W. Nachweis von Botulinum-Toxin-Antikörper. DER NERVENARZT 2008; 79:908-11. [DOI: 10.1007/s00115-008-2470-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Toxins that alter neurotransmitter release from nerve terminals are of considerable scientific and clinical importance. Many advances were recently made in the understanding of their molecular mechanisms of action and use in human therapy. Here, we focus on presynaptic neurotoxins, which are very potent inhibitors of the neurotransmitter release because they are endowed with specific enzymatic activities: (1) clostridial neurotoxins with a metallo-proteolytic activity and (2) snake presynaptic neurotoxins with a phospholipase A2 activity.
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Affiliation(s)
- Ornella Rossetto
- Departimento de Scienze Biomediche and Istituto CNR di Neuroscienze, Universita di Padova, Viale G. Colombo 3, 35121, Padova, Italy
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Yablon SA, Brashear A, Gordon MF, Elovic EP, Turkel CC, Daggett S, Liu J, Brin MF. Formation of neutralizing antibodies in patients receiving botulinum toxin type A for treatment of poststroke spasticity: a pooled-data analysis of three clinical trials. Clin Ther 2007; 29:683-90. [PMID: 17617291 DOI: 10.1016/j.clinthera.2007.04.015] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2007] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The purpose of this study was to investigate the incidence of neutralizing antibody (NAb) formation in patients with poststroke spasticity treated with a specific formulation of botulinum toxin type A (BoNTA). METHODS Data from 3 previous clinical trials of BoNTA in patients with upper and/or lower limb spasticity were pooled and evaluated. Study 1 was a randomized, double-blind, placebo-controlled, multicenter trial of BoNTA in patients aged >/=21 years who had experienced a stroke >6 months before the initiation of the study. Study 2 was an open-label extension of study 1. Study 3 was a randomized, double-blind, multicenter trial of a specific BoNTA formulation in patients aged >/= 21 years who had experienced a stroke >/=6 weeks before study entry. Patients with a fixed contracture of the studied limb were excluded from participation in studies 1 and 2. Serum samples were obtained from each patient before each BoNTA treatment and at the end of each study. The mouse protection assay (MPA) was used for detection of NAbs to BoNTA in serum. RESULTS A total of 235 individual patients with post-stroke spasticity were enrolled in the 3 trials, including 126, 111 (all of whom participated in study 1), and 109 in studies 1, 2, and 3, respectively. Study 1 had an equal (50.0%) distribution of male and female patients (63/63). The distribution of male and female patients was 56 (50.5%) and 55 (49.5%), respectively, in study 2, and 55 (50.5%) and 54 (49.5), respectively, in study 3. The mean (SD) ages of patients in studies 1, 2, and 3 were 61.4 (13.8), 61.5 (14.1), and 58.5 (13.9) years, respectively. The MPA was used for detection of NAbs to BoNTA in the serum samples of 191 patients, including 64 from study 1, 111 from study 2 (55 of these patients were placebo recipients and 56 received their first BoNTA injection in study 1), and 72 (a sample was not obtained for 1 patient who had not received an injection) from study 3. The median number of BoNTA treatments received by these patients was 2 (range, 1-4 treatments) over a period lasting from 12 to 42 weeks. The mean dose of BoNTA was 241 U (range, 100-400 U), with a maximum dose of 960 U in any 1 patient. NAbs to BoNTA were detected in the serum sample of 1/191 (0.5%) patient who had participated in studies 1 and 2. Based on muscle-tone scores (3 and 4 for wrist and fingers, respectively) on a 5-point Ashworth Scale (0 = none to 4 = severe), the patient did not appear to exhibit a clinical response to BoNTA at any time during the studies. CONCLUSION Formation of NAbs was rare (1/191) in this group of adults with poststroke spasticity from three 12- to 42-week clinical trials who received >/=1 treatment with a specific BoNTA formulation at doses ranging from 100 to 400 U.
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Affiliation(s)
- Stuart A Yablon
- Brain Injury Program, Methodist Rehabilitation Center, Jackson, Mississippi 39216, USA.
