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Vergallo A, Cocco A, De Santis T, Lalli S, Albanese A. Eligibility criteria in clinical trials for cervical dystonia. Parkinsonism Relat Disord 2022; 104:110-114. [PMID: 36243553 DOI: 10.1016/j.parkreldis.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 09/10/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Cervical dystonia (CD) is the most common form of adult-onset focal dystonia. Because of a heterogeneous clinical presentation, the diagnosis rests on clinical opinion. During the last decades, several clinical trials have tested safety and efficacy of medical and surgical treatments for CD. We analyzed all the published CD trials and reviewed the strategies adopted for patient enrollment. METHODS The review included clinical trials in patients with CD published in PubMed. Studies were excluded if reviews, meta-analyses, post-hoc analyses on pooled data, or if not reporting a treatment for CD. RESULTS A total of 174 articles were identified; 134 studies met inclusion criteria. Diagnosis of CD varied among studies and in most cases was based on clinical judgement, using different descriptors such as "cervical dystonia" (37 studies), "idiopathic or isolated CD" (35), "primary CD" (13), and "torticollis" (40). Clinical judgement was supported by a phenomenological description of dystonia in four studies, and by a specific diagnostic strategy in other four. Finally, one study adopted general diagnostic criteria for dystonia. Inclusion and exclusion criteria proved heterogeneous across trials and were defined only in 108 studies, mainly considering age or the phenomenological pattern of muscle involvement. CONCLUSION The review showed lack of consolidated diagnostic criteria and non-uniformity of eligibility criteria for CD across clinical trials. There is need to move beyond clinical judgement as diagnostic criterion for selecting participants. New trials assessing specific CD patient subgroups or comparing medical and surgical procedures will need grounds that are more consistent.
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Affiliation(s)
- Andrea Vergallo
- Department of Neurology, IRCCS Humanitas Research Hospital, Rozzano, Milano, Italy
| | - Antoniangela Cocco
- Department of Neurology, IRCCS Humanitas Research Hospital, Rozzano, Milano, Italy
| | - Tiziana De Santis
- Department of Neurology, IRCCS Humanitas Research Hospital, Rozzano, Milano, Italy
| | - Stefania Lalli
- Department of Neurology, IRCCS Humanitas Research Hospital, Rozzano, Milano, Italy
| | - Alberto Albanese
- Department of Neurology, IRCCS Humanitas Research Hospital, Rozzano, Milano, Italy.
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Eleopra R, Rinaldo S, Montecucco C, Rossetto O, Devigili G. Clinical duration of action of different botulinum toxin types in humans. Toxicon 2020; 179:84-91. [PMID: 32184153 DOI: 10.1016/j.toxicon.2020.02.020] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 02/04/2020] [Accepted: 02/26/2020] [Indexed: 12/21/2022]
Abstract
The Botulinum NeuroToxin (BoNT) comprises several serotypes with distinct properties, mechanisms of action, sensitivity and duration of effect in different species. The serotype A (BoNT/A) is the prevalent neurotoxin applied in human's disease. In this paper we present an overview of the current knowledge regarding the duration of effect and the neuromuscular sprouting of different BoNT serotypes in humans. Then, we report the original results of a study in healthy subjects treated with BoNT/A, B, C and F using different neurophysiological techniques. Twelve healthy volunteers (7 men, 5 women) are treated with BoNT/A, B, C and F or placebo in Abductor digiti minimi (ADM) muscle of the hand. Before and after injections, an extensive neurophysiological study is performed with the CMAP amplitude variation, Multi-Motor Unit Action Potentials (MUAPs) analysis, the Turns/Amplitude ratio of interference pattern (IP) and determination of jitter and Fiber Density (FD) at single-fiber electromyography (SFEMG), at week 2 (w2), 4 (w4), 6 (w6) and 8 (w8). A maximal neuromuscular block is obtained at w2 for all the serotypes. Afterwards, the CMAP trend appear similar for BoNT/A, B, and C while, BoNT/F shows a faster recover. Multi-MUAPs analysis and IP detect mild changes at w2 for all serotypes, except for BoNT/F that shows a greater change since w4. SFEMG have minimal changes in FD while, Jitter increase at w2 with a slower decrease over the time for all BoNTs. In conclusion, BoNT/F has earlier sprouting and complete recovery at w8. Other serotypes present a slower and similar profile. The EMG appear useful to study the functional recovery in humans, and these results should provide new evidence for assessing different serotypes. These findings improve our knowledge regarding the methods to evaluate duration of effects and dose equivalents in different serotypes, that in the future could change the clinicians strategy for disease-tailored BoNT therapies.
