[bobotulinum toxin A (Dysport) for the treatment of neurogenic detrusor overactivity]

Increasing of treatment efficiency in patients with neurogenic detrusor overactivity is an important medical and social problem. Its significance is determined not only by the high prevalence of neurogenic lower urinary tract dysfunctions, but also by the high risk of complications, among which an impaired renal function takes the leading place. Botulinum toxin therapy is considered as a second-line treatment and is carried out in case of insufficient efficacy, unsatisfactory tolerability or the presence of contraindications to anticholinergic therapy. Botulinum toxin therapy has been actively used in our country for more than 12 years. In 2022, abobotulinum toxin A (Dysport) was registered in the Russian Federation for the treatment of neurogenic detrusor overactivity. An overview of the results of clinical trials of Dysport, indicating its high efficacy and favorable safety profile, is presented in the article. The availability of botulinum toxin in the arsenal of a urologist, which has a high efficiency, opens up additional prospects for the treatment of patients with a neurourological profile.

A novel technique of botulinum toxin injection around skull sutures for chronic migraine: A randomized controlled clinical trial

Background

Migraine is a chronic headache manifested with attacks. Here we aimed to evaluate and compare the efficacy of 15-point Dysport injection with 31-point Xeomin injections.

Materials and Methods

This is a randomized clinical trial performed in 2020-2021 in Isfahan on patients with refractory chronic migraine. A total number of 60 patients entered the study. The pain of patients was also determined using headache impact test (HIT) questionnaire. Patients were randomized into two groups: Group 1 underwent 31-point Xeomin injection and Group 2 underwent 1 vial of Dysport injection into 15 points of the scalp.

Results

Our study revealed that the data regarding aura, nausea, vomit, photosensitivity, sensitivity to sounds and smells did not change significantly between two groups compared to the beginning of the study. Frequency, duration, intensity of headaches, and the mean HIT score of all patients improved significantly within 3 months after interventions. Comparing both groups showed no significant differences (P > 0.05). HIT score was decreased from 21.26 ± 3.58 before intervention to 15.51 ± 4.58 after 3 months in Group 1 and 22.23 ± 2.59-10.33 ± 2.26 in Group 2. In both groups, these changes were statistically significant (P < 0.001). Although we found more decrease of HIT score in Group 2 comparing with Group 1 (10.33 ± 2.26 vs. 15.51 ± 4.58), this difference was not statistically significant (P = 0.12).

Conclusion

Although Xeomin and Dysport injections are both effective and reduced pain in patients with chronic migraine, our new technique is probably better than the standard technique. Because the injection points are halved, increase patients comfort and reduce overall cost.

Muscle Selection and Dosing in a Phase 3, Pivotal Study of AbobotulinumtoxinA Injection in Upper Limb Muscles in Children With Cerebral Palsy

Background: Guidelines recommend botulinum toxin-A in pediatric upper limb spasticity as part of routine practice. Appropriate dosing is a prerequisite for treatment success and it is important that injectors have an understanding on how to tailor dosing within a safe and effective range. We report upper limb dosing data from a phase 3 study of abobotulinumtoxinA injections in children with cerebral palsy.

Methods: This was a double-blind, repeat-treatment study (NCT02106351). In Cycle 1, children were randomized to abobotulinumtoxinA at 2 U/kg control dose or clinically relevant 8 U/kg or 16 U/kg doses. Doses were divided between the primary target muscle group (PTMG, wrist or elbow flexors) and additional muscles tailored to clinical presentation. During Cycles 2–4, children received doses of 8 U/kg or 16 U/kg and investigators could change the PTMG and other muscles to be injected. Injection of muscles in the other upper limb and lower limbs was also permitted in cycles 2–4, with the total body dose not to exceed 30 U/kg or 1,000 U (whichever was lower) in the case of upper and lower limb treatment.

Results: 212 children were randomized, of which 210 received ≥1 abobotulinumtoxinA injection. Per protocol, the elbow and wrist flexors were the most commonly injected upper limb muscles. Across all 4 cycles, the brachialis was injected in 89.5% of children (dose range 0.8–6 U/kg), the brachioradialis in 83.8% (0.4–3 U/kg), the flexor carpi ulnaris in 82.4% (0.5–3 U/kg) and the flexor carpi radialis in 79.5% (0.5–4 U/kg). Other frequently injected upper limb muscles were the pronator teres(70.0%, 0.3–3 U/kg). adductor pollicis (54.3%, 0.3-1 U/kg), pronator quadratus (44.8%, 0.1–2 U/kg), flexor digitorum superficialis (39.0%, 0.5-4 U/kg), flexor digitorum profundus (28.6%, 0.5–2 U), flexor pollicis brevis/opponens pollicis (27.6%, 0.3-1 U/kg) and biceps (27.1%, 0.5–6 U/kg). AbobotulinumtoxinA was well-tolerated at these doses; muscular weakness was reported in 4.3% of children in the 8 U/kg group and 5.7% in the 16 U/kg group.