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Lee SK. Antibody-induced failure of botulinum toxin type A therapy in a patient with masseteric hypertrophy. Dermatol Surg 2007; 33:S105-10. [PMID: 17278332 DOI: 10.1111/j.1524-4725.2006.32340.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND With the expanding use of botulinum toxin, much concern about the antibody against botulinum toxin is arising. Unlike neurologic indications such as cervical dystonia, antibody-induced failure of botulinum toxin therapy has never been reported in the cosmetic field. OBJECTIVE The objective was to describe a case of an antibody-induced failure of botulinum toxin type A (BTX-A) therapy (BOTOX, Allergan, Inc.) that occurred in a patient with masseteric hypertrophy. METHODS AND MATERIALS We present a 20-year-old girl who developed antibody-induced therapy failure after the fourth injection series. Sixty units of toxin was injected at each series and the intertreatment interval was four to five months. RESULTS Frontalis test revealed no paresis of muscle after a unilateral injection of BTX-A. Circulating antibodies against BTX-A were detected by indirect enzyme-linked immunosorbent assay and mouse protection assay. CONCLUSION This case is unique in that, first, immunoresistance developed in a patient of cosmetic indication where only a small dose of BTX-A was administered and, second, antibodies developed on the so-called new formulation of BOTOX. Our case alerts cosmetic surgeons to the importance of antibody against the botulinum toxin.
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Affiliation(s)
- Soo-Keun Lee
- Mein Skin Clinic, 1306-1 Seocho-4-dong, Seocho-ku, Seoul 137-855, South Korea.
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Cordivari C, Misra VP, Vincent A, Catania S, Bhatia KP, Lees AJ. Secondary nonresponsiveness to botulinum toxin A in cervical dystonia: the role of electromyogram-guided injections, botulinum toxin A antibody assay, and the extensor digitorum brevis test. Mov Disord 2007; 21:1737-41. [PMID: 16874756 DOI: 10.1002/mds.21051] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
We studied 20 patients with cervical dystonia who had started to respond poorly to botulinum toxin A (BTXA) injections after an initial good response. All patients had extensor digitorum brevis (EDB) tests performed in addition to BTXA immunoprecipition assay (IPA) and mouse bioassay (MBA) antibody testing. The patients were reexamined and then treated with carefully placed electromyogram (EMG)-guided BTXA. Nine patients had a good clinical response to EMG-guided injections and all of these patients showed an obvious decrement on the EDB test. All were BTXA blocking antibodies (Abs)-negative via IPA and MBA (apart from one patient who had low BTXA antibodies titers using IPA but no antibodies by MBA). In the other 11 patients, there was a poor clinical response to EMG-guided BTXA injections. Seven of these 11 had small EDB decrement and BTXA antibodies using IPA, suggesting resistance to BTXA. Of the remaining four patients, two had obvious EDB decrement and low antibody titers via IPA (one of them had no antibodies via MBA), while the other two patients showed obvious decrement on the EDB test and no antibodies via IPA. This study shows that the EDB test correlates better with the clinical response than the antibody assays and that EDB decrement does not always correlate quantitatively with the BTXA antibody titers. In patients with secondary nonresponsiveness, it is recommended that an EDB test is the initial investigation of choice. In those patients where the EDB test does not demonstrate resistance to BTXA, a reexamination of the patients and carefully placed injections under EMG guidance may improve results.
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Affiliation(s)
- Carla Cordivari
- Department of Clinical Neurophysiology, National Hospital for Neurology and Neurosurgery, London, United Kingdom.
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Borodic G. Botulinum Toxin, Immunologic Considerations with Long-Term Repeated Use, with Emphasis on Cosmetic Applications. Facial Plast Surg Clin North Am 2007; 15:11-6, v. [PMID: 17317551 DOI: 10.1016/j.fsc.2006.10.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Botulinum toxin is a unique pharmaceutical agent in wide-scale use for cosmetic and multiple therapeutic applications. Physicians using these agents for esthetic purpose must realize the potential for future therapeutic needs. Because most indications require repeated injections, the recipient is at risk for immunologic reactions with possible formation of neutralizing antibodies. An individual who is injected with botulinum toxin for cosmetic purposes could someday require an effective form of type A toxin for dystonia, pain, or spasticity.