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Affiliation(s)
- Roberto Eleopra
- Neurological Unit 1, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, 20133, Milan, Italy.
| | - Sara Rinaldo
- Neurological Unit 1, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, 20133, Milan, Italy.
| | - Cesare Montecucco
- Biochemical Science Department University of Padua, 35121, Padova, Italy.
| | - Ornella Rossetto
- Biochemical Science Department University of Padua, 35121, Padova, Italy.
| | - Grazia Devigili
- Neurological Unit 1, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, 20133, Milan, Italy.
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Kutschenko A, Weisemann J, Kollewe K, Fiedler T, Alvermann S, Böselt S, Escher C, Garde N, Gingele S, Kaehler SB, Karatschai R, Krüger THC, Sikorra S, Tacik P, Wegner F, Wollmann J, Bigalke H, Wohlfarth K, Rummel A. Botulinum neurotoxin serotype D - A potential treatment alternative for BoNT/A and B non-responding patients. Clin Neurophysiol 2019; 130:1066-1073. [PMID: 30871800 DOI: 10.1016/j.clinph.2019.02.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 01/28/2019] [Accepted: 02/10/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Botulinum neurotoxin serotypes A and B (BoNT/A & B) are highly effective medicines to treat hyperactive cholinergic neurons. Due to neutralizing antibody formation, some patients may become non-responders. In these cases, the serotypes BoNT/C-G might become treatment alternatives. BoNT/D is genetically least related to BoNT/A & B and thereby circumventing neutralisation in A/B non-responders. We produced BoNT/D and compared its pharmacology with BoNT/A ex vivo in mice tissue and in vivo in human volunteers. METHODS BoNT/D was expressed recombinantly in E. coli, isolated by chromatography and its ex vivo potency was determined at mouse phrenic nerve hemidiaphragm preparations. Different doses of BoNT/D or incobotulinumtoxinA were injected into the extensor digitorum brevis (EDB) muscles (n = 30) of human volunteers. Their compound muscle action potentials were measured 11 times by electroneurography within 220 days. RESULTS Despite a 3.7-fold lower ex vivo potency in mice, a 110-fold higher dosage of BoNT/D achieved the same clinical effect as incobotulinumtoxinA while showing a 50% shortened duration of action. CONCLUSIONS BoNT/D blocks dose-dependently acetylcholine release in human motoneurons upon intramuscular administration, but its potency and duration of action is inferior to approved BoNT/A based drugs. SIGNIFICANCE BoNT/D constitutes a potential treatment alternative for BoNT/A & B non-responders.
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Affiliation(s)
- Anna Kutschenko
- Neurologische Klinik mit Klinischer Neurophysiologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Jasmin Weisemann
- Institut für Toxikologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Katja Kollewe
- Neurologische Klinik mit Klinischer Neurophysiologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Thiemo Fiedler
- Kliniken für Neurologie, Frührehabilitation und Stroke Unit, Berufsgenossenschaftliche Kliniken Bergmannstrost, Halle (Saale), Germany
| | - Sascha Alvermann
- Neurologische Klinik mit Klinischer Neurophysiologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Sebastian Böselt
- Neurologische Klinik mit Klinischer Neurophysiologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Claus Escher
- Neurologische Klinik mit Klinischer Neurophysiologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Niklas Garde
- Neurologische Klinik mit Klinischer Neurophysiologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Stefan Gingele
- Neurologische Klinik mit Klinischer Neurophysiologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Stefan-Benno Kaehler
- Kliniken für Neurologie, Frührehabilitation und Stroke Unit, Berufsgenossenschaftliche Kliniken Bergmannstrost, Halle (Saale), Germany
| | - Ralf Karatschai
- Kliniken für Neurologie, Frührehabilitation und Stroke Unit, Berufsgenossenschaftliche Kliniken Bergmannstrost, Halle (Saale), Germany
| | - Tillmann H C Krüger
- Klinik für Psychiatrie, Sozialpsychiatrie und Psychotherapie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Stefan Sikorra
- Institut für Zellbiochemie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Pawel Tacik
- Neurologische Klinik mit Klinischer Neurophysiologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Florian Wegner
- Neurologische Klinik mit Klinischer Neurophysiologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Johannes Wollmann
- Kliniken für Neurologie, Frührehabilitation und Stroke Unit, Berufsgenossenschaftliche Kliniken Bergmannstrost, Halle (Saale), Germany
| | - Hans Bigalke
- Institut für Toxikologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Kai Wohlfarth
- Kliniken für Neurologie, Frührehabilitation und Stroke Unit, Berufsgenossenschaftliche Kliniken Bergmannstrost, Halle (Saale), Germany.
| | - Andreas Rummel
- Institut für Toxikologie, Medizinische Hochschule Hannover, Hannover, Germany.