Conclusions: These data provide information on the pattern of injected muscles and dose ranges used in this study, which were well-tolerated. Per protocol, most children received injections into the elbow and wrist flexors. However, there was a wide variety of other upper limb muscles injected as physicians tailored injection patterns to clinical need.

Dose conversion ratio, comparative efficacy, and adverse events after switching from onabotulinum toxin A to abobotulinum toxin A for neurological conditions

OBJECTIVES

Onabotulinum toxin A (ONA, Botox®) and abobotulinum toxin A (ABO, Dysport®) are most frequently used in the treatment of movement disorders. The aim of this study was to identify the dose conversion ratio (ABO dose:ONA dose), comparative efficacy, and adverse events in patients who switched from ONA to ABO.

METHODS

There were 64 patients with cervical dystonia (39), hemifacial spasm (16), oromandibular dystonia (5), blepharospasm (3), and extremity dystonia (1) who switched from ONA to ABO. The efficacy, adverse events, duration of action, and severity of the adverse events after the final dose of ONA, initial dose of ABO, and second dose of ABO were investigated in these patients.

RESULTS

The mean dose conversion ratio was 4.70 (2.27-9.62). The mean efficacy of the final ONA injection was 70.62%; initial ABO injection, 72.27%; and second ABO injection, 73.52%, which showed improvement on a visual analog scale (p = 0.71, p = 0.5). Incidence of adverse events after the final ONA injection was 18.8%; this increased to 39.1% after the initial ABO injection (p < 0.001) and decreased to 14.1% after the second ABO injection (p = 0.77). After the initial ABO injection, 20% of the adverse events were trivial, 36% were mild, and 32% were severe. After the second ABO injection, 7.8% of the adverse events were mild and 6.3% were severe.

CONCLUSION

Although the mean dose conversion ratio was 4.70, the range was very wide (approximately 2-9). Therefore, we conclude that after the switch from Botox to Dysport, the doses should be tailored to the patients' clinical situation at treatment initiation, without using a dose conversion ratio.

Current use of botulinum neurotoxin in esthetic practice-Clinical guide and review

BACKGROUND

Botulinum neurotoxin is one of the most versatile and widely used medical products in the world.

AIMS

The review's focus is the plastic and dermatologic uses of botulinum neurotoxin currently supported by published data.

METHODS

Relevant clinical articles regarding botulinum neurotoxin use in plastic surgery, dermatology, and general esthetic literature were searched and reviewed.

RESULTS

The search yielded 258 studies. Two hundred articles were excluded following title and abstract review. Twenty-one studies were excluded following full-text screening. A total of 37 studies remained and were discussed in this review.

CONCLUSIONS

Botulinum neurotoxin is widely used for numerous off-label indications from head to toe. Some uses are well documented, and their safety has been demonstrated in controlled trials, yet most remain poorly researched.

Patient Satisfaction with AbobotulinumtoxinA for Aesthetic Use in the Upper Face: A Systematic Literature Review and Post-hoc Analysis of the APPEAL Study

BACKGROUND: AbobotulinumtoxinA (AboBoNT-A; Dysport^®; Ipsen, Boulogne-Billancourt, France/Azzalure^®; Galderma, Lausanne, Switzerland) is a botulinum neurotoxin type A approved for aesthetic use in the treatment of glabellar lines in adult patients under 65 years in Europe, the United States, and other countries. OBJECTIVE: We sought to analyze current literature on patient satisfaction with aboBoNT-A for upper facial aesthetic indications. METHODS: A systematic review of literature databases (PubMed/MEDLINE, Embase, the Cochrane Library, and Google Scholar) was performed to identify English-language publications reporting on patients with aesthetic indications (including glabellar lines and wrinkles) receiving aboBoNT-A, that assessed patient and/or physician satisfaction with treatment, with no restrictions on comparator studies. Structured data extraction was used to enable inter-study analysis. A post-hoc analysis was also performed to assess patient satisfaction by sex and age, using results from the noninterventional APPEAL study of patients' satisfaction with aboBoNT-A for treating glabellar lines. RESULTS: Overall, 22 original research papers were identified. Patient satisfaction rates for aboBoNT-A treatment were significantly higher versus placebo from two weeks to between three and five months postinjection. At two to three weeks postinjection, patient satisfaction rates were 52% and 99% across studies. In studies with later time points, patient satisfaction rates were 85 to 87 percent at 5 months and between 25 and 100 percent at 6 months post-injection. Physician satisfaction was also high (97%-100%, across three treatments). No notable differences in patient satisfaction by sex or age were observed in the APPEAL study. CONCLUSION: High rates of patient satisfaction have been achieved with aboBoNT-A treatment for upper facial aesthetic indications. Despite the current recommended interval of ≥12 weeks, satisfaction with the aesthetic results of aboBoNT-A therapy is still evident up to 6 months post-injection in some patients.