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Affiliation(s)
- Gary Borodic
- Massachusetts Eye and Ear Infirmary, Cambridge, MA, USA.
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Abstract
Dystonia may be a sign or symptom, that is comprised of complex abnormal and dynamic movements of different etiologies. A specific cause is identified in approximately 28% of patients, which only occasionally results in specific treatment. In most cases, treatment is symptomatic and designed to relieve involuntary movements, improve posture and function and reduce associated pain. Therapeutic options are dictated by clinical assessment of the topography of dystonia, severity of abnormal movements, functional impairment and progression of disease and consists of pharmacological, surgical and supportive approaches. Several advances have been made in treatment with newer medications, availability of different forms of botulinum toxin and globus pallidus deep brain stimulation (DBS). For patients with childhood-onset dystonia, the majority of whom later develop generalized dystonia, oral medication is the mainstay of therapy. Recently, DBS has emerged as an effective alternative therapy. Botulinum toxin is usually the treatment of choice for those with adult-onset primary dystonia in which dystonia usually remains focal. In patients with secondary dystonia, treatment is challenging and efficacy is typically incomplete and partially limited by side effects. Despite these treatment options, many patients with dystonia experience only partial benefit and continue to suffer significant disability. Therefore, more research is needed to better understand the underlying cause and pathophysiology of dystonia and to explore newer medications and surgical techniques for its treatment.
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Affiliation(s)
- Roongroj Bhidayasiri
- Chulalongkorn University Hospital, Chulalongkorn Comprehensive Movement Disorders Center, Division of Neurology, 1873 Rama 4 Road Bangkok 10330, Thailand.
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Mejia NI, Vuong KD, Jankovic J. Long-term botulinum toxin efficacy, safety, and immunogenicity. Mov Disord 2005; 20:592-7. [PMID: 15645481 DOI: 10.1002/mds.20376] [Citation(s) in RCA: 131] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
To determine the long-term efficacy of botulinum toxin (BTX) treatments, we analyzed longitudinal follow-up data on 45 patients (32 women; mean age, 68.8 years) currently followed in the Baylor College of Medicine Movement Disorders Clinic, who have received BTX treatments continuously for at least 12 years (mean 15.8 +/- 1.5 years). Their mean response rating after the last injection, based one a previously described scale 0-to-4 scale (0 = no effect; 4 = marked improvement) was 3.7 +/- 0.6 and the mean total duration of response was 15.4 +/- 3.4 weeks. Although the latency and total duration of the response to treatment have not changed over time, the peak duration of response (P < 0.005) and dose per visit (P < 0.0001) have increased since the initial visit. Furthermore, global rating (P < 0.02) and peak effect (P < 0.05) have improved. In total, 20 adverse events occurred in 16 of 45 (35.6%) patients after their initial visit and 11 adverse events in 10 of 45 (22.2%) patients at their most recent injection visit. Antibody (Ab) testing was carried out in 22 patients due to nonresponsiveness; blocking Abs were confirmed by the mouse protection assay in 4 of 22 (18%) patients. Of the Ab-negative patients, 16 resumed responsiveness after dose adjustments and 2 persisted as nonrespondents. Except for 1 patient, the 4 Ab-positive and the 2 clinical nonresponders are being treated with BTX-B. This longest reported follow-up of BTX injections confirms the long-term efficacy and safety of this treatment.