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Fonfria E, Maignel J, Lezmi S, Martin V, Splevins A, Shubber S, Kalinichev M, Foster K, Picaut P, Krupp J. The Expanding Therapeutic Utility of Botulinum Neurotoxins. Toxins (Basel) 2018; 10:E208. [PMID: 29783676 PMCID: PMC5983264 DOI: 10.3390/toxins10050208] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 05/15/2018] [Accepted: 05/16/2018] [Indexed: 12/11/2022] Open
Abstract
Botulinum neurotoxin (BoNT) is a major therapeutic agent that is licensed in neurological indications, such as dystonia and spasticity. The BoNT family, which is produced in nature by clostridial bacteria, comprises several pharmacologically distinct proteins with distinct properties. In this review, we present an overview of the current therapeutic landscape and explore the diversity of BoNT proteins as future therapeutics. In recent years, novel indications have emerged in the fields of pain, migraine, overactive bladder, osteoarthritis, and wound healing. The study of biological effects distal to the injection site could provide future opportunities for disease-tailored BoNT therapies. However, there are some challenges in the pharmaceutical development of BoNTs, such as liquid and slow-release BoNT formulations; and, transdermal, transurothelial, and transepithelial delivery. Innovative approaches in the areas of formulation and delivery, together with highly sensitive analytical tools, will be key for the success of next generation BoNT clinical products.
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Affiliation(s)
- Elena Fonfria
- Ipsen Bioinnovation, 102 Park Drive, Milton Park, Abingdon, Oxfordshire OX14 4RY, UK.
| | - Jacquie Maignel
- Ipsen Innovation, 5 Avenue du Canada, 91940 Les Ulis, France.
| | - Stephane Lezmi
- Ipsen Innovation, 5 Avenue du Canada, 91940 Les Ulis, France.
| | - Vincent Martin
- Ipsen Innovation, 5 Avenue du Canada, 91940 Les Ulis, France.
| | - Andrew Splevins
- Ipsen Bioinnovation, 102 Park Drive, Milton Park, Abingdon, Oxfordshire OX14 4RY, UK.
| | - Saif Shubber
- Ipsen Biopharm Ltd., Wrexham Industrial Estate, 9 Ash Road, Wrexham LL13 9UF, UK.
| | | | - Keith Foster
- Ipsen Bioinnovation, 102 Park Drive, Milton Park, Abingdon, Oxfordshire OX14 4RY, UK.
| | - Philippe Picaut
- Ipsen Bioscience, 650 Kendall Street, Cambridge, MA 02142, USA.
| | - Johannes Krupp
- Ipsen Innovation, 5 Avenue du Canada, 91940 Les Ulis, France.
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Current status and future directions of botulinum neurotoxins for targeting pain processing. Toxins (Basel) 2015; 7:4519-63. [PMID: 26556371 PMCID: PMC4663519 DOI: 10.3390/toxins7114519] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 09/29/2015] [Accepted: 10/19/2015] [Indexed: 12/20/2022] Open
Abstract
Current evidence suggests that botulinum neurotoxins (BoNTs) A1 and B1, given locally into peripheral tissues such as skin, muscles, and joints, alter nociceptive processing otherwise initiated by inflammation or nerve injury in animal models and humans. Recent data indicate that such locally delivered BoNTs exert not only local action on sensory afferent terminals but undergo transport to central afferent cell bodies (dorsal root ganglia) and spinal dorsal horn terminals, where they cleave SNAREs and block transmitter release. Increasing evidence supports the possibility of a trans-synaptic movement to alter postsynaptic function in neuronal and possibly non-neuronal (glial) cells. The vast majority of these studies have been conducted on BoNT/A1 and BoNT/B1, the only two pharmaceutically developed variants. However, now over 40 different subtypes of botulinum neurotoxins (BoNTs) have been identified. By combining our existing and rapidly growing understanding of BoNT/A1 and /B1 in altering nociceptive processing with explorations of the specific characteristics of the various toxins from this family, we may be able to discover or design novel, effective, and long-lasting pain therapeutics. This review will focus on our current understanding of the molecular mechanisms whereby BoNTs alter pain processing, and future directions in the development of these agents as pain therapeutics.