Botulinum Toxin for the Treatment of Intractable Raynaud Phenomenon

Raynaud phenomenon (RP) is a condition causing vasospasm in the fingers and toes of patients that can have a significant negative impact on quality of life. This can lead to pain, ulceration, and possible loss of digits. Several pharmacological options are available for treatment. However, RP can often be refractory to traditional modalities, leaving surgery or injections as the next available options. This article provides a review and update on the use of botulinum toxin as an effective therapy for the treatment of RP refractory to medical management.

Use of AbobotulinumtoxinA in Adults with Cervical Dystonia: A Systematic Literature Review

Cervical dystonia (CD) is a neurological movement disorder characterized by sustained involuntary muscle contractions. First-line therapy for CD is intramuscular injections of botulinum neurotoxin (e.g., abobotulinumtoxinA) into the affected muscles. The objective of this systematic literature review is to assess the clinical evidence regarding the effects of abobotulinumtoxinA for treatment of CD in studies of safety, efficacy, patient-reported outcomes, and economic outcomes. Using comprehensive electronic medical literature databases, a search strategy was developed using a combination of Medical Subject Heading terms and keywords. Results were reviewed by two independent reviewers who rated the level of evidence. The search yielded 263 publications, of which 232 were excluded for being duplicate publications, not meeting the selection criteria, or failing to meet predefined eligibility criteria, leaving a total of 31 articles. Clinical efficacy, patient-reported outcomes, and safety data were in 6 placebo-controlled trials (8 articles), 6 active-controlled trials, and 16 observational studies (17 articles). Data on health economic outcomes were provided in one of the clinical trials, in two of the observational studies, and in one specific cost-analysis publication. This review demonstrated that the routine use of abobotulinumtoxinA in CD is well-established, effective, and generally well-tolerated, with a relatively low cost of treatment.

Effectiveness of AbobotulinumtoxinA in Post-stroke Upper Limb Spasticity in Relation to Timing of Treatment

Background: Recent studies of botulinum toxin for post-stroke spasticity indicate potential benefits of early treatment (i. e., first 6 months) in terms of developing hypertonicity, pain and passive function limitations. This non-interventional, longitudinal study aimed to assess the impact of disease duration on the effectiveness of abobotulinumtoxinA treatment for upper limb spasticity. Methods: The early-BIRD study (NCT01840475) was conducted between February 2013 and 2018 in 43 centers across Germany, France, Austria, Netherlands and Switzerland. Adult patients with post-stroke upper limb spasticity undergoing routine abobotulinumtoxinA treatment were followed for up to four treatment cycles. Patients were categorized by time from stroke event to first botulinum toxin-A treatment in the study (as defined by the 1st and 3rd quartiles time distribution) into early-, medium- and late- start groups. We hypothesized that the early-start group would show a larger benefit (decrease) as assessed by the modified Ashworth scale (MAS, primary endpoint) on elbow plus wrist flexors compared with the late-start group. Results: Of the 303 patients enrolled, 292 (96.4%) received ≥1 treatment and 186 (61.4%) received 4 injection cycles and completed the study. Patients in all groups showed a reduction in MAS scores from baseline over the consecutive injection visits (i.e., at end of each cycle). Although reductions in MAS scores descriptively favored the early treatment group, the difference compared to the late group did not reach statistical significance at the last study visit (ANCOVA: difference in adjusted means of 0.15, p = 0.546). Conclusions: In this observational, routine-practice study, patients in all groups displayed a benefit from abobotulinumtoxinA treatment, supporting the effectiveness of treatment for patients at various disease stages. Although the data revealed some trends in favor of early vs. late treatment, we did not find strong evidence for a significant benefit of early vs. late start of treatment in terms of reduction in MAS scores.