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Affiliation(s)
- Nicte I Mejia
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, Texas 77030, USA
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Dressler D, Lange M, Bigalke H. Mouse diaphragm assay for detection of antibodies against botulinum toxin type B. Mov Disord 2005; 20:1617-9. [PMID: 16078216 DOI: 10.1002/mds.20625] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
With the advent of a commercial preparation of botulinum toxin type B (BT-B) for treatment of cervical dystonia detection of antibodies against BT-B (BT-B-AB) becomes necessary. For this purpose, we carried out a mouse diaphragm assay (MDA) by continuous measurement of the twitch force of a mouse hemidiaphragm preparation elicited by electric stimulation of its phrenic nerve. After exposing the preparation to BT-B 3 ng/ml the time to half-maximal twitch force reduction (paralysis time [PT]) was 69 +/- 4 min (n = 25). Addition of sera from patients with antibodies against BT-A produced a PT of 68 +/- 5 min (n = 24), whereas addition of sera from controls with antibodies against tetanus toxoid produced a PT of 67 +/- 6 min (n = 30). When defined amounts of BT-B-AB were added to the MDA, PT was prolonged. This prolongation was correlated closely to the amount of BT-B-AB added, thus producing a calibration curve. The threshold for BT-B-AB detection was 0.4 mU/ml. When sera from 7 patients (4 women, 3 men; age 50.6 +/- 14.2 years) with cervical dystonia (Toronto Western Spasmodic Torticollis Rating Scale score, 18.9 +/- 2.9) and complete secondary failure of BT-B therapy (NeuroBloc; Elan Pharmaceuticals, Shannon, Ireland; 12,229 +/- 2,601 MU/injection series, 1.86 +/- 0.69 injection series before complete secondary therapy failure; 100.4 +/- 15.8 days between injection series with normal therapeutic effect) were tested, BT-B-AB titers of more than 10 mU/ml were found in all of them. The MDA can be used to measure neutralizing BT-B-AB titers quantitatively and with adequate sensitivity and specificity. Further studies are necessary to understand the role of intermediate BT-B-AB titers in partial BT-B therapy failure.
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Affiliation(s)
- Dirk Dressler
- Department of Neurology, Rostock University, Rostock, Germany.
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Brashear A. The safety and tolerability of botulinum toxins for the treatment of cervical dystonia. Expert Opin Drug Saf 2005; 4:241-9. [PMID: 15794717 DOI: 10.1517/14740338.4.2.241] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The use of botulinum toxin to treat cervical dystonia (CD) has dramatically improved the quality of life of patients with this disabling, often painful disease. Two forms of type A toxin (BOTOX and Dysport) and one form of type B toxin (MyoBloc) are available in some parts of the world to treat patients with CD. The literature supports the efficacy of each in reducing the pain and movement of cervical dystonia. The dosing and side effects vary between the toxins. The potential availability of several forms of toxin will allow physicians to offer further treatment options to patients with CD. However, it is incumbent on the treating physicians to have a working knowledge of the different serotypes, different doses used of each formulation of each serotype, the side effect profile of each product and the potential for anti-body formation for each form of toxin.
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Affiliation(s)
- Allison Brashear
- Indiana University Medical Center, Department of Neurology, CL 291, Indianapolis, IN 46202-5250, USA.
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Bakheit AMO, Fedorova NV, Skoromets AA, Timerbaeva SL, Bhakta BB, Coxon L. The beneficial antispasticity effect of botulinum toxin type A is maintained after repeated treatment cycles. J Neurol Neurosurg Psychiatry 2004; 75:1558-61. [PMID: 15489387 PMCID: PMC1738811 DOI: 10.1136/jnnp.2003.035139] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To study the efficacy, safety, and incidence of BtxA antibody formation with repeated treatments with BtxA in post-stroke upper limb muscle spasticity. METHODS The study was a prospective open label trial. Patients with established post-stroke upper limb spasticity received 1000 units of BtxA (Dysport) into five muscles of the affected arm on study entry. Treatment was repeated every 12, 16, or 20 weeks as clinically indicated. Each patient received a total of three treatment cycles. Efficacy of treatment was assessed using the Modified Ashworth Scale. Patients were assessed on study entry and on week 4 and 12 of each treatment cycle for all safety and efficacy parameters. Blood samples for BtxA antibody assay were taken at baseline and on completion of the trial. RESULTS Fifty one patients were recruited and 41 of them completed the study. Improvement from the cycle one baseline was observed in all the outcome measures. Mild to moderately severe treatment related adverse events were reported in 24% of cases. There were no serious adverse events. No BtxA antibodies were detected. CONCLUSION BtxA at a dose of 1000 units Dysport was efficacious in the symptomatic treatment of post-stroke upper limb spasticity. The study suggests that this effect can be maintained with repeated injections for up to at least three treatment cycles, with duration of effect per cycle of between 12 and 20 weeks. BtxA was safe in the dose used in this study and did not induce the formation of detectable levels of neutralising BtxA antibodies.
