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Oliveira KM, Barreto ESR, Alencar VB, Lins-Kusterer LEF, Azi LMTDA, Kraychete DC. The efficacy of botulinum toxin in neuropathic pain: a systematic review. Br J Pain 2024; 18:388-402. [PMID: 39372103 PMCID: PMC11452887 DOI: 10.1177/20494637241254191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/08/2024] Open
Abstract
Introduction Neuropathic pain (NP) is characterised as a lesion or disease directly affecting the somatosensory system. This study aims to analyse the efficacy of botulinum toxin type A (BT-A) in the treatment of neuropathic pain. Methods This systematic literature review, guided by PRISMA, applied the PICO strategy with the following criteria: (P = patients with neuropathic pain, I = botulinum toxin, C = placebo or active drug, and O = pain relief). Results Fourteen articles, all randomised controlled trials with a placebo control, were included in the review. A total of 645 patients were randomised, with 353 patients receiving treatment with botulinum toxin type A in doses ranging from 25U to 400U. The evaluated studies addressed trigeminal neuralgia, diabetic polyneuropathy, post-herpetic neuralgia, spinal cord injury, phantom limb pain, and peripheral neuropathic pain after trauma or surgery. Conclusion BT-A has emerged as a promising treatment for various origins of neuropathic pain. Therefore, future studies should adopt stricter criteria regarding dosage and routes of administration to ensure effective and consistent BT-A application.
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Barreto ESR, Antunes Júnior CR, Alencar VB, Leandro MP, Leite LMB, Lins-Kusterer LEF, Kraychete DC. The efficacy of Botulinum Toxin in Tennis Elbow: a meta-analysis of randomized clinical trials. INTERNATIONAL ORTHOPAEDICS 2024:10.1007/s00264-024-06339-6. [PMID: 39347988 DOI: 10.1007/s00264-024-06339-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2024] [Accepted: 09/21/2024] [Indexed: 10/01/2024]
Abstract
PURPOSE This study aims to assess the efficacy of botulinum toxin type A (BT-A) in treating tennis elbow. METHODS We systematically reviewed the literature and included full-text randomized clinical trials (RCTs) published until June 2024, available in PubMed, Scopus, Embase, and Cochrane CENTRAL databases. Eligible studies involved patients with tennis elbow and compared BT-A with placebo or other injectable treatments. Primary outcomes included pain relief, while secondary outcomes assessed quality of life, adverse effects, and grip strength. The risk of bias was evaluated using the Cochrane Risk of Bias tool. RESULTS Seven RCTs with a total of 381 patients were included. The participants were predominantly middle-aged (mean age 46.64 ± 7.72 years) and diagnosed with chronic tennis elbow. BT-A doses ranged from 20U to 60U. Compared to placebo, BT-A effectively reduced pain at two to four weeks (MD = -1.37; 95% CI = -2.18 to -0.57) and at eight to 12 weeks (MD = -1.13; 95% CI = -1.62 to -0.65). Grip strength was comparable between the BT-A and placebo groups at both time points (2 to 4 weeks: SMD = -0.86; 95% CI -1.78 to 0.05; 8 to 12 weeks: SMD = 0.00; 95% CI = -0.95 to 0.95). CONCLUSION This meta-analysis suggests that BT-A reduces pain in tennis elbow within two to 12 weeks compared to placebo. Findings are limited by study size, and further research is needed to confirm its efficacy and safety.
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Affiliation(s)
- Eduardo Silva Reis Barreto
- Federal University of Bahia, Av. Reitor Miguel Calmon, S/N - Vale do Canela, Salvador, Bahia, 40110-100, Brazil.
| | - César Romero Antunes Júnior
- Federal University of Bahia, Av. Reitor Miguel Calmon, S/N - Vale do Canela, Salvador, Bahia, 40110-100, Brazil
| | - Vinícius Borges Alencar
- Federal University of Bahia, Av. Reitor Miguel Calmon, S/N - Vale do Canela, Salvador, Bahia, 40110-100, Brazil
| | | | | | | | - Durval Campos Kraychete
- Federal University of Bahia, Av. Reitor Miguel Calmon, S/N - Vale do Canela, Salvador, Bahia, 40110-100, Brazil
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Almeida BO, Barreto ESR, Antunes Júnior CR, Alencar VB, Souza AKDN, Azi LMTDA, Lins-Kusterer LEF, Kraychete DC. Evaluating the efficacy of botulinum toxin in treating complex regional pain syndrome: A systematic review. Toxicon 2024; 250:108100. [PMID: 39299653 DOI: 10.1016/j.toxicon.2024.108100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Revised: 08/22/2024] [Accepted: 09/10/2024] [Indexed: 09/22/2024]
Abstract
Complex Regional Pain Syndrome (CRPS) is characterized by pain, swelling, limited range of motion, skin changes, vasomotor instability, and bone demineralization. This study aims to assess the efficacy of botulinum toxin type A (BoNT-A) in the treatment of CRPS. We conducted a systematic literature review following the PRISMA guidelines, using the PICO strategy (Patient, Intervention, Comparison and Outcome) with the following criteria: P = Patients with CRPS; I = Botulinum toxin; C = Placebo or active drug; and O = Pain relief. Three randomized controlled trials with placebo controls were included, involving a total of 64 patients, 36 of whom received BoNT-A in doses ranging from 40U to 200U. The studies examined both lumbar sympathetic block and local application methods. Botulinum toxin shows promise in alleviating pain associated with CRPS, particularly when used as an adjunct to lumbar sympathetic blockade. However, the limited number of studies and small sample sizes impede reaching definitive conclusions regarding its efficacy and safety. Notably, local applications (intradermal or subcutaneous) require further investigation, as current evidence is insufficient and reports indicate patient discomfort. While preliminary findings suggest potential benefits of BoNT-A in managing CRPS, larger randomized trials are necessary to confirm its efficacy and safety.
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4
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Rahman E, Carruthers JDA. Immunogenicity of Botulinum Toxin A: Insights. Dermatol Surg 2024; 50:S117-S126. [PMID: 39196845 DOI: 10.1097/dss.0000000000004293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2024]
Abstract
BACKGROUND Botulinum toxin A (BoNT-A) is widely used in treating dystonia and spasticity to managing chronic migraine and cosmetic applications. However, its immunogenic potential presents challenges, such as the development of neutralizing antibodies that lead to diminished therapeutic efficacy over time, known as secondary nonresponse. OBJECTIVE This review aims to bridge the knowledge gap regarding the immunogenic mechanisms of BoNT-A and to explore effective management strategies to mitigate these immune responses. MATERIALS AND METHODS The authors conducted a systematic search in databases including PubMed, Embase, and Web of Science, using keywords related to BoNT-A's immunogenicity. The selection process refined 157 initial articles down to 23 relevant studies, which underwent analysis to investigate the underlying mechanisms of immunogenicity and the factors influencing it. RESULTS The analysis revealed that both the neurotoxin component and the neurotoxin-associated proteins could elicit an immune response. However, only antibodies against the core toxin influence therapeutic outcomes. Various patient-specific factors such as genetic predispositions and prior immune experiences, along with treatment-related factors such as dosage and frequency, play crucial roles in shaping these responses. CONCLUSION Understanding the specific immunogenic triggers and responses to BoNT-A is critical for optimizing treatment protocols and improving patient outcomes.
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Affiliation(s)
- Eqram Rahman
- Research and Innovation Hub, Innovation Aesthetics, London, United Kingdom
| | - Jean D A Carruthers
- Department of Ophthalmology, University of British Columbia, Vancouver, British Columbia, Canada
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Rasetti-Escargueil C, Palea S. Embracing the Versatility of Botulinum Neurotoxins in Conventional and New Therapeutic Applications. Toxins (Basel) 2024; 16:261. [PMID: 38922155 PMCID: PMC11209287 DOI: 10.3390/toxins16060261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/26/2024] [Accepted: 05/27/2024] [Indexed: 06/27/2024] Open
Abstract
Botulinum neurotoxins (BoNTs) have been used for almost half a century in the treatment of excessive muscle contractility. BoNTs are routinely used to treat movement disorders such as cervical dystonia, spastic conditions, blepharospasm, and hyperhidrosis, as well as for cosmetic purposes. In addition to the conventional indications, the use of BoNTs to reduce pain has gained increased recognition, giving rise to an increasing number of indications in disorders associated with chronic pain. Furthermore, BoNT-derived formulations are benefiting a much wider range of patients suffering from overactive bladder, erectile dysfunction, arthropathy, neuropathic pain, and cancer. BoNTs are categorised into seven toxinotypes, two of which are in clinical use, and each toxinotype is divided into multiple subtypes. With the development of bioinformatic tools, new BoNT-like toxins have been identified in non-Clostridial organisms. In addition to the expanding indications of existing formulations, the rich variety of toxinotypes or subtypes in the wild-type BoNTs associated with new BoNT-like toxins expand the BoNT superfamily, forming the basis on which to develop new BoNT-based therapeutics as well as research tools. An overview of the diversity of the BoNT family along with their conventional therapeutic uses is presented in this review followed by the engineering and formulation opportunities opening avenues in therapy.
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Affiliation(s)
| | - Stefano Palea
- Humana Biosciences-Prologue Biotech, 516 Rue Pierre et Marie Curie, 31670 Labège, France;
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6
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Quitadamo P, Tambucci R, Mancini V, Campanozzi A, Caldaro T, Giorgio V, Pensabene L, Isoldi S, Mallardo S, Fusaro F, Staiano A, Salvatore S, Borrelli O. Diagnostic and therapeutic approach to children with chronic refractory constipation: Consensus report by the SIGENP motility working group. Dig Liver Dis 2024; 56:406-420. [PMID: 38104028 DOI: 10.1016/j.dld.2023.11.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 11/15/2023] [Accepted: 11/29/2023] [Indexed: 12/19/2023]
Abstract
Constipation is a common problem in children, accounting for about 3% of all primary care visits and up to 25% of referrals to paediatric gastroenterologists. Although polyethylene glycol often proves effective, most children require prolonged treatment and about 50% of them have at least one relapse within the first 5 years after initial recovery. When conventional treatment fails, children are considered to have refractory constipation. Children with refractory constipation deserve specialist management and guidance. Over the last decades, there has been a remarkable increase in our knowledge of normal and abnormal colonic and anorectal motility in children, and a number of different techniques to measure transit and motility have been developed. The present review analyses the possible diagnostic investigations for children with refractory constipation, focusing on their actual indications and their utility in clinical practice. Moreover, we have also analytically reviewed medical and surgical therapeutic options, which should be considered in selected patients in order to achieve the best clinical outcome.
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Affiliation(s)
- Paolo Quitadamo
- Pediatric Gastroenterology and Epatology Unit, Santobono-Pausilipon Children's Hospital, Naples, Italy.
| | - Renato Tambucci
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Valentina Mancini
- Department of Pediatrics and Neonatology, San Carlo Hospital, Milan, Italy
| | - Angelo Campanozzi
- Pediatrics, Department of Medical and Surgical Sciences, University of Foggia
| | - Tamara Caldaro
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Valentina Giorgio
- UOC Pediatria, Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italy
| | - Licia Pensabene
- Department of Medical and Surgical Sciences, Pediatric Unit, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Sara Isoldi
- Pediatric Gastroenterology and Epatology Unit, Santobono-Pausilipon Children's Hospital, Naples, Italy; Maternal and Child Health Department, Sapienza - University of Rome, Santa Maria Goretti Hospital, Polo Pontino, Latina, Italy
| | - Saverio Mallardo
- Maternal and Child Health Department, Sapienza - University of Rome, Santa Maria Goretti Hospital, Polo Pontino, Latina, Italy
| | - Fabio Fusaro
- Department of Medical and Surgical Neonatology, Newborn Surgery Unit, Digestive and Endoscopic Surgery, Gastroenterology and Nutrition, Intestinal Failure Rehabilitation Research Group, Bambino Gesù Children's Hospital Research Institute, Rome, Italy
| | - Annamaria Staiano
- Department of Translational Medical Science, Section of Pediatrics, University "Federico II", Naples, Italy
| | - Silvia Salvatore
- Pediatric Department, Ospedale "F. Del Ponte", University of Insubria, Varese, Italy
| | - Osvaldo Borrelli
- Division of Neurogastroenterology and Motility, Department of Paediatric Gastroenterology, UCL Institute of Child Health and Great Ormond Street Hospital, London, UK
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Gupta AD, Baguley I, Estell J, Geffon S, Goh K, Rawicki B, de Graaf S, Olver J. Statement of the Rehabilitation Medicine Society of Australia and New Zealand for the therapeutic use of botulinum toxin A in spasticity management. Intern Med J 2024; 54:178-182. [PMID: 38267377 DOI: 10.1111/imj.16300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 11/19/2023] [Indexed: 01/26/2024]
Abstract
The Rehabilitation Medicine Society of Australia and New Zealand advocates the safe, effective and evidence-based use of botulinum toxin type A for spasticity management. The process requires appropriate training, alongside considerable knowledge and skills, to maximise efficacy. The processes before and after injection contribute to effectiveness. The gold standard of managing spasticity is for assessment by a multidisciplinary specialist team, deriving patient-centric goals, and designing an injection protocol to match these goals. The patient and/or carers are considered part of the decision-making team. Postinjection therapy and measurement of goal achievement are highly recommended as part of the wider holistic approach to management. The Society believes treatment failures can be minimised by following clear clinical guidelines.