Safety and pharmacodynamics of a novel recombinant botulinum toxin E (rBoNT-E): Results of a phase 1 study in healthy male subjects compared with abobotulinumtoxinA (Dysport®)

Naturally occurring botulinum toxin (BoNT) serotypes have different pharmacological features of therapeutic and aesthetic interest. This phase 1, double-blind, placebo-controlled study (EudraCT: 2016-002609-20) assessed safety, tolerability and pharmacodynamics (PD) of the first recombinant BoNT serotype E (rBoNT-E) versus abobotulinumtoxinA (Dysport®), administered to extensor digitorum brevis (EDB) of healthy males. Subjects were randomised 3:1 (n = 28) to single ascending rBoNT-E (0.04-3.6 ng) doses or placebo. A further 24 subjects received abobotulinumtoxinA (20, 40, or 70 U) or placebo. PD were assessed using compound muscle action potential (CMAP) amplitude. Demographics were similar between groups. All rBoNT-E doses were well tolerated (no severe treatment-emergent adverse events [TEAEs], serious adverse events, or treatment-related toxicities). Most TEAEs were mild/moderate and treatment-unrelated. rBoNT-E had a faster onset of action (days 1-2 post-injection), greater peak effect (>90% CMAP inhibition), and shorter duration of effect at highest tested doses versus abobotulinumtoxinA (onset of action ≤7 days post-injection; 70% maximal CMAP inhibition). rBoNT-E duration of effect was 2-7 weeks versus >26 weeks for abobotulinumtoxinA. Dose-dependent effects were observed for magnitude and duration of EDB CMAP inhibition, plateauing at 0.9 and 3.6 ng. rBoNT-E demonstrated a good safety profile and a PD profile that may address unmet therapeutic and aesthetic patient needs.

Switching from onabotulinumtoxin-A to abobotulinumtoxin-A in children with cerebral palsy treated for spasticity: A retrospective safety and efficacy evaluation

OBJECTIVES

To determine whether switching from onabotulinumtoxinA to abobotulinumtoxinA in children with cerebral palsy is safe and whether therapeutic efficacy is maintained.

METHODS

This retrospective observational study of routine care included 118 children with cerebral palsy (mean age 81.4 months (standard deviation; SD 38.9)) who had switched from onabotulinumtoxinA to abobotulinumtoxinA injections into their lower extremities due to a change in hospital policy. Analysis was limited to the final onabotulinumtoxinA treatment-cycle prior to switch, and the first abobotulinumtoxinA treatment-cycle following switch. The primary objective was to document the safety and tolerability of switching products. Efficacy endpoints included muscle tone, spasticity, and gait function based on Modified Ashworth Scale (MAS), Tardieu Scale (TS) and Observational Gait Scale (OGS) scores.

RESULTS

Treatment-emergent adverse events were recorded in 41 (34.7%) and 31 (26.3%) patients during the onabotulinumtoxinA and abobotulinumtoxinA treatment cycles, respectively. Treatment-related adverse events were reported in 5 patients in the onabotulinumtoxinA treatment-cycle vs 7 in the abobotulinumtoxinA treatment-cycle (p?=?0.774). Treatment efficacy (4–6 weeks post-treatment) was similar in the onabotulinumtoxinA and abobotulinumtoxinA treatment-cycles for all variables (MAS, TS, OGS).

CONCLUSION

In children with cerebral palsy, switching from onabotulinumtoxinA to abobotulinumtoxinA is safe and generally well-tolerated and therapeutic efficacy is maintained.

AbobotulinumtoxinA Efficacy and Safety in Children With Equinus Foot Previously Treated With Botulinum Toxin

BACKGROUND

The effects of botulinum toxin are transient, and repeat injections are required in children with lower-limb spasticity. However, the efficacy of botulinum toxin in patients who have received previous injections has remained largely unexplored.

METHODS

We present subgroup analyses of a phase III study conducted in ambulatory children (aged two to 17) with spastic equinus foot. Patients were randomized to single doses of abobotulinumtoxinA 10 U/kg/leg, 15 U/kg/leg, or placebo injected into the gastrocnemius-soleus complex (one or both legs). The first analysis was prespecified to review the effect of abobotulinumtoxinA in children previously treated with botulinum toxin versus those children new to the treatment; a second post hoc analysis evaluated the effect of abobotulinumtoxinA in children who changed botulinum toxin formulation.

RESULTS

Of the 241 randomized patients, 113 had previously received botulinum toxin, including 86 who had been treated with another formulation. In both analyses, muscle tone (Modified Ashworth Scale) and the Physicians Global Assessment, at week 4, improved with abobotulinumtoxinA treatment versus placebo, regardless of baseline botulinum toxin status. Placebo responses in patients new to treatment were consistently higher than in the previously treated group.

CONCLUSIONS

These results demonstrate similar abobotulinumtoxinA efficacy and safety profiles in children with spasticity who are new to botulinum toxin treatment and those children who were previously treated. The efficacy and safety of abobotulinumtoxinA treatment in these previously treated patients were comparable with the overall trial population, indicating that doses of 10 and 15 U/kg/leg are suitable starting doses for children with spasticity regardless of the previous botulinum toxin preparation used.