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Affiliation(s)
- A M O Bakheit
- Peninsula Medical School, Mount Gould Hospital, PL4 7QD, UK.
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Abstract
Botulinum toxin, the most potent biological toxin, has become a powerful therapeutic tool for a growing number of clinical applications. This review draws attention to new findings about the mechanism of action of botulinum toxin and briefly reviews some of its most frequent uses, focusing on evidence based data. Double blind, placebo controlled studies, as well as open label clinical trials, provide evidence that, when appropriate targets and doses are selected, botulinum toxin temporarily ameliorates disorders associated with excessive muscle contraction or autonomic dysfunction. When injected not more often than every three months, the risk of blocking antibodies is slight. Long term experience with this agent suggests that it is an effective and safe treatment not only for approved indications but also for an increasing number of off-label indications.
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Affiliation(s)
- J Jankovic
- Department of Neurology, Baylor College of Medicine, Houston, Texas 77030,USA.
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Dressler D. Clinical presentation and management of antibody-induced failure of botulinum toxin therapy. Mov Disord 2004; 19 Suppl 8:S92-S100. [PMID: 15027060 DOI: 10.1002/mds.20022] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Therapy with botulinum toxin (BT) can fail due to numerous reasons, including failure due to formation of antibodies against BT (BT-AB, AB-TF). AB-TF is a secondary therapy failure, i.e. it occurs during the course of an ongoing BT therapy. It can be subjective or objective, temporary or permanent, and partial or complete. Complete AB-TF is usually preceded by injection series with partial AB-TF in which the therapeutic effect is reduced in its intensity and duration. AB-TF usually occurs within 2 or 3 years after initiation of BT therapy. After 4 years it is rare. BT-AB are neutralising or blocking by definition, i.e. they are directly interfering with BT's biological mechanism of action. Non-neutralizing or non-blocking antibodies occur. BT-AB can be detected by the mouse diaphragm assay, the mouse protection assay, and by patient-based tests such as the sternocleidomastoid test, the extensor digitorum brevis test, and the frowning test. Enzyme-linked immunosorbent assays (ELISA) have a low specificity and a low sensitivity for detection of BT-AB. BT-AB titres drop spontaneously after cessation of BT therapy but latencies are too long to be compatible with an effective BT therapy. BT dosage increase can be successful to overcome AB-TF when AB-TF is partial and when BT-AB titres are low. Usage of alternative BT type A preparations fail to overcome AB-TF. Alternative BT types, such as BT type B and BT type F, are initially successful in AB-TF, but stimulate formation of antibodies against the alternative BT types after few applications. BT-AB reduction with immunosuppressants and inactivation of BT-AB by intravenous immunoglobuline application has not yet been achieved. Extraction of BT-AB by plasmapheresis and immunoadsorption is possible but is associated with substantial logistic problems. Prevention of BT-AB formation, therefore, is of paramount importance. Identified risk factors for BT-AB formation must be taken into account when BT therapy is planned. The most interesting perspective seems to be the development of new BT preparations with reduced antigenicity.
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Affiliation(s)
- Dirk Dressler
- Department of Neurology, Rostock University, Rostock, Germany.