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Affiliation(s)
- Anupam Datta Gupta
- Central Adelaide Local Health Network, Queen Elizabeth Hospital (SA), University of Adelaide, Adelaide, South Australia, Australia
| | - Ian Baguley
- Brain Injury Rehabilitation Service, Westmead Rehabilitation Hospital, Sydney, New South Wales, Australia
| | - John Estell
- Department of Rehabilitation Medicine, St George Hospital, Sydney, New South Wales, Australia
| | - Saul Geffon
- Queensland Rehabilitation Specialists, Brisbane, Queensland, Australia
| | - Kong Goh
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Barry Rawicki
- Masada Hospital Consulting Rooms, Melbourne, Victoria, Australia
| | - Stephen de Graaf
- Epworth Rehabilitation Camberwell, Melbourne, Victoria, Australia
| | - John Olver
- Epworth Rehabilitation Clinical Institute, Melbourne, Victoria, Australia
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Molteni F, Wissel J, Fheodoroff K, Munin MC, Patel AT, Althaus M, Comes G, Dekundy A, Pulte I, Scheschonka A, Vacchelli M, Santamato A. Improvement in Quality-of-Life-Related Outcomes Following Treatment with IncobotulinumtoxinA in Adults with Limb Spasticity: A Pooled Analysis. Toxins (Basel) 2023; 16:19. [PMID: 38251237 PMCID: PMC10821091 DOI: 10.3390/toxins16010019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 12/05/2023] [Accepted: 12/16/2023] [Indexed: 01/23/2024] Open
Abstract
A strong correlation has been reported between patient-reported quality of life (QoL) and the investigator-rated Disability Assessment Scale (DAS) in patients with spasticity. The current analysis evaluates the effect of incobotulinumtoxinA on QoL-related outcomes (limb position abnormality, as well as dressing- and hygiene-related disability, measured with the DAS) in adults with upper limb spasticity, using pooled data from six studies. Separate analyses for each DAS domain were performed using data from patients with disabilities for that domain (DAS score ≥1). Results showed that a significantly greater proportion of incobotulinumtoxinA-treated compared with placebo-treated patients achieved a ≥1-point reduction from baseline in each of the DAS domains (improvement) 4 weeks after the first injection. The benefits of incobotulinumtoxinA were observed regardless of the baseline severity of DAS impairment and of the time elapsed since stroke. The effects of incobotulinumtoxinA 4 weeks after injection were maintained or enhanced over multiple injection cycles for all three DAS domains, supporting the use of repeated injection cycles to provide sustained QoL benefit. IncobotulinumtoxinA represents an important treatment option to achieve better QoL-related outcomes for patients with upper limb spasticity, irrespective of the duration of their condition.
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Affiliation(s)
- Franco Molteni
- Department of Rehabilitation, Valduce Villa Beretta Hospital, 23845 Costa Masnaga, Italy
| | - Jörg Wissel
- Department of Neurorehabilitation and Physical Therapy, Vivantes Hospital Spandau, 13585 Berlin, Germany
| | | | - Michael C. Munin
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Atul T. Patel
- Kansas City Bone and Joint Clinic, Overland Park, KS 66211, USA
| | - Michael Althaus
- Merz Therapeutics GmbH, 60318 Frankfurt am Main, Germany; (M.A.); (G.C.)
| | - Georg Comes
- Merz Therapeutics GmbH, 60318 Frankfurt am Main, Germany; (M.A.); (G.C.)
| | - Andrzej Dekundy
- Merz Therapeutics GmbH, 60318 Frankfurt am Main, Germany; (M.A.); (G.C.)
| | - Irena Pulte
- Merz Therapeutics GmbH, 60318 Frankfurt am Main, Germany; (M.A.); (G.C.)
| | - Astrid Scheschonka
- Merz Therapeutics GmbH, 60318 Frankfurt am Main, Germany; (M.A.); (G.C.)
| | - Matteo Vacchelli
- Merz Therapeutics GmbH, 60318 Frankfurt am Main, Germany; (M.A.); (G.C.)
| | - Andrea Santamato
- Unit of Spasticity and Movement Disorders, Division of Physical Medicine and Rehabilitation, University Hospital of Foggia, 71100 Foggia, Italy
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Raman S, Yamamoto Y, Suzuki Y, Matsuka Y. Mechanism and clinical use of botulinum neurotoxin in head and facial region. J Prosthodont Res 2023; 67:493-505. [PMID: 36740263 DOI: 10.2186/jpr.jpr_d_22_00238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE Botulinum neurotoxin (BoNT) is a biological toxin produced by Clostridium botulinum. BoNT is a potent toxin extensively used in therapeutic interventions. This review provides an updated overview of the mechanisms of action and clinical applications of BoNT in head and facial region. STUDY SELECTION MEDLINE/PubMed searches were conducted using the terms "botulinum neurotoxin" and "dentistry" along with a combination of other related terms. In addition, studies were manually selected from reference lists of the selected articles. RESULTS The Food and Drug Administration in the United States initially approved BoNT to treat strabismus, blepharospasm, and hemifacial spasms. The use of BoNT in dermatology and cosmetics has been widely established and has created a revolution in these fields. Over the years, its applications in various medical specialties have expanded widely. Owing to its safety, efficacy, and long duration of action, it is well-accepted by patients. BoNT/A and BoNT/B are widely used in clinical practice. Several off-label uses of BoNT in the dental fraternity have yielded promising results. We have elaborated on the speculated mechanism of action, dosage, effective sites of injection, and adverse effects of each therapeutic application. The various clinical indications for BoNT include bruxism, myofascial pain, temporomandibular joint dislocation, hemifacial pain, orofacial dystonia, facial paralysis, chronic migraine, and trigeminal neuralgia. CONCLUSIONS BoNT is a safe treatment that can be used effectively, provided that the clinician has adequate knowledge regarding the mechanism, injection techniques, and local and systemic side effects and that it is administered cautiously and purposefully.
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Affiliation(s)
- Swarnalakshmi Raman
- Department of Stomatognathic Function and Occlusal Reconstruction, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Yumiko Yamamoto
- Department of Bacteriology, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Yoshitaka Suzuki
- Department of Stomatognathic Function and Occlusal Reconstruction, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Yoshizo Matsuka
- Department of Stomatognathic Function and Occlusal Reconstruction, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
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Pini Prato A, Faticato MG, Mazzola C, Arrigo S, Mattioli G, Arnoldi R, Mosconi M. Intrasphincteric Botox injections in Hirschsprung's disease: indications and outcome in 64 procedures over a ten-year period. Minerva Pediatr (Torino) 2023; 75:482-489. [PMID: 30419742 DOI: 10.23736/s2724-5276.18.05238-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND Intrasphincteric botulinum toxin (Botox) injection for symptomatic postoperative anal achalasia in Hirschsprung's disease (HSCR) has found wide application in the last twenty years. The aim of this study was to describe effectiveness and functional outcome of a series of patients treated over a 10-year period. METHODS All consecutive HSCR patients who received intrasphincteric Botox injections between January 2007 and December 2016 were included. Demographic data and clinical features were collected. A detailed questionnaire focusing on outcome in the medium and long-term was administered to all families. RESULTS In the study period 64 intrasphincteric Botox injections were performed in 31 patients. Completed questionnaires were returned by 27 out of 28 eligible patients (96%) reporting improvement or symptoms resolution in 16 (59%). The highest success rates were experienced by patients younger than 4, with long HSCR forms and with recurrent enterocolitis (75%, 100% and 100% of success rates, respectively). No major complications occurred. Minor complications were described by 7 patients (26%). CONCLUSIONS Intrasphincteric Botox injection proved to be feasible, safe and reasonably effective in children with HSCR and postoperative anal achalasia. Infants and toddlers with long HSCR forms and recurrent bouts of enterocolitis are those who would benefit most from this treatment.
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Affiliation(s)
- Alessio Pini Prato
- Unit of Pediatric Surgery, The Children Hospital, AON SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy -
| | - Maria G Faticato
- Department of Pediatric Surgery, Institute for Scientific Research, Giannina Gaslini Children's Hospital, Genoa, Italy
- Department of Neuroscience, Ophthalmology, Rehabilitation, Genetics and Maternal-Infant Science - DINOGMI, University of Genoa, Genoa, Italy
| | - Cinzia Mazzola
- Department of Pediatric Surgery, Institute for Scientific Research, Giannina Gaslini Children's Hospital, Genoa, Italy
| | - Serena Arrigo
- Unit of Pediatric Gastroenterology, Institute for Scientific Research, Giannina Gaslini Children's Hospital, Genoa, Italy
| | - Girolamo Mattioli
- Department of Pediatric Surgery, Institute for Scientific Research, Giannina Gaslini Children's Hospital, Genoa, Italy
- Department of Neuroscience, Ophthalmology, Rehabilitation, Genetics and Maternal-Infant Science - DINOGMI, University of Genoa, Genoa, Italy
| | - Rossella Arnoldi
- Unit of Pediatric Surgery, The Children Hospital, AON SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Manuela Mosconi
- Department of Pediatric Surgery, Institute for Scientific Research, Giannina Gaslini Children's Hospital, Genoa, Italy
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11
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Miyashita SI, Karatsu S, Fujiishi M, Huang IH, Nagashima Y, Morobishi T, Hosoya K, Hata T, Dong M, Sagane Y. Characterization of Serotype CD Mosaic Botulinum Neurotoxin in Comparison with Serotype C and A. Toxins (Basel) 2023; 15:123. [PMID: 36828437 PMCID: PMC9962336 DOI: 10.3390/toxins15020123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/19/2023] [Accepted: 01/24/2023] [Indexed: 02/05/2023] Open
Abstract
Botulinum neurotoxin (BoNT), produced by Clostridium botulinum, cleaves proteins involved in neurotransmitter release, thereby triggering flaccid paralyses, which are responsible for botulism. BoNT is classified into seven serotypes (BoNT/A-G); BoNT/A and BoNT/B are used as medical therapeutics and anti-wrinkle reagents. In this study, we investigated the efficacy of BoNT/CD, a mosaic toxin of BoNT/C and BoNT/D, to assess its potential as a therapeutic alternative for BoNT/A. In a cultured neuron assay, BoNT/CD cleaved syntaxin and SNAP-25 with higher efficacy than BoNT/C and BoNT/A. Intramuscularly administrated BoNT/CD induced dose-dependent muscle paralysis, and the paralysis lasted ~21 days in a mouse digit abduction score assay (BoNT/A-induced paralysis lasted ~30 days). BoNT/C failed to induce local paralysis without systemic toxicity. Multiple alignment analyses of the amino acid sequences of the receptor binding domain (HC) of eight BoNT/CDs and two BoNT/Ds showed sequence clustering in five groups. Comparing BoNT/CD strain 003-9 (BoNT/CD003-9) and strain 6813 (BoNT/CD6813) showed that both BoNT/CDs displayed similar efficacies in cultured neurons, but BoNT/CD003-9 displayed higher efficacy in a mouse model than BoNT/CD6813. These findings suggest that BoNT/CD may be a potential alternative for patients who do not respond to existing BoNT-based therapeutics.
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Affiliation(s)
- Shin-Ichiro Miyashita
- Department of Food, Aroma and Cosmetic Chemistry, Faculty of Bioindustry, Tokyo University of Agriculture, Abashiri 099-2493, Hokkaido, Japan
| | - Shura Karatsu
- Department of Food, Aroma and Cosmetic Chemistry, Faculty of Bioindustry, Tokyo University of Agriculture, Abashiri 099-2493, Hokkaido, Japan
| | - Mako Fujiishi
- Department of Food, Aroma and Cosmetic Chemistry, Faculty of Bioindustry, Tokyo University of Agriculture, Abashiri 099-2493, Hokkaido, Japan
| | - I Hsun Huang
- Department of Food, Aroma and Cosmetic Chemistry, Faculty of Bioindustry, Tokyo University of Agriculture, Abashiri 099-2493, Hokkaido, Japan
| | - Yuki Nagashima
- Department of Food, Aroma and Cosmetic Chemistry, Faculty of Bioindustry, Tokyo University of Agriculture, Abashiri 099-2493, Hokkaido, Japan
| | - Tamaki Morobishi
- Department of Food, Aroma and Cosmetic Chemistry, Faculty of Bioindustry, Tokyo University of Agriculture, Abashiri 099-2493, Hokkaido, Japan
| | - Keita Hosoya
- Department of Food, Aroma and Cosmetic Chemistry, Faculty of Bioindustry, Tokyo University of Agriculture, Abashiri 099-2493, Hokkaido, Japan
| | - Tsuyoshi Hata
- Department of Food, Aroma and Cosmetic Chemistry, Faculty of Bioindustry, Tokyo University of Agriculture, Abashiri 099-2493, Hokkaido, Japan
| | - Min Dong
- Department of Urology, Boston Children’s Hospital, Boston, MA 02115, USA
- Department of Microbiology, Harvard Medical School, Boston, MA 02115, USA
- Department of Surgery, Harvard Medical School, Boston, MA 02115, USA
| | - Yoshimasa Sagane
- Department of Food, Aroma and Cosmetic Chemistry, Faculty of Bioindustry, Tokyo University of Agriculture, Abashiri 099-2493, Hokkaido, Japan
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12
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Fang Y, Chang AY, Verma D, Miyashita SI, Eszterhas S, Lee PG, Shen Y, Davis LR, Dong M, Bailey-Kellogg C, Griswold KE. Functional Deimmunization of Botulinum Neurotoxin Protease Domain via Computationally Driven Library Design and Ultrahigh-Throughput Screening. ACS Synth Biol 2023; 12:153-163. [PMID: 36623275 PMCID: PMC9872818 DOI: 10.1021/acssynbio.2c00426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Indexed: 01/11/2023]
Abstract
Botulinum neurotoxin serotype A (BoNT/A) is a widely used cosmetic agent that also has diverse therapeutic applications; however, adverse antidrug immune responses and associated loss of efficacy have been reported in clinical uses. Here, we describe computational design and ultrahigh-throughput screening of a massive BoNT/A light-chain (BoNT/A-LC) library optimized for reduced T cell epitope content and thereby dampened immunogenicity. We developed a functional assay based on bacterial co-expression of BoNT/A-LC library members with a Förster resonance energy transfer (FRET) sensor for BoNT/A-LC enzymatic activity, and we employed high-speed fluorescence-activated cell sorting (FACS) to identify numerous computationally designed variants having wild-type-like enzyme kinetics. Many of these variants exhibited decreased immunogenicity in humanized HLA transgenic mice and manifested in vivo paralytic activity when incorporated into full-length toxin. One variant achieved near-wild-type paralytic potency and a 300% reduction in antidrug antibody response in vivo. Thus, we have achieved a striking level of BoNT/A-LC functional deimmunization by combining computational library design and ultrahigh-throughput screening. This strategy holds promise for deimmunizing other biologics with complex superstructures and mechanisms of action.
