A preliminary comparison of the efficacy and tolerability of botulinum toxin serotypes A and B in the treatment of myofascial pain syndrome: a retrospective, open-label chart review

The Evaluation of the Clinical Effects of Botulinum Toxin on Nocturnal Bruxism

OBJECTIVES

Nocturnal bruxism can be managed by botulinum toxin (Botox®) in patients who have not responded to conservative treatment. The aim of this study was to evaluate the efficacy of botulinum toxin A (BTXA) in the treatment of nocturnal bruxism.

MATERIAL AND METHODS

The retrospective study comprised 25 female patients, aged 23-55 years (mean 35.84 ± 8.41 years). All patients received a single injection of BTXA in the right and left masseters. Evaluation was made by Visual Analogue Scale (VAS) values, complaint duration, onset of effect, and duration of effectiveness.

RESULTS

BTXA produced significant improvements in pain scores. Only 2 adverse events (8%) were recorded.

CONCLUSION

BTX-A is effective in the treatment of nocturnal bruxism.

RimabotulinumtoxinB in sialorrhea: systematic review of clinical trials

OBJECTIVE

The aim of this study was to examine the efficacy, safety and dosing practices of rimabotulinumtoxinB (BoNT-B) for the treatment of patients with sialorrhea based on a systematic review of clinical trials.

METHODS

A systematic literature review was performed to identify randomized controlled trials and other comparative clinical studies of BoNT-B for the treatment of sialorrhea published in English between January 1999 and December 2015. Medical literature databases (PubMed, Cochrane Library, and EMBASE) were searched and a total of 41 records were identified. Of these, six primary publications that evaluated BoNT-B for the treatment of sialorrhea met criteria and were included in the final data report.

SYNTHESIS

Total BoNT-B doses ranged from 1500 to 4000 units for sialorrhea. Most of the studies in sialorrhea showed statistically significant benefits of BoNT-B versus placebo (range 4-19.2 weeks). BoNT-B was generally well tolerated across the individual studies; most adverse events reported were considered unrelated to treatment. Adverse events considered potentially associated with BoNT-B included: dry mouth, change in saliva thickness, mild transient dysphagia, mild weakness of chewing and diarrhea.

CONCLUSIONS

BoNT-B significantly reduces sialorrhea at doses between 1500 and 4000 units. The relatively mild dose-dependent adverse events suggest both direct and remote toxin effects.

Botulinum Toxin A and B: A Comparative Dosing Study for Spasmodic Dysphonia

OBJECTIVE: The purpose of this study was to find the conversion factor, safety, and efficacy of type A to type B toxin for laryngeal muscles.

METHODS: Thirty-two patients with adductor spasmodic dysphonia with stable doses of A toxin to manage their symptom were given type B toxin starting at a conversion of 1 Uof BTX-A to 50 U of BTX-B. The patients were followed for 1 year, and doses adjusted according to response.

RESULTS: The conversion factor was found to be 52.3 U:1 U. The onset of action of type B was more rapid (2.09 days vs 3.2 days [ P = 0.028]), with a shorter duration of benefit (10.8 weeks vs 17 weeks [ P = 0.002). The safety profile for A and B toxin appeared the same, with 3 patients receiving Myobloc reporting dry mouth.

CONCLUSION: This study shows that a conversion factor of 52.3:1 Myobloc (BTX-B) to Botox (BTX-A) and that Myobloc is an effective alternative to Botox (BTX-A) for patients with spasmodic dysphonia.

EBM RATING: B-2

Botulinum injection for the management of myofascial pain in the masticatory muscles. A prospective outcome study

We prospectively analysed the outcome after botulinum injection in patients who did not recover after conservative measures to manage masticatory myofascial pain, and who were not willing to take low dose tricyclic antidepressants as a muscle relaxant. We prospectively 62 patients were assessed with visual analogue scores (VAS) for pain on the affected side before, and 6 weeks after botulinum injection(s) (50 units Dysport in up to 3 sites), and measured mouth opening in mm. Of those treated 49 (79%) showed at least some improvement (pain reduced by more than 25%). Patients reported more than a 90% reduction in the VAS for 25 (30%) of the 84 sides of the face treated. Only 22 of the 62 patients had more than one course of treatment to the same side. Interincisal distance improved by a mean/median of 0.9 mm (p<0.03) after treatment. Side effects included 3 cases of temporary weakness of a facial muscle. Ranking the VAS pain scores using the Wilcoxon test before and after injection showed a significant reduction in pain (median change -29.5, interquartile range -53 to -16, p<0.0001). The treatment significantly improved patients' pain scores and the overall mean/median reduction in pain was 57%. Botulinum injection does not guarantee complete resolution of myofascial pain, but it usually has some beneficial effect in improving the symptoms, and should be considered as an alternate treatment for masticatory myofascial pain if conservative methods have failed.

Therapeutic use of botulinum toxin in neurorehabilitation

The botulinum toxins (BTX), type A and type B by blocking vesicle acetylcholine release at neuro-muscular and neuro-secretory junctions can result efficacious therapeutic agents for the treatment of numerous disorders in patients requiring neuro-rehabilitative intervention. Its use for the reduction of focal spasticity following stroke, brain injury, and cerebral palsy is provided. Although the reduction of spasticity is widely demonstrated with BTX type A injection, its impact on the improvement of dexterity and functional outcome remains controversial. The use of BTX for the rehabilitation of children with obstetrical brachial plexus palsy and in treating sialorrhea which can complicate the course of some severe neurological diseases such as amyotrophic lateral sclerosis and Parkinson's disease is also addressed. Adverse events and neutralizing antibodies formation after repeated BTX injections can occur. Since impaired neurological persons can have complex disabling feature, BTX treatment should be viewed as adjunct measure to other rehabilitative strategies that are based on the individual's residual ability and competence and targeted to achieve the best functional recovery. BTX therapy has high cost and transient effect, but its benefits outweigh these disadvantages. Future studies must clarify if this agent alone or adjunctive to other rehabilitative procedures works best on functional outcome.