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Voller B, Moraru E, Auff E, Benesch M, Poewe W, Wissel J, Müller J, Entner T, Bigalke H, Schnider P. Ninhydrin sweat test: A simple method for detecting antibodies neutralizing botulinum toxin type A. Mov Disord 2004; 19:943-7. [PMID: 15300661 DOI: 10.1002/mds.20073] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Approximately 5% of patients with cervical dystonia receiving repeated botulinum neurotoxin A (BoNT/A) injections develop secondary loss of treatment benefit. Currently available tests to directly detect neutralizing BoNT/A antibodies (BoNT/A-AB) are either expensive or time consuming. To establish a simple, clinically useful test for antibody detection, we adapted the ninhydrin sweat test (NST). Eighteen dystonic patients with secondary nonresponse and clinically suspected BoNT/A-AB formation were tested for BoNT/A-AB in the mouse diaphragm test (MDT). In addition, the size of the anhidrotic area was determined by the NST 21 days after an intradermal dose of 10 U Dysport into the hypothenar region of the left palm. In nine patients, positive BoNT-AB titers were found in the MDT. There was a significant correlation between the BoNT/A-AB titers and the anhidrotic area (Spearman's rho = -0.9, P < 0.0001). Both tests provided comparably good results with respect to qualitative antibody detection. In the clinical situation of secondary nonresponse to BoNT/A therapy, the economical NST may be a helpful tool to detect neutralizing BoNT/A-AB.
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Affiliation(s)
- Bernhard Voller
- Department of Neurology, Division of Neurorehabilitation, University of Vienna, Austria.
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Abstract
Cervical dystonia (CD) is the most common form of dystonia encountered in a movement disorders clinic. The treatment of this focal dystonia has improved markedly with the advent on botulinum toxin (BTX) injections, which has now become the treatment of choice. Initial studies, even double-blind controlled trials, failed to show robust effect, largely as a result of poor design, often using fixed dosage and site of administration. When the BTX treatment is customized to the needs of the individual patients and the most involved muscles are targeted, the effects can be quite dramatic and the improvement usually lasts 3 to 4 months. Experience and improved skills can largely prevent the adverse effects such as dysphagia and neck weakness. Although there is no evidence that BTX slows the progression of the disease, as a result of early intervention with BTX, many of the long-term complications of CD, such as contractures and radiculopathy, have been largely eliminated.
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Affiliation(s)
- Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, Texas 77030, USA.
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Sesardic D, Jones RGA, Leung T, Alsop T, Tierney R. Detection of antibodies against botulinum toxins. Mov Disord 2004; 19 Suppl 8:S85-91. [PMID: 15027059 DOI: 10.1002/mds.20021] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
After immunisation with botulinum vaccine, antibodies to multiple epitopes are produced. Only some of these will have the capacity to neutralise the toxin activity. In fact, the ability of toxoid vaccine to induce toxin neutralising antibodies has provided the basis for the use of therapeutic antitoxins and immunoglobulins for the prophylaxis and treatment of diseases caused by bacterial toxins. Increasing indications for the chronic use of botulinum toxin for therapy have inevitably resulted in concern for patients becoming unresponsive because of the presence of circulating toxin-specific antibodies. Highly sensitive and relevant assays to detect only clinically relevant toxin neutralising antibodies are essential. Although immunoassays often provide the sensitivity, their relevance and specificity is often questioned. The mouse protection LD(50) bioassay is considered most relevant but can often only detect 10 mIU/ml of antitoxin. This sensitivity, although sufficient for confirming protective immunity, is inadequate for patients undergoing toxin therapy. An intramuscular paralysis assay improves the sensitivity to ca. 1 mIU/ml, and a mouse ex vivo diaphragm assay, with sensitivity of < 0.5 mIU/ml, is the most sensitive functional assay to date for this purpose. Alternative approaches for the detection of antibodies to botulinum toxin have included in vitro endopeptidase activity neutralisation. Unlike any other functional assay, this approach is not reliant on serotype-specific antibodies for specificity. Most recent promising developments are focused on cellular assays utilising primary rat embryonic cord cells or more conveniently in vitro differentiated established cell lines such as human neuroblastoma cells.
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Affiliation(s)
- Dorothea Sesardic
- Division of Bacteriology, National Institute for Biological Standards and Control, Potters Bar, Hertfordshire, United Kingdom.