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Affiliation(s)
- Yongliang Fang
- Thayer
School of Engineering, Dartmouth, Hanover, New Hampshire 03755, United States
- Department
of Urology, Boston Children’s Hospital, Boston, Massachusetts 02115, United States
- Department
of Microbiology and Department of Surgery, Harvard Medical School, Boston, Massachusetts 02115, United States
| | - Andrew Y. Chang
- Thayer
School of Engineering, Dartmouth, Hanover, New Hampshire 03755, United States
| | - Deeptak Verma
- Department
of Computer Science, Dartmouth, Hanover, New Hampshire 03755, United States
| | - Shin-Ichiro Miyashita
- Department
of Urology, Boston Children’s Hospital, Boston, Massachusetts 02115, United States
- Department
of Microbiology and Department of Surgery, Harvard Medical School, Boston, Massachusetts 02115, United States
- Department
of Food, Aroma and Cosmetic Chemistry, Tokyo
University of Agriculture, 196 Yasaka, Abashiri 099-2493, Japan
| | - Susan Eszterhas
- Thayer
School of Engineering, Dartmouth, Hanover, New Hampshire 03755, United States
| | - Pyung-Gang Lee
- Department
of Urology, Boston Children’s Hospital, Boston, Massachusetts 02115, United States
- Department
of Microbiology and Department of Surgery, Harvard Medical School, Boston, Massachusetts 02115, United States
| | - Yi Shen
- Department
of Urology, Boston Children’s Hospital, Boston, Massachusetts 02115, United States
- Department
of Microbiology and Department of Surgery, Harvard Medical School, Boston, Massachusetts 02115, United States
| | - Lydia R. Davis
- Thayer
School of Engineering, Dartmouth, Hanover, New Hampshire 03755, United States
| | - Min Dong
- Department
of Urology, Boston Children’s Hospital, Boston, Massachusetts 02115, United States
- Department
of Microbiology and Department of Surgery, Harvard Medical School, Boston, Massachusetts 02115, United States
| | - Chris Bailey-Kellogg
- Department
of Computer Science, Dartmouth, Hanover, New Hampshire 03755, United States
| | - Karl E. Griswold
- Thayer
School of Engineering, Dartmouth, Hanover, New Hampshire 03755, United States
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13
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Hong SO. Cosmetic Treatment Using Botulinum Toxin in the Oral and Maxillofacial Area: A Narrative Review of Esthetic Techniques. Toxins (Basel) 2023; 15:toxins15020082. [PMID: 36828397 PMCID: PMC9964918 DOI: 10.3390/toxins15020082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/13/2023] [Accepted: 01/15/2023] [Indexed: 01/18/2023] Open
Abstract
Botulinum toxin (BoNT) is an anaerobic rod-shaped-neurotoxin produced by Clostridium botulinum, that has both therapeutic and lethal applications. BoNT injection is the most popular cosmetic procedure worldwide with various applications. Patients with dynamic wrinkles in areas such as the glabella, forehead, peri-orbital lines, nasal rhytides, and perioral rhytides are indicated. Excessive contraction of muscles or hyperactivity of specific muscles such as bulky masseters, cobble stone chins, gummy smiles, asymmetric smiles, and depressed mouth corners can achieve esthetic results by targeting the precise muscles. Patients with hypertrophic submandibular glands and parotid glands can also benefit esthetically. There are several FDA-approved BoNTs (obabotuli-numtoxinA, abobotulinumtoxinA, incobotulinumtoxinA, letibotulinumtoxinA, prabotulinumtox-inA, daxibotulinumtoxinA, rimbotulinumtoxinB) and novel BoNTs on the market. This paper is a narrative review of the consensus statements of expert practitioners and various literature on the injection points and techniques, highlighting both the Asian and Caucasian population separately. This paper can serve as a practical illustrative guide and reference for optimal, safe injection areas and effective doses for application of BoNT in the face and oral and maxillofacial area. The history of BoNT indications, contraindications, and complications, and the merits of ultrasonography (US)-assisted injections are also discussed.
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Affiliation(s)
- Sung Ok Hong
- Department of Oral and Maxillofacial Surgery, Kyung Hee University College of Dentistry, Kyung Hee University Hospital at Gangdong, Seoul 05278, Republic of Korea
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14
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Shin DM, Lee J, Noh H, Jang D, Oh SJ, Park JH, Lee JH. A Double-Blind, Split-Face, Randomized Study on the Effects and Safety of Intradermal Injection of Botulinum Toxin A (Incobotulinum Toxin A) in the Cheek. Ann Dermatol 2022; 34:442-450. [PMID: 36478426 PMCID: PMC9763912 DOI: 10.5021/ad.21.316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 03/11/2022] [Accepted: 08/01/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Intradermal injection of botulinum toxin A (BTXA) is used for cosmetic purposes without strong evidence for clinical use, as opposed to intramuscular injection. OBJECTIVE To evaluate the efficacy and safety of intradermal injection of incobotulinum toxin A (iBTXA) in the cheeks. METHODS We conducted a study with 18 volunteers who received intradermal injection of iBTXA into one cheek and normal saline into the contralateral side as a control. Volunteers visited the clinic at weeks 2, 4, 8, and 12 after injection. At each visit, pores and wrinkles were evaluated by a facial analyzer, sebum secretion by a sebumeter, skin texture by both volunteers and clinicians, and wrinkles of the nasolabial fold were graded with photographic reviews. RESULTS There were no significant effects on the wrinkles of the infraorbital area and sebum secretion. However, there were significant improvements in the wrinkles of the nasolabial fold and skin texture on the iBTXA injected side. The effects on the wrinkles of the nasolabial fold lasted 12 weeks, and those on skin texture lasted 8 weeks. Improvement in the pore size was observed only at week 2. No serious adverse events were reported except one volunteer who complained of facial palsy after the injection of 30 units of iBTXA in one cheek. However, injection of 20 units of iBTXA in one cheek was not associated with any adverse events. CONCLUSION Intradermal injection of iBTXA, could provide clinical benefits for skin texture and wrinkles overcoming the skin prick effect without obvious side effects.
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Affiliation(s)
- Dong Min Shin
- Department of Dermatology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jongeun Lee
- Department of Dermatology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyungrye Noh
- Department of Dermatology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Donghwi Jang
- Department of Dermatology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Se Jin Oh
- Department of Dermatology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Hye Park
- Department of Dermatology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Hee Lee
- Department of Dermatology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Medical Device Management & Research, The Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University, Seoul, Korea
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15
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Safety Profile and Lack of Immunogenicity of IncobotulinumtoxinA in Pediatric Spasticity and Sialorrhea: A Pooled Analysis. Toxins (Basel) 2022; 14:toxins14090585. [PMID: 36136523 PMCID: PMC9505819 DOI: 10.3390/toxins14090585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/16/2022] [Accepted: 08/19/2022] [Indexed: 11/16/2022] Open
Abstract
IncobotulinumtoxinA, a pure botulinumtoxinA formulation, is free of accessory proteins. This analysis provides pooled safety data from phase 3 trials of children/adolescents (2–17 years), investigating incobotulinumtoxinA for the treatment of spasticity associated with cerebral palsy (at doses ≤20 U/kg (max. 500 U) per injection cycle (IC) for ≤6 ICs; three trials) or sialorrhea associated with neurologic disorders (at total doses of 20–75 U per IC for ≤4 ICs; one trial) for ≤96 weeks. Safety endpoints included the incidences of different types of treatment-emergent adverse events (TEAEs) and immunogenicity. IncobotulinumtoxinA dose groups were combined. Of 1159 patients (mean age 7.3 years, 60.4% males) treated with incobotulinumtoxinA, 3.9% experienced treatment-related TEAEs, with the most common being injection site reactions (1.3%) (both indications), muscular weakness (0.7%) (spasticity), and dysphagia (0.2%) (sialorrhea). Two patients (0.2%) experienced a treatment-related treatment-emergent serious adverse event, and 0.3% discontinued the study due to treatment-related TEAEs. No botulinumtoxinA-naïve patients developed neutralizing antibodies (NAbs) after incobotulinumtoxinA. All children/adolescents with known pre-treatment status and testing positive for Nabs at final visit (n = 7) were previously treated with a botulinumtoxinA other than incobotulinumtoxinA. IncobotulinumtoxinA was shown to be safe, with very few treatment-related TEAEs in a large, diverse cohort of children/adolescents with chronic conditions requiring long-term treatment and was without new NAb formation in treatment-naïve patients.
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16
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Zhang HL, Jin RJ, Guan L, Zhong DL, Li YX, Liu XB, Xiao QW, Xiao XL, Li J. Extracorporeal Shock Wave Therapy on Spasticity After Upper Motor Neuron Injury: A Systematic Review and Meta-analysis. Am J Phys Med Rehabil 2022; 101:615-623. [PMID: 35152251 PMCID: PMC9197142 DOI: 10.1097/phm.0000000000001977] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate the effectiveness and safety of extracorporeal shock wave therapy on spasticity after upper motor neuron injury. DESIGN Eight electronic databases were searched systematically from their inception to August 3, 2021, to provide robust evidence for the efficacy of extracorporeal shock wave therapy for spasticity and range of motion after upper motor neuron injury. Study screening, data extraction, risk of bias assessment, and evaluation of the certainty of evidence were performed independently by two independent reviewers. Data analysis was conducted using RevMan 5.3.5 and R 3.6.1 software. RESULTS Forty-two studies with 1973 patients who met the eligibility criteria were selected from articles published from 2010 to 2021, of which 34 were included in the meta-analysis. A comparison intervention revealed that extracorporeal shock wave therapy significantly decreased the Modified Ashworth Scale score and increased the passive range of motion of a joint. Regarding the safety of extracorporeal shock wave therapy, slightly adverse effects, such as skin injury, bone distortion, muscle numbness, pain, petechiae, and weakness, were reported in five studies. CONCLUSIONS Extracorporeal shock wave therapy may be an effective and safe treatment for spasticity after upper motor neuron injury. However, because of poor methodological qualities of the included studies and high heterogeneity, this conclusion warrants further investigation. TO CLAIM CME CREDITS Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME. CME OBJECTIVES Upon completion of this article, the reader should be able to: (1) Determine the impact of extracorporeal shock wave therapy on spasticity after upper motor neuron injury; (2) Describe the factors that affect the efficacy of extracorporeal shock wave therapy on spasticity; and (3) Discuss the mechanism of action of extracorporeal shock wave therapy on spasticity. LEVEL Advanced. ACCREDITATION The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
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17
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Byun J, Kwak S, Kwon JH, Shin M, Lee DK, Rhee CH, Kang WH, Oh JW, Cruz DJM. Comparative Pharmacodynamics of Three Different Botulinum Toxin Type A Preparations following Repeated Intramuscular Administration in Mice. Toxins (Basel) 2022; 14:toxins14060365. [PMID: 35737026 PMCID: PMC9227525 DOI: 10.3390/toxins14060365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 05/23/2022] [Accepted: 05/23/2022] [Indexed: 12/10/2022] Open
Abstract
Botulinum neurotoxin type A (BoNT/A) causes muscle paralysis by blocking cholinergic signaling at neuromuscular junctions and is widely used to temporarily correct spasticity-related disorders and deformities. The paralytic effects of BoNT/A are time-limited and require repeated injections at regular intervals to achieve long-term therapeutic benefits. Differences in the level and duration of effectivity among various BoNT/A products can be attributed to their unique manufacturing processes, formulation, and noninterchangeable potency units. Herein, we compared the pharmacodynamics of three BoNT/A formulations, i.e., Botox® (onabotulinumtoxinA), Xeomin® (incobotulinumtoxinA), and Coretox®, following repeated intramuscular (IM) injections in mice. Three IM injections of BoNT/A formulations (12 U/kg per dose), 12-weeks apart, were administered at the right gastrocnemius. Local paresis and chemodenervation efficacy were evaluated over 36 weeks using the digit abduction score (DAS) and compound muscle action potential (CMAP), respectively. One week after administration, all three BoNT/A formulations induced peak DAS and maximal reduction of CMAP amplitudes. Among the three BoNT/A formulations, only Coretox® afforded a significant increase in paretic effects and chemodenervation with a prolonged duration of action after repeated injections. These findings suggest that Coretox® may offer a better overall therapeutic performance in clinical settings.
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Affiliation(s)
- Jaeyoon Byun
- Medytox Gwanggyo R&D Center, 114 Central town-ro, Yeongtong-gu, Suwon-si 16506, Korea; (J.B.); (S.K.); (J.-H.K.); (M.S.); (D.-K.L.); (W.-h.K.)