The efficacy and complications of a new technique of Abobotulinum-toxin A (Dysport) injection in patients with glabellar lines

BACKGROUND

Abobotulinum- toxin A is used extensively for the treatment of frown (glabellar) lines.

AIMS

The aim of this study was to evaluate the efficacy and complications of a new injection technique and to assess the amount of satisfaction in patients with the frown lines.

METHODS

This cross-sectional study was conducted in 104 patients with moderate-to-severe glabellar lines. In the new technique by reassessing the responsible anatomic muscles of wrinkles, we tried to modify the injection technique of Abobotulinum-toxin A to yield more favorable results. The range and severity of frown lines were assessed by a 4-score test and a photograph taken before and 2 weeks after the injection. Patients were followed up to 180 days after injection.

RESULTS

The response time of 87.5% of patients was within the first 48 hours and the remaining 12.5% showed the symptoms within the first week after injection. At 30 days after injection, the frown lines had disappeared in 88.5% of patients in static mode and 85.6% in mechanic mode. Maximum injection durability in the first 3, 4, and 6 months after injection was 82%, 52%, and 38%, respectively. The amount of complete satisfaction after 3 months was reported to be 86.5%.

CONCLUSIONS

This study indicated that the new injection technique of Abobotulinum-toxin A could be beneficial in the treatment of frown lines with more satisfactory results, especially in those patients who were not contented with the present conventional method.

Safety and Efficacy of Repeat Open-Label AbobotulinumtoxinA Treatment in Pediatric Cerebral Palsy

This was a prospective, repeat-treatment, open-label study (NCT01251380) of abobotulinumtoxinA for the management of lower limb spasticity in children who had completed a double-blind study. Children (2-17 years) received injections into the gastrocnemius-soleus complex, and other distal and proximal muscles as required (maximum total dose per injection cycle: 30 U/kg or 1000U). A total of 216 of the 241 double-blind patients entered the extension study and 207 received ≥1 open label injection into the gastrocnemius-soleus; 17-24% of patients also had injections into the hamstrings. The most frequent adverse events were related to common childhood infections and the most frequent treatment-related adverse event was injection site pain (n = 10). There was no evidence of a cumulative effect on adverse events. Sustained significant clinical improvements in muscle tone (Modified Ashworth Scale), spasticity (Tardieu Scale), overall clinical benefit (Physicians Global Assessment), and goal attainment (Goal Attainment Scale) were also observed across treatment cycles.

AbobotulinumtoxinA (Dysport®) Improves Function According to Goal Attainment in Children With Dynamic Equinus Due to Cerebral Palsy

This secondary analysis of a large (n = 241), randomized, double-blind study evaluated the efficacy of 2 doses of abobotulinumtoxinA + standard of care (SOC) versus placebo + SOC in enabling children with dynamic equinus due to cerebral palsy to achieve their functional goals using Goal Attainment Scaling. Most parents/caregivers selected goals targeting aspects of gait improvement as most relevant. Mean (95% confidence interval) Goal Attainment Scaling T scores at week 4 were higher for both abobotulinumtoxinA groups versus placebo (treatment difference vs placebo: 10 U/kg/leg: 5.32 [2.31, 8.32], P = .0006, and 15 U/kg/leg 4.65 [1.59, 7.71], P = .0031). Superiority of both abobotulinumtoxinA doses versus placebo was maintained at week 12. Best goal attainment T scores were higher in the abobotulinumtoxinA groups versus placebo for the common goals of improved walking pattern, decreased falling, decreased tripping, and improved endurance. These findings demonstrate that single injections of abobotulinumtoxinA (10 and 15 U/kg/leg) significantly improved the ability of pediatric cerebral palsy patients to achieve their functional goals.

Medium- to long-term outcomes of botulinum toxin A for idiopathic overactive bladder

Botulinum toxin A (BoNT-A) has become an important therapeutic tool in the management of refractory overactive bladder (OAB). Over the last decade, there have been growing numbers of patients receiving repeat injections and these outcomes have begun to be reported in large, high-quality cohorts. This article reviews the current evidence for the medium- to long-term use of BoNT-A in adults with idiopathic detrusor overactivity (IDO) receiving repeat injections. We find that medium-term outcomes are encouraging but long-term outcomes are not as extensively reported. There is high-quality evidence that efficacy following the first injection persists across multiple treatment cycles. There are no additional safety concerns from repeat injections up to six treatment cycles. However, there is a need for further data to confirm the efficacy and safety of BoNT-A beyond the follow-up period in the current literature.