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Abstract
Botulinum toxins are among the most potent neurotoxins known to humans. In the past 25 years, botulinum toxin has emerged as both a potential weapon of bioterrorism and as a powerful therapeutic agent, with growing applications in neurological and non-neurological disease. Botulinum toxin is unique in its ability to target peripheral cholinergic neurons, preventing the release of acetylcholine through the enzymatic cleavage of proteins involved in membrane fusion, without prominent central nervous system effects. There are seven serotypes of the toxin, each with a specific activity at the molecular level. Currently, serotypes A (in two preparations) and B are available for clinical use, and have been shown to be safe and effective for the treatment of dystonia, spasticity, and other disorders in which muscle overactivity gives rise to symptoms. This review focuses on the pharmacology, electrophysiology, immunology, and application of botulinum toxin in selected neurological disorders.
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Affiliation(s)
- Cynthia L Comella
- Department of Neurological Sciences, Rush University Medical Center, 1725 West Harrison, Chicago, Illinois 60612, USA.
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Cardoso F. [Botulinum toxin type B in the management of dystonia non-responsive to botulinum toxin type A]. ARQUIVOS DE NEURO-PSIQUIATRIA 2003; 61:607-10. [PMID: 14513166 DOI: 10.1590/s0004-282x2003000400015] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Botulinum toxin (BTX) injection is the first choice treatment for focal dystonias. However 10% or more of patients who receive repetitive injections of BTX type A (BTX-A) lose response (secondary non-responders). One of the strategies to manage such patients is to treat them with another serotype. The aim of this article is to describe my experience with BTX type B (BTX-B) in the management of patients with focal dystonia who became secondary non-responders to BTX-A. METHOD Open-label non-controlled use of BTX-B injections to treat dystonia patients who developed secondary nonresponse to BTX-A Response to treatment was rated on a 0-4 scale (Jankovic). RESULTS Four patients entered the study. Pacient 1- At age 48 this man developed idiopathic cervical dystonia. Five years later he also presented with blepharospasm and idiopathic oromandibular dystonia. He was treated with 7604U of BTX-A along 23 sessions separated by a mean interval of 18.8 weeks (range 6-39). Loss of response was noticed after the seventh session. First treatment with BTX-B consisted of injection of 20000U with response rated 3 but duration of 3 weeks. Second session, 23500U, resulted in score 4 with response lasting 12 weeks. Patient 2- This man, with Tourette syndrome since age 8 years, developed tardive blepharospasm at age 51. On 8 sessions of BTX-A injections he received a cumulative dosage of 550U with a mean interval between sessions of 8.8 weeks (range 6-12). Decline of response was noticed after the fifth session. First treatment with BTX-B, 3000U, had a response rated 3 with duration of 12 weeks. Second session, 6000U, resulted in score 4. Patient 3- This woman noticed onset of blepharospasm at age 58 and developed oromandibular and laryngeal dystonia as well as cervical dystonia, respectively, at ages 59 and 65. In other institutions she received 6 sessions of BTX-A. In my service she received a dosage of 1404U along 8 sessions with a mean interval between sessions of 17.4 weeks (range 16-18). She became secondary non-responder after the ninth session. First treatment with BTX-B, 6000U, was rated 0. Second session, 12000U, was rated 4. Patient 4- At age 69 this man developed idiopathic cranial dystonia. Prior to follow up with me, he received 6 sessions of BTX-A in other services. In my institution he was treated with a cumulative dosage of 730U along 4 sessions with a mean interval between sessions of 16.3 weeks (range 15-18). He developed loss of response on the sixth session. Treatment with BTX-B, 12000U, was rated 4 and lasted 20 weeks. Side-effects: local pain (all patients) and dryness of mouth and ptosis (one patient each). CONCLUSION My findings confirm that BTX-B injections are a safe and effective option for the management of dystonia patients who become secondary non-responders to BTX-A. The results also underscore the need of individualizing dosage regimens before optimum results are achieved.
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Affiliation(s)
- Francisco Cardoso
- Serviço de Neurologia, Universidade Federal de Minas Gerais, Belo Horizonte, Brasil.