- Department of Stem Cell and Regenerative Biotechnology, Konkuk University, 120 Neungdong-ro, Gwangjin-gu, Seoul 05029, Korea
| | - Seongsung Kwak
- Medytox Gwanggyo R&D Center, 114 Central town-ro, Yeongtong-gu, Suwon-si 16506, Korea; (J.B.); (S.K.); (J.-H.K.); (M.S.); (D.-K.L.); (W.-h.K.)
| | - Jin-Hee Kwon
- Medytox Gwanggyo R&D Center, 114 Central town-ro, Yeongtong-gu, Suwon-si 16506, Korea; (J.B.); (S.K.); (J.-H.K.); (M.S.); (D.-K.L.); (W.-h.K.)
| | - Minhee Shin
- Medytox Gwanggyo R&D Center, 114 Central town-ro, Yeongtong-gu, Suwon-si 16506, Korea; (J.B.); (S.K.); (J.-H.K.); (M.S.); (D.-K.L.); (W.-h.K.)
| | - Dong-Kyu Lee
- Medytox Gwanggyo R&D Center, 114 Central town-ro, Yeongtong-gu, Suwon-si 16506, Korea; (J.B.); (S.K.); (J.-H.K.); (M.S.); (D.-K.L.); (W.-h.K.)
| | - Chang-Hoon Rhee
- Medytox Osong R&D Center, 102 Osongsaengmyeong 4-ro, Osong-eup, Heungdeok-gu, Cheongju-si 28161, Korea;
| | - Won-ho Kang
- Medytox Gwanggyo R&D Center, 114 Central town-ro, Yeongtong-gu, Suwon-si 16506, Korea; (J.B.); (S.K.); (J.-H.K.); (M.S.); (D.-K.L.); (W.-h.K.)
| | - Jae-Wook Oh
- Department of Stem Cell and Regenerative Biotechnology, Konkuk University, 120 Neungdong-ro, Gwangjin-gu, Seoul 05029, Korea
- Correspondence: (J.-W.O.); (D.J.M.C.); Tel.: +82-2-2049-6271 (J.-W.O.); +82-31-8065-8254 (D.J.M.C.)
| | - Deu John M. Cruz
- Medytox Gwanggyo R&D Center, 114 Central town-ro, Yeongtong-gu, Suwon-si 16506, Korea; (J.B.); (S.K.); (J.-H.K.); (M.S.); (D.-K.L.); (W.-h.K.)
- Correspondence: (J.-W.O.); (D.J.M.C.); Tel.: +82-2-2049-6271 (J.-W.O.); +82-31-8065-8254 (D.J.M.C.)
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18
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Immunogenicity Associated with Aesthetic Botulinumtoxin A: A Survey of Asia-Pacific Physicians' Experiences and Recommendations. Plast Reconstr Surg Glob Open 2022; 10:e4217. [PMID: 35450268 PMCID: PMC9015201 DOI: 10.1097/gox.0000000000004217] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 01/31/2022] [Indexed: 12/27/2022]
Abstract
Background: Most botulinum toxin A (BoNT/A) products contain unnecessary bacterial components that increase the risk of developing neutralizing antibodies (nAbs). Reports of secondary nonresponse and treatment failures (STF) due to nAbs have accompanied a surge in new BoNT/A products. Methods: To formulate recommendations on managing toxin resistance, we reviewed the evidence on BoNT/A-associated immunogenicity and evaluated Asian physicians' current BoNT/A practices, knowledge, and real-world experiences, as provided by survey outcomes conducted with 128 Asian experts (regular botulinum toxin injectors). Results: Most doctors believe STF occurs, some patients exhibit partial symptoms, and impurities (eg, complexing proteins) in BoNT/A preparations risk STF. Bioassays that distinguish non-nAbs from nAbs that hinder toxin function remain unavailable to most doctors, though most would perform testing if given the option. Doctors in the Asia-Pacific region have differing strategies for managing STF, depending on the availability of alternatives or tests. They recommended switching to a highly-purified formulation free of complexing proteins and other impurities to lower the risk of immunogenicity, or offering treatment holidays of 2 -2.5 years. They suggested restarting treatment with the same highly purified formulation, especially for repeated treatments, large-dose injections, and younger patients who will accumulate higher lifetime doses, so as to minimize immunogenic risks and preserve long-term treatment outcomes. Importantly, doctors should always initiate patients on pure formulations rather than switching to these only after resistance develops. Conclusion: Choosing highly purified BoNT/A products at treatment initiation enhances long-term efficacy and patient satisfaction while minimizing the risk of immune activation and nAb formation.
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19
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Abstract
Botulinum toxin treatment is the most common non-surgical cosmetic treatment. Although there are many available treatments using botulinum toxin, their effects are temporary and repeated injections are required. These frequent injections can trigger an immunological response. In addition, botulinum toxin acts as an antigen in the body; thus, its effect disappears progressively due to this immunological reaction, which may cause treatment failure. Active botulinum toxin consists of a core neurotoxin and complexing proteins, the exact effects of which remain unclear. However, the complexing proteins are closely related to the immune response and the formation of neutralizing antibodies. Since neutralizing antibodies can lead to treatment failure, their formation should be prevented. Furthermore, various methods of detecting neutralizing antibodies have been used to predict treatment failure.
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20
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Masakado Y, Dekundy A, Tateishi S, Kaji R. IncobotulinumtoxinA for Post-stroke Upper Limb Spasticity in Neutralizing Antibody-positive Patients after Botulinum Toxin Therapy: A Report of Two Cases. Prog Rehabil Med 2022; 7:20220012. [PMID: 35342835 PMCID: PMC8898682 DOI: 10.2490/prm.20220012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 01/27/2022] [Indexed: 11/29/2022] Open
Abstract
Background: Botulinum toxin type A is an effective treatment widely used to address post-stroke spasticity. Long-term repeated treatment with botulinum toxin type A may result in reduced efficacy due to the induction of neutralizing antibodies. Based on data from a phase 3 study of incobotulinumtoxinA for post-stroke upper limb spasticity, we describe the therapeutic response to botulinum toxin type A treatment in two neutralizing antibody-positive patients previously treated with other preparations of botulinum toxin type A. Case: Two patients (a 65-year-old woman and a 36-year-old woman) with post-stroke upper limb spasticity were previously treated with onabotulinumtoxinA, and neutralizing antibodies were detected in their sera at baseline using the mouse hemidiaphragm assay. After onabotulinumtoxinA had been discontinued for at least 16 weeks, incobotulinumtoxinA (400 U) was administered in three or four injection cycles. Good therapeutic responses, manifested by a reduction of 1–2 points on the modified Ashworth scale, were noted after each injection. The patients’ sera remained positive for neutralizing antibodies throughout the incobotulinumtoxinA treatment period. Discussion: These patients, who were previously treated with onabotulinumtoxinA and were neutralizing antibody positive throughout the clinical study period, showed stable therapeutic responses following incobotulinumtoxinA treatment. IncobotulinumtoxinA could be initiated for patients with neutralizing antibodies induced by onabotulinumtoxinA.
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Affiliation(s)
- Yoshihisa Masakado
- Department of Rehabilitation Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Andrzej Dekundy
- Global Clinical Development Therapeutics, Merz Pharmaceuticals GmbH, Frankfurt am Main, Germany
| | - Shohei Tateishi
- Pharmaceutical Development Administration Department, Teijin Pharma Limited, Tokyo, Japan
| | - Ryuji Kaji
- Department of Clinical Neuroscience, Tokushima University, Tokushima, Japan
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21
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Grenda T, Grenda A, Krawczyk P, Kwiatek K. Botulinum toxin in cancer therapy-current perspectives and limitations. Appl Microbiol Biotechnol 2021; 106:485-495. [PMID: 34951660 PMCID: PMC8763801 DOI: 10.1007/s00253-021-11741-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 12/06/2021] [Accepted: 12/12/2021] [Indexed: 11/25/2022]
Abstract
Abstract Different serotypes of botulinum toxins (BoNTs) act upon different types of SNARE proteins. This property is used in aesthetic medicine to treat certain eye disorders such as crossed eyes (strabismus) and uncontrolled blinking (blepharospasm), to treat muscle spasms or movement disorders, and, for the two last decades, more and more often, to provide support in cancer therapy, especially so as to obtain analgesic effects upon spastic conditions. The limited literature data also suggests that the addition of BoNTs to the culture of cancer cell lines reduces cell growth, and mitotic activity, and promotes their apoptosis. BoNTs have several advantages that can be emphasized: BoNTs act on both perfusion and oxygenation; moreover, BoNTs are considered to be safe and free of systemic side effects upon administration. Recently, advances in molecular biology techniques have allowed a wide variety of novel BoNT constructs with alternative functions. These constructs could be assessed as potential new classes of anti-cancer drugs. This creates new potential perspectives in the wider use of non-toxic modified BoNT constructs in cancer therapy. In the light of the mentioned premises and existing literature reports, the aim of this review is to summarize current data and reports considering BoNT use in cancer therapy. Key points •Botulinum toxin (BoNTs) may be useful in cancer treatment. •Botulinum toxin can serve as an analgesic after cancer radiotherapy. •Botulinum toxin has the ability to inhibit tumor growth and promote apoptosis of neoplastic cells.
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Affiliation(s)
- Tomasz Grenda
- Department of Hygiene of Animal Feeding Stuffs, National Veterinary Research Institute, Partyzantow Avenue 57, 24-100, Pulawy, Poland.
| | - Anna Grenda
- Department of Pneumology, Oncology and Allergology, Medical University of Lublin, Jaczewskiego 8, 20-954, Lublin, Poland.
| | - Paweł Krawczyk
- Department of Pneumology, Oncology and Allergology, Medical University of Lublin, Jaczewskiego 8, 20-954, Lublin, Poland
| | - Krzysztof Kwiatek
- Department of Hygiene of Animal Feeding Stuffs, National Veterinary Research Institute, Partyzantow Avenue 57, 24-100, Pulawy, Poland
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22
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Czyz CN, Burns JA, Bergstrom RE. Antibody Development in Patients Treated Long-Term With OnabotulinumtoxinA for Benign Essential Blepharospasm and Hemifacial Spasm. J Neuroophthalmol 2021; 41:e684-e687. [PMID: 33470741 DOI: 10.1097/wno.0000000000001171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Report the development of onabotulinumtoxinA neutralizing antibodies in patients treated consecutively for 20 years or longer for benign essential blepharospasm (BEB), hemifacial spasm (HFS), and Meige Syndrome. METHODS Prospective, randomized, cross-sectional study of 12 randomly selected patients from a single clinical practice that have been treated consecutively for 20 or more years with onabotulinumtoxinA for BEB, HFS, or Meige Syndrome. Serum samples were collected from each subject and analyzed for neutralizing antibody formation using the Mouse Protection Assay. RESULTS None of the tested patients (0%) displayed neutralizing antibodies to onabotulinumtoxinA. The mean duration of treatment was 27.5 years (range 22.1-34.1, SD 3.1, 95% confidence interval 25.45-29.50). Nine of the patients had a diagnosis of BEB, 2 HFS, and one Meige. Eleven of the 12 patients were women. There was no statistically significant difference in treatment dosage or interval over the course of treatment. CONCLUSIONS The data support previous studies showing low incidence of antibody formation for botulinum A toxins with this subset of long-term treated patients. The results also provide further evidence for studies that have suggested increased onabotulinumtoxinA treatment volumes and/or decreased intervals between treatments are not due to neutralizing antibody formation and secondary non-response, but rather study designs that do not consider the titration phase of initial treatments. This study is specific to long-term treated patients, and the results cannot be generalized to patients naive to treatment.
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Affiliation(s)
- Craig N Czyz
- Division of Ophthalmology (CNC, RB), Section Oculofacial Plastic and Reconstructive Surgery, Ohio University/Ohio Health Doctor's Hospital, Columbus, Ohio; and Department of Ophthalmology (CNC, JAB), Oral and Maxillofacial Surgery, Grant Medical Center, Columbus, Ohio
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23
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Miguel C, Cirera A. Retrospective study of the clinical effect of incobotulinumtoxinA for the management of myofascial pain syndrome in refractory patients. Toxicon 2021; 203:117-120. [PMID: 34600908 DOI: 10.1016/j.toxicon.2021.09.022] [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: 06/03/2021] [Revised: 09/15/2021] [Accepted: 09/23/2021] [Indexed: 10/20/2022]
Abstract
The aim was to evaluate the effectiveness and safety of IncobotulinumtoxinA (IncoA) for the management of myofascial pain syndrome (MPS) in refractory patients. This single-center, observational, retrospective study includes 37 patients. The pain reduction was 4.7 points (95%CI: 5.6 to -3.8) from baseline to one-month post-injection (using a 10-point visual analogue scale). Only 18.9% experienced mild adverse events. In conclusion, IncoA is an effective and safe alternative for the treatment of MPS in refractory patients.
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Affiliation(s)
- Carolina Miguel
- Physical Medicine and Rehabilitation Department, Hospital de La Vega Lorenzo Guirao, Vereda de Morcillo, S/n, 30530, Cieza, Murcia, Spain.
| | - Alejandra Cirera
- Physical Medicine and Rehabilitation Department, Hospital de La Vega Lorenzo Guirao, Vereda de Morcillo, S/n, 30530, Cieza, Murcia, Spain.