Botulinum toxin A versus B in sialorrhea: a prospective, randomized, double-blind, crossover pilot study in patients with amyotrophic lateral sclerosis or Parkinson's disease

BACKGROUND

Either botulinum toxins (BoNTs) A and B have been used for improving drooling in different neurological conditions.

METHODS

Consecutive patients affected by Amyotrophic Lateral Sclerosis (ALS) or Parkinson's Disease (PD) accompanied by severe drooling were randomized to receive botulinum neurotoxin type A (BoNT-A) or B (BoNT-B) injections into the salivary glands. Following the first treatment, when sialorrhea returned to baseline (at least three months after the first injection), subjects were re-treated with the other serotype. Ultrasound-guided injections into parotid and submandibular glands were bilaterally performed: total doses were 250 U BoNT-A (Dysport) and 2500 U BoNT-B (Neurobloc). Objective (cotton roll weight) and subjective (ad hoc clinical scales) evaluations were performed at baseline, after 1 and 4 weeks, and every 4 weeks until drooling returned to baseline.

RESULTS

Twenty-seven patients (15 ALS and 12 PD) were enrolled, fourteen completed the study. BoNT-A and BoNT-B treatments gave both subjective and objective improvements in all patients. The latency was significantly shorter after BoNT-B treatments (3.2 ± 3.7 days) compared to BoNT-A (6.6 ± 4.1 days; P = 0.002). The mean benefit duration was similar at 75 and 90 days for BoNT-A and BoNT-B, respectively (P = NS). The only toxin-related side effect was a change to saliva thickness.

CONCLUSIONS

Either 250 U Dysport or 2500 U Neurobloc have similar effectiveness and safety in controlling sialorrhea. BoNT-B has a shorter latency and comparable duration. Cost analysis, considering the doses used in this study protocol favored BoNT-B treatment.

Botulinum toxin type A in the treatment of primary axillary hyperhidrosis: a 52-week multicenter double-blind, randomized, placebo-controlled study of efficacy and safety

BACKGROUND

The long-term effects of botulinum toxin type A (BoNTA) on the global impairment associated with severe primary axillary hyperhidrosis have not been comprehensively assessed relative to placebo.

OBJECTIVE

To assess the efficacy and safety of 2 dosages of BoNTA compared with placebo in subjects with primary axillary hyperhidrosis.

METHODS

Subjects (N = 322) were randomized to the use of BoNTA (75 U or 50 U/axilla) or placebo in this 52-week, multicenter, double-blind study.

RESULTS

BoNTA treatment significantly reduced daily activity limitations at 4 weeks after injection. A 2-point improvement on the 4-point Hyperhidrosis Disease Severity Scale (HDSS) was reported in 75% of subjects in the 75-U and 50-U BoNTA groups and in 25% of the placebo group (P < .001). Improvements in HDSS scores were corroborated by gravimetric results. The median duration of effect was 197 days, 205 days, and 96 days in the 75-U, 50-U, and placebo groups, respectively. BoNTA was well tolerated.

LIMITATIONS

The effect of total surface area involvement on treatment efficacy was not evaluated.

CONCLUSION

BoNTA treatment effectively reduces the symptoms of primary axillary hyperhidrosis and is well tolerated.

Place des doses élevées dans les injections de toxine botulique

OBJECTIVE

To bring general elements of reflection on the use of the high doses of botulinum toxin in spastic children and adults.

MATERIAL AND METHODS

Review of the literature on the high doses and the benefit-risk associated with botulinum toxin injections.

RESULTS

The medical literature exclusively relates to the use of the high doses in children and adolescents. Comparative work with conventional doses suggests a relative interest, but with a risk of increased side effects. Several articles report on treatments with high and even very high doses in series of patient, with a documented effectiveness. But their justification remains partial and the study of the possible side effects is limited. Reflections are brought to contribute to the debate on the use of high doses, taking into account the local physiological effect of botulinum toxin, the risk of regional and general diffusion, the need for a progressive strategy, the variability of effects, the cost of the treatment and the need for obtaining an informed consent of the patient and of significant others.

CONCLUSION

The use of high doses of botulinum toxin increases progressively, but must remain very careful.

From frown lines to fissures: Therapeutic uses for botulinum toxin

INTRODUCTION

Since the pharmacological mode of action of botulinum toxin (BTX) has been elucidated, its therapeutic potential has been increasingly recognised. The aims of this review were to summarize our current understanding of the pharmacological action of this agent and to review its therapeutic uses.

METHODS

An electronic literature search with Medline (January 1965 to December 2004) was carried out to identify articles related to the pharmacological mode of action and clinical uses for botulinum toxin using the keyword "botulinum toxin".

RESULTS AND CONCLUSION

Botulinum toxin A is emerging as a valuable clinical tool, both for diagnostic and therapeutic purposes in a wide variety of disorders, and is already the treatment of choice for selected conditions. Better understanding of its modes of action may identify alternative targets for pharmacological intervention, and may allow development of longer acting drugs with lower immunogenicity. Therapeutic uses of BTX-A must be assessed systematically in prospective studies, and the clinical role of other subtypes requires evaluation.