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Abstract
Therapeutic strategies in the treatment of dystonia consist primarily of pharmacologic, surgical, and supportive approaches. Many recent advances have been made in the treatment of dystonia with newer medications, availability of different botulinum toxins, and surgical procedures. However, these treatment modalities all have limiting factors and varying levels of efficacy. Studies range from case reports and open-label trials to double-blind placebo-controlled trials. More research and larger studies are needed to explore these newer medications and surgical techniques for both primary focal and generalized dystonia. Studies in functional outcome and quality of life further support the importance of discovering safe and effective means to treat dystonia. An algorithmic approach may be useful to guide the physician along the various treatment choices.
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Affiliation(s)
- Jennifer G Goldman
- Department of Neurological Sciences, Rush-Presbyterian-St. Luke's Medical Center, 1725 W. Harrison Street, Suite 755, Chicago, IL 60612, USA.
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Birklein F, Walther D, Bigalke H, Winterholler M, Erbguth F. Sudomotor testing predicts the presence of neutralizing botulinum A toxin antibodies. Ann Neurol 2002; 52:68-73. [PMID: 12112049 DOI: 10.1002/ana.10243] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The increasing number of patients being treated with botulinum toxin A complex (BoNT/A) has led to a higher incidence of neutralizing anti-BoNT/A antibodies (ABAs). Because BoNT/A is known to inhibit sweating, here we report sudometry as a possibility for predicting the presence of ABA. Sixteen patients suffering from spasmodic torticollis were selected: in 2 patients, BoNT/A treatment continued to be effective, in 9 patients, the treatment effect was impaired, and in 5 patients, secondary treatment failure developed. BoNT/A (100 mouse units, Dysport; Ipsen Pharma, Berkshire, United Kingdom) was injected subcutaneously into the lateral calves. Sweating was visualized with iodine starch staining. In addition, quantitative sudomotor axon reflex testing was performed at the injection site. Individual ABA titers were determined with a mouse bioassay. Results of sudometry significantly correlated with the BoNT/A treatment success. The quantitative sudomotor axon reflex testing was 0.58 +/- 0.63 fraction of the normal mean in patients with treatment failure, 0.18 +/- 0.13 fraction of the normal mean in those who responded partially, and 0 in responders (p < 0.01). Accordingly, the areas of the anhidrotic skin after subcutaneous injections were 4.5 +/- 10.3 cm(2), 32.7 +/- 16.5 cm(2), and 62 cm(2) (p < 0.01). Discrimination analysis indicated that the presence of ABA (6 ABA-positive and 10 ABA-negative) could be predicted correctly in all patients from the results of sudometry. Therefore, sudometry is a useful tool for identifying patients with neutralizing ABAs and might be helpful for identifying reasons for BoNT/A treatment failure.
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Affiliation(s)
- Frank Birklein
- Neurologische Klinik, Johannes-Gutenberg Universität Mainz, Germany.
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Adler CH, Factor SA, Brin M, Sethi KD. Secondary nonresponsiveness to botulinum toxin type A in patients with oromandibular dystonia. Mov Disord 2002; 17:158-61. [PMID: 11835455 DOI: 10.1002/mds.10001] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Intramuscular injection of botulinum toxin type A is the treatment of choice for most cases of oromandibular dystonia. We report on five patients with oromandibular dystonia that developed secondary nonresponsiveness to botulinum toxin type A following multiple injections over a 6-year period.
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Affiliation(s)
- Charles H Adler
- Parkinson's Disease and Movement Disorders Center, Mayo Clinic Scottsdale, Scottsdale, Arizona, USA.
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Abstract
Cervical dystonia (CD) causes involuntary muscle spasms and is often associated with pain. Recently, botulinum toxin type B (BTX-B) (Myobloc, Elan South San Francisco, CA, USA) was approved for general use in the treatment of CD in the USA. In two large pivotal trials, BTX-B was found to be safe and effective in decreasing the movements, pain and disability associated with CD. Benefits were noted both in patients who no longer respond and in those who continue to respond to botulinum toxin type A (BTX-A). BTX-B offers an additional therapeutic option for patients with CD.
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Affiliation(s)
- A Brashear
- Indiana University School of Medicine, Department of Neurology, 550 University Boulevard, Room 6620, Indianapolis, IN 46202-5250, USA.
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