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Immunogenicity of Botulinum Toxin Formulations: Potential Therapeutic Implications. Adv Ther 2021; 38:5046-5064. [PMID: 34515975 PMCID: PMC8478757 DOI: 10.1007/s12325-021-01882-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 08/02/2021] [Indexed: 12/21/2022]
Abstract
Botulinum neurotoxins (BoNTs) are proteins produced by bacteria of the Clostridium family. Upon oral ingestion, BoNT causes the neuroparalytic syndrome botulism. There are seven serotypes of BoNT (serotypes A-G); BoNT-A and BoNT-B are the botulinum toxin serotypes utilized for therapeutic applications. Treatment with BoNT injections is used to manage chronic medical conditions across multiple indications. As with other biologic drugs, immunogenicity after long-term treatment with BoNT formulations may occur, and repeated use can elicit antibody formation leading to clinical nonresponsiveness. Thus, approaching BoNT treatment of chronic conditions with therapeutic formulations that minimize stimulating the host immune response while balancing patient responsiveness to therapy is ideal. Immunogenicity is a clinical limitation in many settings that use biologic drugs for treatment, and clinically relevant immunogenicity reduction has been achieved through engineering smaller protein constructs and reducing unnecessary formulation components. A similar approach has influenced the evolution of BoNT formulations. Three BoNT-A products and one BoNT-B product have been approved by the Food and Drug Administration (FDA) for therapeutic use: onabotulinumtoxinA, abobotulinumtoxinA, incobotulinumtoxinA, and rimabotulinumtoxinB; a fourth BoNT-A product, daxibotulinumtoxinA, is currently under regulatory review. Additionally, prabotulinumtoxinA is a BoNT-A product that has been approved for aesthetic indications but not therapeutic use. Here, we discuss the preclinical and clinical immunogenicity data that exist within the scientific literature and provide a perspective for considering immunogenicity as a key factor in choice of BoNT formulation.
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The Efficacy and Safety of Botulinum Toxin Injections in Preventing Postoperative Scars and Improving Scar Quality: A Systematic Review and Meta-Analysis. Aesthetic Plast Surg 2021; 45:2350-2362. [PMID: 33674930 DOI: 10.1007/s00266-021-02196-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 02/15/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND Scars exposed on the body surface lead to a large psychological burden on patients. However, no satisfactory scar treatments exist. Botulinum toxin type A is a neurotoxin that has been widely applied in the plastic and cosmetic surgery field. The purpose of this meta-analysis was to assess the efficacy and safety of botulinum toxin in scar management. METHODS PubMed, the Cochrane Library, EMBASE, MEDLINE, and Web of Science were searched for randomized controlled trials that evaluated the efficacy of botulinum toxin injections in preventing postoperative scars and improving scars quality and were published prior to Dec. 29, 2020. The outcome indicators were the visual analog scale score, Vancouver scar scale score, Stony Brook scar evaluation scales score, scar width, patient self-assessment results, and complications. RESULTS Seventeen randomized controlled trials with a total of 633 cases were identified in this meta-analysis. The quantitative synthesis results showed that compared with the control group, the botulinum toxin group had a significantly lower VSS score (MD = -0.97, 95%CI = -1.56 to -0.39, p = 0.001), higher VAS score (MD = 1.26, 95%CI = 1.04 to 1.47, p < 0.00001), thinner scar width (MD = -0.25, 95%CI = -0.37 to -0.12, p < 0.0001) and higher patient satisfaction (RR = 3.38 95%CI = 1.45 to 7.89, p = 0.005). There were no significant differences between the two groups in the number of adverse events. CONCLUSIONS This meta-analysis demonstrated that botulinum toxin injections can significantly improve cosmetic appearance and postoperative scar quality. At the therapeutic dose, no significant complications were observed, indicating that botulinum toxin injections are safe. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Lai KKH, Tsang A, Kuk AKT, Ko CKL, Chan E, Ko STC. A Review of Tolerance and Safety Profiles of Long-Term Botulinum Neurotoxin Type A in Asian Patients with Hemifacial Spasm and Benign Essential Blepharospasm. Neuroophthalmology 2021; 45:293-300. [PMID: 34566211 DOI: 10.1080/01658107.2021.1916043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
This article reports the tolerance and long-term safety profiles of botulinum neurotoxin type A among Asian patients with benign essential blepharospasm (BEB) and hemifacial spasm (HFS). We performed a retrospective review of clinical documents and procedure records of consecutive BEB and HFS patients receiving onabotulinum toxin A (Botox) treatment in our clinic over the past 20 years. We reviewed the information of 105 patients diagnosed with BEB (n = 31) and HFS (n = 74). All of the patients were Asian. The mean age of disease onset was 59 (range 37-80) years old for BEB and 61 (range 31-83) for HFS. The mean follow up was 84 (range 12-240) months and the mean number of sessions per patient was 19 (range 1-61). The botulinum toxin dose per session increased significantly in both BEB (16.5 versus 21.6 units, p < .05) and HFS (22.6 versus 26.9 units, p < .05) patients after a mean of 18 sessions; however, the onset time, effective duration and subjective treatment outcome were similar over time in both BEB and HFS patients. At least one local complication was reported among 26% and 41% of patients with BEB and HFS respectively, with ptosis (32%) being most frequent.
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Affiliation(s)
- Kenneth Ka Hei Lai
- Department of Ophthalmology, Tung Wah Eastern Hospital, Hong Kong, China
| | - Alan Tsang
- Department of Ophthalmology, Tung Wah Eastern Hospital, Hong Kong, China
| | - Andrew K T Kuk
- Department of Ophthalmology, Tung Wah Eastern Hospital, Hong Kong, China
| | - Callie K L Ko
- Department of Ophthalmology, Tung Wah Eastern Hospital, Hong Kong, China
| | - Edwin Chan
- Department of Ophthalmology, Tung Wah Eastern Hospital, Hong Kong, China
| | - Simon T C Ko
- Department of Ophthalmology, Tung Wah Eastern Hospital, Hong Kong, China
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Fabi SG, Carruthers J, Joseph J, Cox SE, Yoelin S, Few J, Kaufman-Janette J, Dayan S. High-Dose Neuromodulators: A Roundtable on Making Sense of the Data in Real-World Clinical Practice. Aesthet Surg J Open Forum 2021; 3:ojab036. [PMID: 34708202 PMCID: PMC8545706 DOI: 10.1093/asjof/ojab036] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND For aesthetic treatment with botulinum neurotoxin type A (BoNTA), interest in maximizing treatment duration and efficacy has prompted study of doses higher than those used in registration studies. As data emerge, it is important that physicians understand how to apply study findings to their own practice so that patient demand is satisfied. OBJECTIVES To bring together leading experts in neuromodulators for a roundtable discussion on the implications of high-dose BoNTA studies for patient care. METHODS The authors reviewed and discussed recent data from high-dose BoNTA studies for abobotulinum toxin A, incobotulinum toxin A, and Oonobotulinumtoxin A. RESULTS Discussion focused on the challenges of data interpretation and extrapolation of study findings for real-world patient care. The authors participated in a candid discussion of whether the observed improvements in treatment duration and patient satisfaction warrant treatment with high-dose regimens delivered as high-concentration injections. Safety was also discussed, as well as economic considerations for both practices and patients. Of note, for BoNTA products, the registration dose, when administered in a smaller total volume, appears to give rise to more durable results than those observed in pivotal trials, implicating product concentration as an important consideration. Importantly, at higher doses, extended duration of effect does not appear to be at the expense of natural-looking results. CONCLUSIONS While the authors provide considerations for the development of individual clinical practice, there is no one-size-fits-all recommendation. It may be that "high-dose" BoNTA is in reality the optimal dose; however, important economic considerations may prevent rapid uptake for all patients.
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Affiliation(s)
- Sabrina Guillen Fabi
- Corresponding Author: Dr Sabrina Guillen Fabi, 9339 Genesee Ave Unit 300, San Diego, CA 92121, USA. E-mail:
| | - Jean Carruthers
- Department of Ophthalmology, University of British Columbia, Vancouver, BC, Canada
| | - John Joseph
- Clinical Testing of Beverly Hills, Encino, CA, USA
| | | | | | | | | | - Steven Dayan
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, University of Illinois at Chicago, Chicago, IL, USA
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Bekkers S, Leow TYS, Van Hulst K, Orriëns LB, Scheffer ART, Van Den Hoogen FJA. Repeated onabotulinum neurotoxin A injections for drooling in children with neurodisability. Dev Med Child Neurol 2021; 63:991-997. [PMID: 33772779 PMCID: PMC8359949 DOI: 10.1111/dmcn.14872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2021] [Indexed: 11/28/2022]
Abstract
AIM To evaluate the effect of repeated onabotulinum neurotoxin A injections for the treatment of drooling in children with neurodisabilities. METHOD This was a retrospective cohort study, in which the first, second, and third onabotulinum neurotoxin A injection were compared within children treated between 2000 and 2020. Primary outcomes included drooling quotient, visual analogue scale (VAS), and treatment success defined as ≥50% reduction in drooling quotient and/or VAS 8 weeks after treatment. Each outcome was obtained at baseline and 8 weeks posttreatment. RESULTS Seventy-seven children were included (mean age at first injection: 8y 3mo, SD 3y 7mo, range 3-17y; 44 males, 33 females; 51.9% with cerebral palsy, 45.5% wheelchair-bound). The objective (drooling quotient) and subjective (VAS) effect after the second injection was lower compared to the first injection. The third injection showed less objective and significantly less subjective effect compared to the first injection. An overall success rate of 74.0%, 41.6%, and 45.8% were found for the first, second, and third injection respectively. INTERPRETATION Although onabotulinum neurotoxin A remained effective throughout the entire treatment course, there is less effect of subsequent onabotulinum neurotoxin A injections compared to the first. Although there might be a loss of effect after repeated injections, there is continued improvement for most children. What this paper adds Repeated injections show a diminished treatment effect after the second injection. A continued improvement is seen in most patients.
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Affiliation(s)
- Stijn Bekkers
- Department of Otorhinolaryngology and Head and Neck SurgeryRadboud Institute for Health SciencesNijmegenthe Netherlands
| | - Theresa YS Leow
- Department of Otorhinolaryngology and Head and Neck SurgeryRadboud Institute for Health SciencesNijmegenthe Netherlands
| | - Karen Van Hulst
- Department of RehabilitationRadboud University Medical CenterDonders Institute for Brain, Cognition and BehaviourNijmegenthe Netherlands
| | - Lynn B Orriëns
- Department of RehabilitationRadboud University Medical CenterDonders Institute for Brain, Cognition and BehaviourNijmegenthe Netherlands
| | - Arthur RT Scheffer
- Department of Otorhinolaryngology and Head and Neck SurgeryRadboud Institute for Health SciencesNijmegenthe Netherlands
| | - Frank JA Van Den Hoogen
- Department of Otorhinolaryngology and Head and Neck SurgeryRadboud Institute for Health SciencesNijmegenthe Netherlands
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Sensitive assay design for detection of anti-drug antibodies to biotherapeutics that lack an immunoglobulin Fc domain. Sci Rep 2021; 11:15467. [PMID: 34326436 PMCID: PMC8322160 DOI: 10.1038/s41598-021-95055-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 07/20/2021] [Indexed: 12/13/2022] Open
Abstract
Today the evaluation of unwanted immunogenicity is a key component in the clinical safety evaluation of new biotherapeutic drugs and macromolecular delivery strategies. However, the evolving structural complexity in contemporary biotherapeutics creates a need for on-going innovation in assay designs for reliable detection of anti-drug antibodies, especially for biotherapeutics that may not be well-suited for testing by a bridging assay. We, therefore, initiated systematic optimization of the direct binding assay to adapt it for routine use in regulatory-compliant assays of serum anti-drug antibodies. Accordingly, we first prepared a SULFO-TAG labeled conjugate of recombinant Protein-A/G to create a sensitive electrochemiluminescent secondary detection reagent with broad reactivity to antibodies across many species. Secondly, we evaluated candidate blocker-diluents to identify ones producing the highest signal-to-noise response ratios. Lastly, we introduced use of the ratio of signal responses in biotherapeutic-coated and uncoated wells as a data transformation strategy to identify biological outliers. This alternative data normalization approach improved normality, reduced skewness, and facilitated application of a parametric screening cut point. We believe the optimized direct binding assay design employing SULFO-TAG labeled Protein-A/G represents a useful analytical design for detecting serum ADA to biotherapeutics that lack an immunoglobulin Fc domain.
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Patil A, Kassir M, Wollina U, Goldust M. [New botulinum toxins for aesthetic dermatology : A comprehensive review]. Hautarzt 2021; 72:393-402. [PMID: 33822278 DOI: 10.1007/s00105-021-04801-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2021] [Indexed: 10/21/2022]
Abstract
Facial rejuvenation is gaining immense popularity among patients and clinicians. Botulinum toxins derived from bacteria are well-tolerated options as minimally invasive interventions for facial rejuvenation or other aesthetic procedures. These products have revolutionized aesthetic treatments. Several types of botulinum toxins (BoNT) are available. Currently type A and B are clinically used and only BoNT‑A products are approved for use for cosmetic indications in the Germany and the United States. Each product is unique in terms of its composition. Understanding the various BoNT‑A products is essential in choosing the optimal treatment for our patients. In this article we discuss different BoNT‑A products used for aesthetic intervention.
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Affiliation(s)
- A Patil
- Department of Pharmacology, Dr DY Patil Medical College, Navi Mumbai, India
| | - M Kassir
- Worldwide Laser Institute, Dallas, USA
| | - U Wollina
- Klinik für Dermatologie und Allergologie, Städtisches Klinikum Dresden, Dresden, Deutschland
| | - M Goldust
- Universitäts-Hautklinik, University Medical Center Mainz, Johannes Gutenberg-Universität, Langenbeckstr.1, 55131, Mainz, Deutschland.