Overview of Botulinum Toxins for Aesthetic Uses

Botulinum toxin type A (BTA) can be used for facial aesthetics. The 3 currently available BTA types include onabotulinumtoxinA (Botox; Botox Cosmetic, Allergan, Irvine, CA), abobotulinumtoxinA (Dysport; Ipsen, Ltd, Berkshire, UK), and incobotulinumtoxinA (Xeomin; Merz Pharmaceuticals, Frankfurt, Germany). The mechanism of action and clinical uses for treatment of dynamic lines of the forehead, brow, glabella, lateral orbit, nose, and lips are presented, as well as treatment of masseter hypertrophy, platysmal bands, and improvements of the perioral region. Specific BTA injection sites and suggested doses are presented.

Botulinum Toxin Injection for Treatment of Acute Traumatic Superior Oblique Muscle Palsy

Purpose:

To evaluate the outcomes of botulinum toxin injection into the inferior oblique (IO) muscle for management of unilateral acute traumatic superior oblique (SO) palsy.

Methods:

In this prospective case series, 10-20 units of botulinum toxin A (Dysport, Ipsen, Biopharm Ltd., Wrexham, UK) was injected into the ipsilateral IO muscle of 13 consecutive patients with unilateral acute traumatic SO palsy. All patients received injections within four weeks of the incident.

Results:

Mean age was 29 ± 15 years and 12 (92%) subjects were male. Mean amount of hypertropia (in primary position) was decreased from 10.0 ± 3.9^Δ at baseline to 4.6 ± 8.9^Δ, one month after the injection, and to 1.5 ± 2.7^Δ at final follow-up (P = 0.001). IO overaction improved from 2.7 ± 0.6 to 1.0 ± 1.2 and 0.6 ± 0.9 (P ≤ 0.001), and subjective torsion from 5.3 ± 3.9 to 3.2 ± 3.4 and 1.6 ± 2.5 degrees (P ≤ 0.001), at the same time intervals respectively. One month after the injection as well as at final follow-up, 10 (77%) patients were diplopia-free in primary and reading positions. Subgroup analysis showed that patients who recovered had less baseline hypertropia as compared to those who failed (8.3^Δ vs. 15.7^Δ, respectively; P = 0.01). All patients with a favorable outcome had baseline hypertropia of 10^Δ or less.

Conclusion:

A single injection of BTA into the IO muscle can rapidly and safely resolve symptomatic diplopia in patients with acute traumatic SO palsy, while waiting for spontaneous recovery.

Botulinum toxin injections for the treatment of hemifacial spasm over 16 years

The aim of this study was to investigate the efficacy and side effects of botulinum toxin (BTX) in the treatment of hemifacial spasm (HFS). We also focused on the divergence between different injection techniques and commercial forms. We retrospectively evaluated 470 sessions of BTX injections administered to 68 patients with HFS. The initial time of improvement, duration and degree of improvement, and frequency and duration of adverse effects were analysed. Pretarsal and preseptal injections and Botox (Allergan, Irvine, CA, USA) and Dysport (Ipsen Biopharmaceuticals, Paris, France) brands were compared in terms of efficacy and side effects, accompanied by a review of papers which reported BTX treatment of HFS. An average of 34.5 units was used per patient. The first improvement was felt after 8 days and lasted for 14.8 weeks. Patients experienced a 73.7% improvement. In 79.7% of injections, no adverse effect was reported, in 4.9% erythema, ecchymosis, and swelling in the injection area, in 3.6% facial asymmetry, in 3.4% ptosis, in 3.2% diplopia, and in 2.3% difficulty of eye closure was detected. Patients reported 75% improvement on average after 314 sessions of pretarsal injections and 72.7% improvement after 156 sessions of preseptal injections (p=0.001). The efficacy and side effects of Botox and Dysport were similar. BTX is an effective and safe treatment option for HFS. No difference was determined between Botox and Dysport, and pretarsal injection is better than preseptal injection regarding the reported degree of improvement.

Botulinum toxin in the management of blepharospasm: current evidence and recent developments

Blepharospasm is a focal (although usually bilateral) dystonia of the orbicularis oculi muscles, producing excessive eye closure. This produces significant disability through functional blindness. Botulinum neurotoxins (BoNT) have become the treatment of choice for blepharospasm; the impressive response rate and the tolerable safety profile have been proven through multiple clinical studies. There are currently four BoNT approved in the United States for different indications - we review the data on blepharospasm for each of these drugs. Currently, incobotulinumtoxinA and onabotulinumtoxinA have the most evidence of benefit for patients with blepharospasm. Current evidence, recent development and future directions are discussed.