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Vachiramon V, Subpayasarn U, Triyangkulsri K, Jurairattanaporn N, Rattananukrom T. Different injection patterns of incobotulinumtoxinA for crow's feet: a split-face comparative study. J Eur Acad Dermatol Venereol 2020; 35:256-262. [PMID: 33068445 DOI: 10.1111/jdv.16997] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 10/05/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND IncobotulinumtoxinA has been previously used for the treatment of lateral periorbital lines (crow's feet). However, a standardized injection technique has not been established. OBJECTIVES To compare the efficacy and effect duration of two injection techniques of incobotulinumtoxinA for crow's feet treatment. METHODS Forty-eight patients with crow's feet were recruited and randomly assigned to receive bilateral treatments using either a 3-point intramuscular or a 6-point intradermal injection technique (8-12 units of incobotulinumtoxinA on each side). Improvement was assessed at 1, 2, 4, 8, 12, 16, 20 and 24 weeks postinjection. An objective evaluation was assessed by the indentation index using a 3D camera and a subjective evaluation was assessed by a blinded dermatologist using the Flynn validated assessment scale (FVAS) for the upper face. The patients assessed the results using the Global Aesthetic Improvement Scale (GAIS). Side-effects were evaluated at each visit. RESULTS After treatment, a significantly greater reduction in the indentation index of periorbital wrinkles on the 3-point intramuscular injection side compared with the 6-point intradermal injection side was observed at 8, 12, and 16 weeks. The results from the FVAS and GAIS scores showed significantly longer median times to relapse of the periorbital wrinkle for the 3-point intramuscular injection compared with the 6-point intradermal injection. Pain and bruising were slightly greater with the 6-point intradermal technique. CONCLUSIONS This study reaffirmed the efficacy of incobotulinumtoxinA for the treatment of crow's feet. The 3-point intramuscular injection technique yielded greater efficacy and longer duration of action than the 6-point intradermal injection technique.
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Affiliation(s)
- V Vachiramon
- Division of Dermatology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - U Subpayasarn
- Division of Dermatology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - K Triyangkulsri
- Division of Dermatology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - N Jurairattanaporn
- Division of Dermatology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - T Rattananukrom
- Division of Dermatology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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McLean T, Norbury L, Conduit R, Shepherd N, Coloe P, Sasse A, Smooker P. Inactivated tetanus as an immunological smokescreen: A major step towards harnessing tetanus-based therapeutics. Mol Immunol 2020; 127:164-174. [PMID: 33002728 DOI: 10.1016/j.molimm.2020.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/01/2020] [Accepted: 09/08/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND PURPOSE Tetanus neurotoxin has many potential therapeutic applications, due to its ability to increase localised muscle tone when injected directly into a muscle. It is a closely related molecule to botulinum neurotoxin (most commonly known as Botox), which has been widely used to release muscle tension for therapeutic and cosmetic applications. However, tetanus toxin has been relegated to the "maybe pile" for protein therapeutics - as most of the population is vaccinated, leading to highly effective antibody-mediated protection against the toxin. The potential for tetanus-based therapeutics remains substantial if the problem of pre-existing immunity can be resolved. EXPERIMENTAL APPROACH A well-established murine model of localised muscular contraction was utilised. We administered functional tetanus toxin combined with an immunogenic, but functionally inactive, decoy molecule. KEY RESULTS Incorporation of the decoy molecule greatly reduces the dose of active toxin required to induce a localised increase in muscle tone in mice vaccinated with the human toxoid vaccine. CONCLUSION AND IMPLICATIONS Our results clearly demonstrate that the barriers to developing a tetanus toxin therapeutic are not insurmountable and the technology presented here is the first major step towards realising the therapeutic potential of this powerful neurotoxin. Opening the therapeutic potential of tetanus toxin will have huge implications for the wide range of diseases caused by low-tone muscle.
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Affiliation(s)
- Thomas McLean
- Bioscience and Food Technology, School of Science, Plenty Road, Building 223 Bundoora West campus, RMIT University, Bundoora, VIC 3083, Australia.
| | - Luke Norbury
- Bioscience and Food Technology, School of Science, Plenty Road, Building 223 Bundoora West campus, RMIT University, Bundoora, VIC 3083, Australia.
| | - Russell Conduit
- School of Health and Biomedical Sciences, College of Science, Engineering and Health, RMIT University, Bundoora, VIC 3083, Australia.
| | - Natalie Shepherd
- Bioscience and Food Technology, School of Science, Plenty Road, Building 223 Bundoora West campus, RMIT University, Bundoora, VIC 3083, Australia
| | - Peter Coloe
- Bioscience and Food Technology, School of Science, Plenty Road, Building 223 Bundoora West campus, RMIT University, Bundoora, VIC 3083, Australia.
| | - Anthony Sasse
- Bioscience and Food Technology, School of Science, Plenty Road, Building 223 Bundoora West campus, RMIT University, Bundoora, VIC 3083, Australia; Latrobe Regional Hospital, Gippsland, Australia.
| | - Peter Smooker
- Bioscience and Food Technology, School of Science, Plenty Road, Building 223 Bundoora West campus, RMIT University, Bundoora, VIC 3083, Australia.
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Esquenazi A, Delgado MR, Hauser RA, Picaut P, Foster K, Lysandropoulos A, Gracies JM. Duration of Symptom Relief Between Injections for AbobotulinumtoxinA (Dysport®) in Spastic Paresis and Cervical Dystonia: Comparison of Evidence From Clinical Studies. Front Neurol 2020; 11:576117. [PMID: 33101184 PMCID: PMC7546809 DOI: 10.3389/fneur.2020.576117] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 08/12/2020] [Indexed: 12/20/2022] Open
Abstract
Background: Botulinum toxin-A is a well-established treatment for adult and pediatric spastic paresis and cervical dystonia. While guidelines and approved labels indicate that treatment should not occur more frequently than every 12 weeks, studies and real-world evidence show that the timing of symptom recurrence between treatments may vary. Methods: We report retreatment criteria and response duration (retreatment intervals) from four pivotal, double-blind, placebo-controlled studies with open-label extensions involving patients treated with abobotulinumtoxinA (aboBoNTA) for upper limb (NCT01313299) or lower limb (NCT01249404) spastic paresis in adults, lower limb spastic paresis in children (NCT01249417), and cervical dystonia in adults (NCT00257660). We review results in light of recently available preclinical data. Results: In spastic paresis, 24.0-36.9% of upper limb patients treated with aboBoNTA and 20.1-32.0% of lower limb patients did not require retreatment before 16 weeks. Moreover, 72.8-93.8% of aboBoNTA-treated pediatric patients with lower limb spastic paresis did not require retreatment before 16 weeks (17.7-54.0% did not require retreatment before 28 weeks). In aboBoNTA-treated patients with cervical dystonia, 72.6-81.5% did not require retreatment before 16 weeks. Conclusion: AboBoNTA, when dosed as recommended, offers symptom relief beyond 12 weeks to many patients with spastic paresis and cervical dystonia. From recently available preclinical research, the amount of active neurotoxin administered with aboBoNTA might be a factor in explaining this long duration of response.
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Affiliation(s)
- Alberto Esquenazi
- Department of Physical Medicine and Rehabilitation, MossRehab Gait and Motion Analysis Laboratory, Elkins Park, PA, United States
| | - Mauricio R Delgado
- Neurology and Neurotherapeutics Department, University of Texas Southwestern Medical Center and Scottish Rite Hospital for Children, Dallas, TX, United States
| | - Robert A Hauser
- University of South Florida Parkinson's Disease and Movement Disorders Center of Excellence, Tampa, FL, United States
| | | | | | | | - Jean-Michel Gracies
- UR 7377, Université Paris-Est Créteil, Service de Rééducation Neurolocomotrice, Albert Chenevier-Henri Mondor Hospital, Créteil, France
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Srinoulprasert Y, Wanitphakdeedecha R. Antibody-induced botulinum toxin treatment failure: A review and novel management approach. J Cosmet Dermatol 2020; 19:2491-2496. [PMID: 32702171 DOI: 10.1111/jocd.13637] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/19/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Botulinum neurotoxin A (BoNT/A) has been used for cosmetic indications for many decades. Consumption of BoNT/A usage has been markedly increased for a few years. Even new formulations of BoNT/A to decrease immunogenicity have been released, repeated treatment to maintain efficacy outcome is inevitable and could finally provoke immune response. In the past, prevalence of botulinum treatment failure (BTF) in cosmetic indication was rare leading to less medical concern. Current decade, case reports on BTF, especially antibody-induced botulinum toxin treatment failure (ABTF), have been increasingly revealed and risk factors associated with ABTF have been intensively studied. AIMS In this article, we will review antibody-induced botulinum toxin treatment failure (ABTF), risk-associated ABTF, prevalence and recent case reports of ABTF, and new approach to deal with ABTF. METHODS Literature search was conducted using PubMed. The relevant literatures published between January 2000 and May 2020 concerning BTF and ABTF including investigation for ABTF were included and analyzed. RESULTS Possible causes of BTF were summarized. ABTF could be a tip of iceberg of BTF, its prevalence, and currently, 10-year case reports of ABTF were published evidence. Risk factors and investigation methods for ABTF were also summarized. Based on previous studies and our experience, novel approach to management of ABTF was described. CONCLUSION Effective management of BTF is to explore causes of treatment failure. Antibodies against BoNT/A complex could be one of many possibilities. Laboratory in vitro tests could be alternative tools to decrease adverse effect and rebooting immune responses in BTF patients.
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Affiliation(s)
- Yuttana Srinoulprasert
- Department of Immunology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Chao YYY, Tseng FW, Yang YL, Chen YH, Hsu NJ, Chang LY. IncobotulinumtoxinA for the Treatment of Glabellar Frown Lines: A Prospective, Multicenter, Single-arm Study in Taiwan. THE JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY 2019; 12:E53-E57. [PMID: 32038766 PMCID: PMC7002052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Objective: We assessed clinical effectiveness, longevity of treatment effects, and patient satisfaction with incobotulinumtoxinA for glabellar frown lines (GFL) treatment in Asian patients. Design, Setting, and Participants: This was a prospective, multicenter, single-arm, open-label study at six sites in Taiwan. Patients aged 20 to 65 years with mild to very severe GFLs (Merz scale: 1-4 points) were eligible; 45 patients [including 23 BoNT/A-naïve and 22 previously-treated ("switch") patients were enrolled. Patients received intramuscular incobotulinumtoxinA injection at up to five injection points. Total doses ranged from 12 to 20U. Measurements: Investigators assessed improvements in dynamic GFLs at Days 14 and 120 using the validated five-point Merz scale (0=no lines; 4=very severe lines). Treatment satisfaction was self-reported by patients via questionnaire. Results: All patients showed excellent response to treatment in that Merz scores at Day 14 were 0 or 1 point(s). Both groups showed a mean improvement of 2.9 points; the response rate (1-point improvement or more from baseline) was 100 percent. GFL improvement was maintained over at least four months in both groups (mean improvements at Day 120: 1.5 points, naïve; 1.7 points, switch). Patient satisfaction ratings remained high (almost 100% in both groups) throughout the study. There were no statistically significant differences between groups regarding treatment satisfaction or GFL improvement (Merz score) at Days 14 and 120. No adverse events occurred. Conclusion: In Asian patients, incobotulinumtoxinA treatment for dynamic GFLs is effective and long lasting, with no expected differences between BoNT/A-naïve patients and those switching from other BoNT/As. IncobotulinumtoxinA yields consistent and natural-looking results for first and subsequent treatments.