Isosorbide dinitrate ointment vs botulinum toxin A (Dysport) as the primary treatment for chronic anal fissure: a randomized multicentre study

AIM

Nitric oxide donors, such as isosorbide dinitrate ointment (ISDN), are considered as first-choice agents in the treatment of chronic anal fissure. Injection with botulinum toxin A in the internal anal sphincter is often used as a second-line therapy, although it may give better results and fewer side effects than nitric oxide donors. The aim of this randomized clinical trial was to investigate whether botulinum toxin A (Dysport) is more effective than ISDN in the primary treatment of chronic anal fissure.

METHOD

From April 2005 until October 2009, 60 patients (32 men) with a median age of 42 (25-82) years were randomized to receive either ISDN 10 mg/ml (1%) (n = 33) or injection with 60 units of Dysport (n = 27). The primary end-point was the percentage of complete fissure healing after 8 weeks.

RESULTS

After a median of 9 weeks complete fissure healing was noted in 18 of 27 patients in the Dysport group and in 11 of 33 patients in the ISDN group (P = 0.010). Absolute improvement of pain scores after 9 weeks was similar in both groups (P = 0.733). Patients treated with Dysport had fewer side effects than patients treated with ISDN (P = 0.028). Of the patients with a healed fissure, 28% of the Dysport group and 50% of the ISDN group had a recurrence within 1 year (P = 0.286; hazard ratio 2.08; 95% CI = 0.54-7.97).

CONCLUSION

Dysport is more effective than ISDN ointment and has fewer side effects in the primary treatment of chronic anal fissure. The recurrence rate within 1 year in both treatment groups is high.

Intravesical botulinum type-A toxin (Dysport®) in the treatment of idiopathic detrusor overactivity in children

OBJECTIVE

Botulinum type-A toxin is increasingly used for refractory idiopathic detrusor overactivity (IDO) in children. We reviewed our experience and sought to ascertain the influence of dose and functional bladder capacity on outcome.

PATIENTS AND METHODS

Thirty patients, aged 6-16 years, with urodynamically proven IDO, had intravesical injections of 400-500 iu of Dysport(®). Outcome was assessed clinically at least 5 months after the injection.

RESULTS

Data were available for 27 patients. Urinary frequency was improved in 10; nocturia was improved in 7. Urgency resolved in 10 patients and urge incontinence in 12 (44%). Complications reported were UTI (7), urinary retention (1) and bladder pain (1). The dose of Dysport(®) used was not significantly higher (14 iu/kg v 13 iu/kg) in patients dry at follow up than in those who remained wet (p = 0.45). Functional bladder capacity was not significantly different in patients dry after treatment (p = 0.82).

CONCLUSION

This retrospective study demonstrates similar response to a single treatment with intravesical Botulinum type-A toxin to previous series. We did not demonstrate a correlation between dose or functional bladder capacity and resolution of incontinence. A multi-centre study is required to further investigate this promising treatment.

An updated systematic review and statistical comparison of standardised mean outcomes for the use of botulinum toxin in the management of lower urinary tract disorders

CONTEXT

Botulinum toxin A (BoNTA) has received regulatory approval for use in neurogenic detrusor overactivity (NDO) and overactive bladder (OAB), but it remains unlicensed in other lower urinary tract symptoms (LUTS) indications such as nonneurogenic LUTS in men with benign prostatic enlargement (LUTS/BPE), bladder pain syndrome (BPS), and detrusor sphincter dyssynergia (DSD).

OBJECTIVE

To compare statistically the outcomes of high level of evidence (LE) studies with placebo using BoNTA for LUTS indications; NDO, OAB, LUTS/BPE, BPS and DSD.

EVIDENCE ACQUISITION

We conducted a systematic review of the published literature on PubMed, Scopus, and Embase reporting on BoNTA use in LUTS dysfunction. Statistical comparison was made between high LE studies with placebo and low LE studies.

EVIDENCE SYNTHESIS

In adult NDO, there are significantly greater improvements with BoNTA in daily incontinence and catheterisation episodes (-63% and -18%, respectively; p<0.01), and the urodynamic parameters of maximum cystometric capacity (MCC), reflex volume, and maximum detrusor pressure (MDP) (68%, 61%, and -42%, respectively; all p<0.01). In OAB, BoNTA leads to significant improvements in bladder diary parameters such as daily frequency (-29%), daily urgency (-38%), and daily incontinence (-59%) (all p<0.02). The urodynamic parameters of MCC and MDP improved by 58% (p=0.04) and -29% (p=0.002), respectively. The risk of urinary tract infection was significantly increased from placebo at 21% versus 7% (p<0.001), respectively; the risk of intermittent self-catherisation increased from 0% to 12% (p<0.001). Men with LUTS/BPE showed no significant improvements in International Prostate Symptom Score, maximum flow rate, or prostate volume. There were insufficient data for statistical analysis in DSD, BPS, and paediatric studies. Low LE studies were found to overestimate the effects of BoNTA in all indications, but differences from high LE studies were significant in only a few parameters.