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Affiliation(s)
- Yates Yen-Yu Chao
- Dr. Chao is with the CHAO Institute of Aesthetic Medicine in Taipei, Taiwan
- Dr. Tseng is with the Milano Aesthetic Clinic in Taipei, Taiwan
- Dr. Yang is with the MED Aesthetic Clinic in Kaohsiung, Taiwan
- Dr. Chen is with the YaSkin Dermatology Clinic in Kaohsiung, Taiwan
- Dr. Hsu is with the Nai Jen Hsu Dermatology Clinic in Tainan, Taiwan
- Dr. Chang is with Liyen's Clinic of Plastic Surgery in Taichung, Taiwan
| | - Fang-Wen Tseng
- Dr. Chao is with the CHAO Institute of Aesthetic Medicine in Taipei, Taiwan
- Dr. Tseng is with the Milano Aesthetic Clinic in Taipei, Taiwan
- Dr. Yang is with the MED Aesthetic Clinic in Kaohsiung, Taiwan
- Dr. Chen is with the YaSkin Dermatology Clinic in Kaohsiung, Taiwan
- Dr. Hsu is with the Nai Jen Hsu Dermatology Clinic in Tainan, Taiwan
- Dr. Chang is with Liyen's Clinic of Plastic Surgery in Taichung, Taiwan
| | - Yu-Li Yang
- Dr. Chao is with the CHAO Institute of Aesthetic Medicine in Taipei, Taiwan
- Dr. Tseng is with the Milano Aesthetic Clinic in Taipei, Taiwan
- Dr. Yang is with the MED Aesthetic Clinic in Kaohsiung, Taiwan
- Dr. Chen is with the YaSkin Dermatology Clinic in Kaohsiung, Taiwan
- Dr. Hsu is with the Nai Jen Hsu Dermatology Clinic in Tainan, Taiwan
- Dr. Chang is with Liyen's Clinic of Plastic Surgery in Taichung, Taiwan
| | - Ya-Hui Chen
- Dr. Chao is with the CHAO Institute of Aesthetic Medicine in Taipei, Taiwan
- Dr. Tseng is with the Milano Aesthetic Clinic in Taipei, Taiwan
- Dr. Yang is with the MED Aesthetic Clinic in Kaohsiung, Taiwan
- Dr. Chen is with the YaSkin Dermatology Clinic in Kaohsiung, Taiwan
- Dr. Hsu is with the Nai Jen Hsu Dermatology Clinic in Tainan, Taiwan
- Dr. Chang is with Liyen's Clinic of Plastic Surgery in Taichung, Taiwan
| | - Nai-Jen Hsu
- Dr. Chao is with the CHAO Institute of Aesthetic Medicine in Taipei, Taiwan
- Dr. Tseng is with the Milano Aesthetic Clinic in Taipei, Taiwan
- Dr. Yang is with the MED Aesthetic Clinic in Kaohsiung, Taiwan
- Dr. Chen is with the YaSkin Dermatology Clinic in Kaohsiung, Taiwan
- Dr. Hsu is with the Nai Jen Hsu Dermatology Clinic in Tainan, Taiwan
- Dr. Chang is with Liyen's Clinic of Plastic Surgery in Taichung, Taiwan
| | - Li-Yen Chang
- Dr. Chao is with the CHAO Institute of Aesthetic Medicine in Taipei, Taiwan
- Dr. Tseng is with the Milano Aesthetic Clinic in Taipei, Taiwan
- Dr. Yang is with the MED Aesthetic Clinic in Kaohsiung, Taiwan
- Dr. Chen is with the YaSkin Dermatology Clinic in Kaohsiung, Taiwan
- Dr. Hsu is with the Nai Jen Hsu Dermatology Clinic in Tainan, Taiwan
- Dr. Chang is with Liyen's Clinic of Plastic Surgery in Taichung, Taiwan
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Development of inhibition ELISA to detect antibody-induced failure of botulinum toxin a therapy in cosmetic indications. J Immunol Methods 2019; 473:112635. [PMID: 31361995 DOI: 10.1016/j.jim.2019.112635] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 07/26/2019] [Accepted: 07/26/2019] [Indexed: 11/22/2022]
Abstract
Secondary treatment failure (STF) of botulinum toxin A (BoNT/A) therapy in cosmetic indication has been postulated as production of antibody against active sites of BoNT/A in unresponsive patients. To prove of concept, detection of anti-BoNT/A antibody is required, however, current enzyme-linked immunosorbent assay (ELISA) detects human IgGs against whole BoNT/A molecule. We developed an inhibition ELISA to quantify antibodies bound to the active sites of BoNT/A using three mouse monoclonal antibodies targeting translocation domain, receptor binding site and catalytic domain of BoNT/A prior to processing ELISA to detect human IgG (hIgG) against BoNT/A. Adults naïve to BoNT/A, or treated and responsive (toxin-response), or treated but unresponsive (toxin-tolerance) were recruited. Detection of hIgG revealed that naïve volunteers had basal level of hIgG against whole BoNT/A, whereas its level was significantly lower than those hIgG in BoNT/A-exposed cohorts. Higher anti-BoNT/A levels in sera from volunteers ever-exposed to BoNT/A indicates that BoNT/A may provoke immune responses in BoNT/A-treated cohorts. Inhibition ELISA demonstrated that levels of BoNT/A-specific hIgG in tolerance patients had a dramatic decrease in mouse monoclonal antibody blockage, suggesting presence of hIgG specific to BoNT/A's three active sites in STF patients. Therefore, our ELISA detected hIgG against whole BoNT/A protein and BoNT/A active sites suggesting that human antibodies may cause STF. To compare with frontalis test, our inhibition ELISA provided good accuracy at 83.1% (50% sensitivity and 89.9% specificity). Our test may help clinicians to diagnose possibility of STF and also to monitor immune status against BoNT/A.
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Hobbs RJ, Thomas CA, Halliwell J, Gwenin CD. Rapid Detection of Botulinum Neurotoxins-A Review. Toxins (Basel) 2019; 11:E418. [PMID: 31319550 PMCID: PMC6669533 DOI: 10.3390/toxins11070418] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 07/15/2019] [Accepted: 07/15/2019] [Indexed: 12/13/2022] Open
Abstract
A toxin is a poisonous substance produced within living cells or organisms. One of the most potent groups of toxins currently known are the Botulinum Neurotoxins (BoNTs). These are so deadly that as little as 62 ng could kill an average human; to put this into context that is approximately 200,000 × less than the weight of a grain of sand. The extreme toxicity of BoNTs leads to the need for methods of determining their concentration at very low levels of sensitivity. Currently the mouse bioassay is the most widely used detection method monitoring the activity of the toxin; however, this assay is not only lengthy, it also has both cost and ethical issues due to the use of live animals. This review focuses on detection methods both existing and emerging that remove the need for the use of animals and will look at three areas; speed of detection, sensitivity of detection and finally cost. The assays will have wide reaching interest, ranging from the pharmaceutical/clinical industry for production quality management or as a point of care sensor in suspected cases of botulism, the food industry as a quality control measure, to the military, detecting BoNT that has been potentially used as a bio warfare agent.
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Affiliation(s)
- Robert J Hobbs
- Applied Research in Chemistry and Health (ARCH) Research Group, School of Natural Sciences, Bangor University, Bangor, Gwynedd, Wales LL57 2UW, UK
| | - Carol A Thomas
- Applied Research in Chemistry and Health (ARCH) Research Group, School of Natural Sciences, Bangor University, Bangor, Gwynedd, Wales LL57 2UW, UK
| | - Jennifer Halliwell
- Applied Research in Chemistry and Health (ARCH) Research Group, School of Natural Sciences, Bangor University, Bangor, Gwynedd, Wales LL57 2UW, UK
| | - Christopher D Gwenin
- Applied Research in Chemistry and Health (ARCH) Research Group, School of Natural Sciences, Bangor University, Bangor, Gwynedd, Wales LL57 2UW, UK.
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38
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Riedel P, Marino MH. Pharmacologic Treatment Tools: Systemic Medications and Toxins, Opportunities, and Pitfalls. Phys Med Rehabil Clin N Am 2019; 29:501-517. [PMID: 30626511 DOI: 10.1016/j.pmr.2018.04.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Treatment of pathologic muscle overactivity associated with upper motor neuron syndrome can be multifaceted. One of the initial decisions to be made when formulating an overarching treatment plan is selecting a combination of strategies that is most applicable. Strategies may include physical interventions, such as stretching or splinting modalities, or surgery, whereas pharmacotherapeutic strategies encompass oral/systemic medications as well as agents, such as toxins and alcohols, used for focal chemodenervation. This article reviews the oral/systemic therapies as well as toxins that are used focally. Although medication can also be administered via intrathecal pumps, this treatment approach is discussed elsewhere.
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Affiliation(s)
- Peter Riedel
- Physical Medicine and Rehabilitation, Moss Rehab, 60 Township Line Road, Elkins Park, PA 19027, USA
| | - Michael H Marino
- Physical Medicine and Rehabilitation, Moss Rehab, 60 Township Line Road, Elkins Park, PA 19027, USA; Physical Medicine and Rehabilitation, ReMed, 16 Industrial Boulevard, Paoli, PA 19301, USA.
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39
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Shinn JR, Nwabueze NN, Patel P, Norton C, Ries WR, Stephan SJ. Contemporary Review and Case Report of Botulinum Resistance in Facial Synkinesis. Laryngoscope 2018; 129:2269-2273. [PMID: 30592301 DOI: 10.1002/lary.27709] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 10/09/2018] [Accepted: 10/29/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND Botulinum resistance poses significant treatment challenges for both patients and healthcare practitioners. We first present a case highlighting botulinum resistance in a patient who failed to respond to alternative formulations but who responded remarkably to incobotulinum toxinA, an identical toxin free of complexing proteins. Secondly, we provide a treatment algorithm and a review of the literature detailing clinical and immunochemical botulinum resistance. RESULTS Patients with botulinum resistance show a predisposition to failure on subsequent injections and possess a propensity toward neutralizing and nonneutralizing antibody development. The mechanisms of resistance are not entirely understood but thought to be secondary to an immunologic response. Risk factors for resistance include higher botulinum doses, more frequent injections, and high total lifetime dosage. Patients may still respond to other botulinum formulations or subtypes; however, this effect may be temporary. CONCLUSION This case report describes a patient who responded to incobotulinum toxinA after failing treatment with the identical toxin compounded with buffer proteins, ultimately supporting the possibility of immune-mediated resistance to the surrounding proteins and not the toxin itself. Often, impending treatment resistance is preceded by a poor or limited clinical response. Antibody testing is not indicated because it is neither sensitive nor specific and does not change clinical practice. Initially, higher doses of botulinum may overcome resistance without increasing treatment frequency, and side effects are far less common in those with clinical resistance. If higher dosages fail to produce a response, alternative botulinum formulations or subtypes can be considered. Laryngoscope, 129:2269-2273, 2019.
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Affiliation(s)
- Justin R Shinn
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Nkechi N Nwabueze
- Vanderbilt University School of Medicine, Nashville, Tennessee, U.S.A
| | - Priyesh Patel
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Cathey Norton
- Pi Beta Phi Institute, Bill Wilkerson Center, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - W Russell Ries
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A.,Division of Facial Plastics and Reconstructive Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Scott J Stephan
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A.,Division of Facial Plastics and Reconstructive Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
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40
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Shoffel-Havakuk H, Rosow DE, Lava CX, Hapner ER, Johns MM. Common practices in botulinum toxin injection for spasmodic dysphonia treatment: A national survey. Laryngoscope 2018; 129:1650-1656. [DOI: 10.1002/lary.27696] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 09/27/2018] [Accepted: 10/22/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Hagit Shoffel-Havakuk
- the Department of Otolaryngology-Head and Neck Surgery; Rabin Medical Center; Petah Tikva Israel
- Sackler Faculty of Medicine; Tel-Aviv University; Tel Aviv Israel
| | - David E. Rosow
- Department of Otolaryngology; University of Miami Miller School of Medicine; Miami Florida
| | - Christian X. Lava
- USC Voice Center, Department of Otolaryngology-Head and Neck Surgery; University of Southern California; Los Angeles California U.S.A
| | - Edie R. Hapner
- USC Voice Center, Department of Otolaryngology-Head and Neck Surgery; University of Southern California; Los Angeles California U.S.A
| | - Michael M. Johns
- USC Voice Center, Department of Otolaryngology-Head and Neck Surgery; University of Southern California; Los Angeles California U.S.A
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41
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Pirazzini M, Carle S, Barth H, Rossetto O, Montecucco C. Primary resistance of human patients to botulinum neurotoxins A and B. Ann Clin Transl Neurol 2018; 5:971-975. [PMID: 30128321 PMCID: PMC6093845 DOI: 10.1002/acn3.586] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 05/08/2018] [Indexed: 11/13/2022] Open
Abstract
Botulinum neurotoxin serotypes A and B are successfully used to treat a variety of human diseases characterized by hyperactive peripheral nerve terminals. However, a number of patients are primary resistant to these pharmaceuticals, without having antitoxin‐neutralizing antibodies. A straightforward explanation of this phenomenon posits that mutations of the toxin sites of interaction with their receptors or protein substrates prevent their neuroparalytic action. After a careful investigation of available human genomic databases, we conclude that it is very unlikely that humans are resistant to these two therapeutic neurotoxins because of mutations that would affect their binding or intracellular proteolytic actions.
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Affiliation(s)
- Marco Pirazzini
- Department of Biomedical Sciences University of Padova Via Ugo Bassi 58/B 35131 Padova Italy
| | - Stefan Carle
- Institute of Pharmacology and Toxicology University of Ulm Medical Center Albert-Einstein-Allee 11 89081 Ulm Germany
| | - Holger Barth
- Institute of Pharmacology and Toxicology University of Ulm Medical Center Albert-Einstein-Allee 11 89081 Ulm Germany
| | - Ornella Rossetto
- Department of Biomedical Sciences University of Padova Via Ugo Bassi 58/B 35131 Padova Italy
| | - Cesare Montecucco
- Department of Biomedical Sciences University of Padova Via Ugo Bassi 58/B 35131 Padova Italy.,Institute for Neuroscience National Research Council Via Ugo Bassi 58/B 35131 Padova Italy
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42
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Santamato A, Panza F. Benefits and Risks of Non-Approved Injection Regimens for Botulinum Toxins in Spasticity. Drugs 2018; 77:1413-1422. [PMID: 28726023 DOI: 10.1007/s40265-017-0786-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Spasticity with muscle paresis and loss of dexterity is a common feature of upper motor neuron syndrome due to injuries or the pyramidal tract in several neurological conditions. Botulinum toxin type A has been considered the gold standard treatment for spasticity and movement disorders, with efficacy, reversibility, and low prevalence of complications. During the last 30 years, thousands of studies of its use have been performed, but few guidelines are available. Therefore, there is great variability in both the doses and intervals of administration and the approaches taken by clinicians with considerable experience in spasticity and movement disorder treatment. In the present review article, we provide a short overview of the benefits and risks of non-approved injection regimens and doses for botulinum toxins, focusing on the treatment of post-stroke spasticity, where there is great interest in the potential for increasing the number of treatment/years and the dose of botulinum toxin treatment for subjects with upper and lower limb spasticity. However, many doubts exist regarding antibody development and possible adverse effects.
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Affiliation(s)
- Andrea Santamato
- Physical Medicine and Rehabilitation Section, "OORR Hospital", University of Foggia, Viale Pinto, 71100, Foggia, Italy.
- "Fondazione Turati" Rehabilitation Centre, Vieste, Foggia, Italy.
| | - Francesco Panza
- Complex Structure of Geriatrics, Department of Medical Sciences, IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Foggia, Italy
- Unit of Neurodegenerative Disease, Department of Basic Medicine Sciences, Neuroscience, and Sense Organs, University of Bari "Aldo Moro", Bari, Italy
- Unit of Neurodegenerative Disease, Department of Clinical Research in Neurology, University of Bari "Aldo Moro" at "Pia Fondazione Card. G. Panico", Tricase, Lecce, Italy
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Abstract
Several formulations of Botulinum toxin serotype A (BoNT-A) for aesthetic indications are available, with numbers likely to increase. Preparations are not interchangeable, based on dose unit comparisons.
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44
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LeWitt PA. Delayed Hypersensitivity Reaction to OnabotulinumtoxinA. Mov Disord Clin Pract 2018; 5:321-322. [PMID: 30363389 DOI: 10.1002/mdc3.12575] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 12/07/2017] [Accepted: 12/07/2017] [Indexed: 11/09/2022] Open
Abstract
http://onlinelibrary.wiley.com/journal/10.1002/(ISSN)2330-1619/homepage/mdc312575-sup-v001.htm.
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Affiliation(s)
- Peter A LeWitt
- Department of Neurology Henry Ford Hospital West Bloomfield MI USA.,Wayne State University School of Medicine West Bloomfield MI USA
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45
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Safety of IncobotulinumtoxinA in the Treatment of Facial Lines: Results From a Pooled Analysis of Randomized, Prospective, Controlled Clinical Studies. Dermatol Surg 2017; 43 Suppl 3:S293-S303. [PMID: 33065955 DOI: 10.1097/dss.0000000000001409] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The safety and efficacy of incobotulinumtoxinA in aesthetics has been established in multiple studies. Although individual studies have been reported, a combined assessment of incobotulinumtoxinA safety across studies is not available. OBJECTIVE To assess the frequency of adverse events (AEs) across prospective incobotulinumtoxinA studies in aesthetics. MATERIALS AND METHODS Safety data were assessed from 9 placebo-controlled or active-controlled single-dose studies on glabellar frown lines (GFL), crow's feet (CF), and upper facial lines (UFL). Analyses by treatment cycle included 4 repeat-dose studies on GFL and UFL. RESULTS One thousand three hundred seventy-seven subjects received incobotulinumtoxinA (GFL, n = 1,189; CF, n = 83; UFL, n = 105) in single-dose studies (placebo-controlled studies: incobotulinumtoxinA, n = 866; placebo, n = 395). Over 1,000 subjects received incobotulinumtoxinA in repeat-dose studies (GFL, n = 880; UFL, n = 290). In placebo-controlled single-dose studies, incidences of treatment-related AEs ranged from 5.4% (GFL) to 22.9% (UFL). The most frequent treatment-related AE in single-dose studies was headache (GFL, 4.8%; UFL, 11.4%). In repeat-dose studies, incidence of AEs was highest during cycle 1 (GFL, 8.9%; UFL, 17.2%) and decreased across treatment cycles. No serious treatment-related AEs were observed. CONCLUSION Results confirm the favorable safety and tolerability of incobotulinumtoxinA. The frequency of treatment-related AEs was low and may decrease with subsequent treatments.
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46
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Orlova OR, Timerbaeva SL, Khatkova SE, Kostenko EV, Krasavina DA, Zakharov DV. [Conversion ratio between different botulinum neuroprotein product in neurological practice]. Zh Nevrol Psikhiatr Im S S Korsakova 2017; 117:132-141. [PMID: 29053134 DOI: 10.17116/jnevro201711791132-141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Despite nearly 30 years of experience in the application of botulinum toxin type A (BTA) in clinical practice, many fundamental questions of therapy remain valid. There are 5 botulinum toxin type A used for neurological indications in the Russian Federation in 2017. They contain different number of active neuroprotein (150 kDa) in a therapeutic dose of the drug that may have a potential impact on the efficacy and duration of action. The current SmPC of each BTA stated that the unit of activity is unique and can not be compared with any other BTA. In scientific publications one can find many details concerning the equivalence doses of onabotulinumtoxin A (botox) and abobotulinumtoxin A (dysport) and the ratio of units varies from 1:1 to 1:11. However, according to clinical guidelines, systematic reviews and high quality research evidence of recent years, the ratio of units of abobotulinumtoxin A (dysport) and onabotulinumtoxin A (botox) is 3(2,5):1. Use of a fixed ratio of units is possible only when switching from one drug to another or in case of limiting access to specific drug. Botulinum toxin type A is the first line of therapy in the treatment of several neurological diseases. The most commonly used drugs of botulinum toxin type A (botox, dysport, xeomin) have a significant evidence base that confirms their efficacy and optimal safety profile. The main difference between botulinum toxin type A is their potential activity of action, i.e., activity units and total therapeutic dose.
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Affiliation(s)
- O R Orlova
- Sechenov First Moscow State Medical University, Moscow, Russia
| | | | - S E Khatkova
- Clinical and Rehabilitation Center, Moscow, Russia
| | - E V Kostenko
- Branch #7 of Moscow Scientific Practical Center for Medical Rehabilitation, Restorative and Sports Medicine, Moscow, Russia
| | - D A Krasavina
- St-Petersburg State Pediatry University, St. Petersburg, Russia
| | - D V Zakharov
- Bekhterev St-Petersburg Research Psychoneurological Institute, St. Petersburg, Russia
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47
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Lacroix-Desmazes S, Mouly S, Popoff MR, Colosimo C. Systematic analysis of botulinum neurotoxin type A immunogenicity in clinical studies. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.baga.2017.06.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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48
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Nestor M, Ablon G, Pickett A. Key Parameters for the Use of AbobotulinumtoxinA in Aesthetics: Onset and Duration. Aesthet Surg J 2017; 37:S20-S31. [PMID: 28388717 PMCID: PMC5434495 DOI: 10.1093/asj/sjw282] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Time to onset of response and duration of response are key measures of botulinum toxin efficacy that have a considerable influence on patient satisfaction with aesthetic treatment. However, there is no overall accepted definition of efficacy for aesthetic uses of botulinumtoxinA (BoNT-A). Mechanical methods of assessment do not lend themselves to clinical practice and clinicians rely instead on assessment scales such as the Frontalis Activity Measurement Standard, Frontalis Rating Scale, Wrinkle Severity Scale, and Subject Global Assessment Scale, but not all of these have been fully validated. Onset of activity is typically seen within 5 days of injection, but has also been recorded within 12 hours with abobotulinumtoxinA. Duration of effect is more variable, and is influenced by parameters such as muscle mass (including the effects of age and sex) and type of product used. Even when larger muscles are treated with higher doses of BoNT-A, the duration of effect is still shorter than that for smaller muscles. Muscle injection technique, including dilution of the toxin, the volume of solution injected, and the positioning of the injections, can also have an important influence on onset and duration of activity. Comparison of the efficacy of different forms of BoNT-A must be made with the full understanding that the dosing units are not equivalent. Range of equivalence studies for abobotulinumtoxinA (Azzalure; Ipsen Limited, Slough UK/Galderma, Lausanne CH/Dysport, Ipsen Biopharm Limited, Wrexham UK/Galderma LP, Fort Worth, TX) and onabotulinumtoxinA (Botox; Allergan, Parsippany, NJ) have been conducted, and results indicate that the number of units of abobotulinumtoxinA needs to be approximately twice as high as that of onabotulinumtoxinA to achieve the same effect. An appreciation of the potential influence of all of the parameters that influence onset and duration of activity of BoNT-A, along with a thorough understanding of the anatomy of the face and potency of doses, are essential to tailoring treatment to individual patient needs and expectations.
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Affiliation(s)
- Mark Nestor
- Voluntary Associate Professor, Department of Dermatology and Cutaneous Surgery, Department of Surgery, Division of Plastic Surgery, University of Miami Leonard Miller School of Medicine, Miami, FL, USA
| | - Glynis Ablon
- Associate Clinical Professor of Dermatology, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Andy Pickett
- Director and Founder of Toxin Science Limited, Wrexham, UK
- Adjunct Professor at the Botulinum Research Center, Institute of Advanced Sciences, Dartmouth, MA, USA
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49
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Cohen JL, Scuderi N. Safety and Patient Satisfaction of AbobotulinumtoxinA for Aesthetic Use: A Systematic Review. Aesthet Surg J 2017; 37:S32-S44. [PMID: 28388721 PMCID: PMC5434490 DOI: 10.1093/asj/sjx010] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
A systematic review of the published literature (from January 2000 to January 2016) to ascertain the safety of, and patient satisfaction with, the aesthetic use of abobotulinumtoxinA was conducted. In addition to the licensed indications, other special populations were considered for discussion. The potential impact of neutralizing antibodies and systemic toxicity were also addressed. A total of 364 papers were screened and 86 were found to be relevant to the population, intervention(s), and outcomes stipulated in the protocol. The safety and patient satisfaction data from these publications are discussed in this review.
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Affiliation(s)
- Joel L Cohen
- Associate Clinical Professor, Department of Dermatology, University of Colorado, Boulder, CO, USA
- Assistant Clinical Professor, Department of Dermatology, University of California Irvine, Irvine, CA, USA
| | - Nicolo Scuderi
- Full Professor of Plastic and Reconstructive Surgery, Department of Surgery, Sapienza University of Rome, Rome, Italy
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Contarino MF, Van Den Dool J, Balash Y, Bhatia K, Giladi N, Koelman JH, Lokkegaard A, Marti MJ, Postma M, Relja M, Skorvanek M, Speelman JD, Zoons E, Ferreira JJ, Vidailhet M, Albanese A, Tijssen MAJ. Clinical Practice: Evidence-Based Recommendations for the Treatment of Cervical Dystonia with Botulinum Toxin. Front Neurol 2017; 8:35. [PMID: 28286494 PMCID: PMC5323428 DOI: 10.3389/fneur.2017.00035] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 01/25/2017] [Indexed: 12/14/2022] Open
Abstract
Cervical dystonia (CD) is the most frequent form of focal dystonia. Symptoms often result in pain and functional disability. Local injections of botulinum neurotoxin are currently the treatment of choice for CD. Although this treatment has proven effective and is widely applied worldwide, many issues still remain open in the clinical practice. We performed a systematic review of the literature on botulinum toxin treatment for CD based on a question-oriented approach, with the aim to provide practical recommendations for the treating clinicians. Key questions from the clinical practice were explored. Results suggest that while the beneficial effect of botulinum toxin treatment on different aspects of CD is well established, robust evidence is still missing concerning some practical aspects, such as dose equivalence between different formulations, optimal treatment intervals, treatment approaches, and the use of supportive techniques including electromyography or ultrasounds. Established strategies to prevent or manage common side effects (including excessive muscle weakness, pain at injection site, dysphagia) and potential contraindications to this treatment (pregnancy and lactation, use of anticoagulants, neurological comorbidities) should also be further explored.
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Affiliation(s)
- Maria Fiorella Contarino
- Department of Neurology, Haga Teaching Hospital, The Hague, Netherlands; Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands
| | - Joost Van Den Dool
- Department of Neurology AB 51, University Medical Centre Groningen, Groningen, Netherlands; ACHIEVE Centre of Expertise, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, Netherlands
| | - Yacov Balash
- Movement Disorders Unit of the Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Kailash Bhatia
- Sobell Department, Institute of Neurology, National Hospital for Neurology, University College London , London , UK
| | - Nir Giladi
- Movement Disorders Unit of the Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Johannes H Koelman
- Department of Neurology/Clinical Neurophysiology, Academic Medical Center , Amsterdam , Netherlands
| | - Annemette Lokkegaard
- Department of Neurology, Copenhagen University Hospital Bispebjerg , Copenhagen , Denmark
| | - Maria J Marti
- Department of Neurology, Hospital Clinic i Universitari, Institut D'Investigacio Biomedica August Pi i Sunyer (IDIBAPS), CIBERNED , Barcelona , Spain
| | - Miranda Postma
- Department of Neurology/Clinical Neurophysiology, Academic Medical Center , Amsterdam , Netherlands
| | - Maja Relja
- Movement Disorders Center, Department of Neurology, Clinical Medical Center School of Medicine, Zagreb University , Zagreb , Croatia
| | - Matej Skorvanek
- Department of Neurology, P. J. Safarik University, Kosice, Slovakia; Department of Neurology, University Hospital of L. Pasteur, Kosice, Slovakia
| | - Johannes D Speelman
- Department of Neurology/Clinical Neurophysiology, Academic Medical Center , Amsterdam , Netherlands
| | - Evelien Zoons
- Department of Neurology/Clinical Neurophysiology, Academic Medical Center , Amsterdam , Netherlands
| | - Joaquim J Ferreira
- Clinical Pharmacology Unit, Faculty of Medicine, Instituto de Medicina Molecular, University of Lisbon , Lisbon , Portugal
| | - Marie Vidailhet
- Sorbonne University, UPMC Paris-6, Paris, France; Brain and Spine Institute - ICM, Centre for Neuroimaging Research - CENIR, UPMC UMR 1127, Paris, France; INSERM U 1127, Paris, France; CNRS UMR 7225, Team Control of Normal and Abnormal Movement, Paris, France; Department of Neurology, Salpêtriere Hospital, AP-HP, Paris, France
| | - Alberto Albanese
- Department of Neurology, Humanitas Research Hospital, Milano, Italy; Department of Neurology, Università Cattolica del Sacro Cuore, Milano, Italy
| | - Marina A J Tijssen
- Department of Neurology AB 51, University Medical Centre Groningen , Groningen , Netherlands
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