CONCLUSIONS

BoNTA significantly improves all symptoms and urodynamic parameters in NDO and OAB. The effect of BoNTA in treating LUTS dysfunction appears to be overestimated in lower as opposed to higher LE studies.

Comparing the efficacy of botulinum toxin with tizanidine in upper limb post stroke spasticity

BACKGROUND

This study evaluated the efficacy of focal intramuscular injection of botulinum (BoNT) toxin type A in comparison with oral tizanidine (TZD) in treatment of post-stroke upper limb spasticity.

METHODS

This was a double-blinded randomized clinical trial that recruited 68 patients with post-stroke upper limb spasticity. Thirty-four patients received BoNT (Dysport(®)) injections in affected muscles of upper limb at the baseline and week 12. Thirty-four patients were treated with tizanidine (Sirdalude) by gradual increase in dosage of 2mg/week to reach maximum 24mg at week 12. Modified Ashworth Scale (MAS) and Action Research Arm Test (ARAT) were evaluated at the baseline, week 12 and week 24 for all the participants.

RESULTS

The mean score of MAS reduced from 3.32 and 3.13 at baseline to 1.79 and 1.56 at week 24 on elbow and wrist joints, respectively (P < 0.01). However, there were only reductions from 2.79 and 2.77 to 2.32 and 2.31 (P < 0.001) in TZD group. ARAT increased from 1.79 to 10.97 (P < 0.001) in BoNT group. ARAT increased from 11.08 to 11.35 in TZD group (P = 0.026).

CONCLUSION

BoNT injection was safe and effective in reducing post-stroke upper extremity spasticity in comparison with TZD.

Lidocaine Cyclodextrin complex Ophthalmic Drop, a New Topical Anesthetic Choice

BACKGROUND

Topical anesthesia is a safe and cost-effective method considered as the first-choice in many procedures. Due to the physiological characteristics of eye, most of the local anesthetics cannot efficiently penetrate through the conjunctiva deep to tenon. The aim of this pilot study was to find a new form of lidocaine to give a sufficient level of anesthesia.

METHODS

Lidocaine Cyclodextrin complex ophthalmic drop was produced and its pharmacological properties were studied [tested] in standard temperature and pressure. 30 patients (18 males, 12 females) with the mean age of 30.68±8.02 years enrolled in this clinical trial. All the patients were fully informed and signed the ethics committee consent forms. The patients were given tetracaine drop as the anesthetic: 3 drops separated 2 minute apart 10 min before the intervention. If we achieved a sufficient level of anesthesia, the procedure was done after. If the patient could not tolerate the procedure, the method was changed to lidocaine drop (administered after wash-out period like the first drop).The last option was conventional injection method if the patient could not tolerate the procedure with the second method either.We used this type of anesthesia for conventional procedures such as forced duction test, symblepharon, pterygium, and disport injection into extra-ocular muscles. All the procedures were done by one surgeon in a university hospital. We used a 0 to 10 visual analogue scale for pain and two 0 to 4 patient and physician satisfaction scales designed for this study.

RESULTS

The mean pain score was 7.53±0.90 in group 1 and 3.03±1.83 in group 2 (P=0.00). Patient and surgeon satisfaction in group 1 were 1.33±0.48 and 1.40±0.56 respectively; while 3.23±1.00 and 3.56±0.77 for group 2 (P=0.00). Tetracaine drop could not induce sufficient anesthesia for none of the patients. Cyclodextrin based lidocaine drop was successful except For two patients for whom we changed the anesthesia to Sub-conjunctival injection method.

CONCLUSION

Our newly manufactured cyclodextrin based lidocaine eye drop could successfully induce sufficient anesthesia for 28 of 30 patients. Further studies with larger sample sizes are now being designed to find more clinical evidence about this method.

Botulinum toxin type A for the management of glabellar rhytids

There is an increasing demand for minimally-invasive cosmetic procedures to arrest the aging process. Botulinum toxin type A injections are the most commonly used nonsurgical cosmetic procedures in the United States. There has been research spanning over two decades dedicated to safety, efficacy, dosing, and complications of botulinum toxin type A. There are now two Food and Drug Administration (FDA) approved botulinum toxin type A options in the United States: Botox(®) and Dysport(™), with new advances being made in the field.