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Guo J, Wang J, Chan EW, Chen S. Exploration of endogenous substrate cleavage by various forms of botulinum neurotoxins. Toxicon 2015; 100:42-5. [PMID: 25912942 DOI: 10.1016/j.toxicon.2015.04.008] [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: 02/05/2015] [Revised: 04/02/2015] [Accepted: 04/21/2015] [Indexed: 11/28/2022]
Abstract
Botulinum neurotoxins are the most potent protein neurotoxin known to human. The dual roles of BoNTs as both the causative agent of human botulism and a widely used protein-based therapeutic agent for treatment of numerous neuromuscular disorders/cosmetic uses make it an extremely hot topic of research. Biochemical characterization of these toxins was mainly confined to the recombinant light chains and substrate and little is known about their efficiency on the cleavage of endogenous substrates. In the present study, we showed that BoNTs exhibited variable activities on their endogenous substrates and that their efficiency to cleave recombinant and endogenous substrate was not consistent, presumably due to the differential recognition of their respective substrates in the natural SNARE complex format. Through testing the combinatorial effects of different BoNTs on cleavage of endogenous substrates, we showed that the combinations of LC/A and LC/B, as well as LC/A and LC/F, could enhance the activity of each individual BoNT. This finding may shed light on the future development of new BoNT serotypes for clinical application, and formulation of combinatorial uses of different BoNTs to minimize the development of immuno-resistance by using a lower amount of individual type.
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Affiliation(s)
- Jiubiao Guo
- Shenzhen Key Lab for Food Biological Safety Control, Food Safety and Technology Research Center, Hong Kong PolyU Shen Zhen Research Institute, Shenzhen, PR China; State Key Lab of Chirosciences, Department of Applied Biology and Chemical Technology, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong, PR China
| | - Jinglin Wang
- State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Fengtai District, Beijing, PR China
| | - Edward Waichi Chan
- Shenzhen Key Lab for Food Biological Safety Control, Food Safety and Technology Research Center, Hong Kong PolyU Shen Zhen Research Institute, Shenzhen, PR China; State Key Lab of Chirosciences, Department of Applied Biology and Chemical Technology, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong, PR China
| | - Sheng Chen
- Shenzhen Key Lab for Food Biological Safety Control, Food Safety and Technology Research Center, Hong Kong PolyU Shen Zhen Research Institute, Shenzhen, PR China; State Key Lab of Chirosciences, Department of Applied Biology and Chemical Technology, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong, PR China.
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7
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Wheeler A, Smith HS. Botulinum toxins: mechanisms of action, antinociception and clinical applications. Toxicology 2013; 306:124-46. [PMID: 23435179 DOI: 10.1016/j.tox.2013.02.006] [Citation(s) in RCA: 103] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Revised: 02/07/2013] [Accepted: 02/10/2013] [Indexed: 10/27/2022]
Abstract
Botulinum toxin (BoNT) is a potent neurotoxin that is produced by the gram-positive, spore-forming, anaerobic bacterium, Clostridum botulinum. There are 7 known immunologically distinct serotypes of BoNT: types A, B, C1, D, E, F, and G. Clostridum neurotoxins are produced as a single inactive polypeptide chain of 150kDa, which is cleaved by tissue proteinases into an active di-chain molecule: a heavy chain (H) of ∼100 kDa and a light chain (L) of ∼50 kDa held together by a single disulfide bond. Each serotype demonstrates its own varied mechanisms of action and duration of effect. The heavy chain of each BoNT serotype binds to its specific neuronal ecto-acceptor, whereby, membrane translocation and endocytosis by intracellular synaptic vesicles occurs. The light chain acts to cleave SNAP-25, which inhibits synaptic exocytosis, and therefore, disables neural transmission. The action of BoNT to block the release of acetylcholine botulinum toxin at the neuromuscular junction is best understood, however, most experts acknowledge that this effect alone appears inadequate to explain the entirety of the neurotoxin's apparent analgesic activity. Consequently, scientific and clinical evidence has emerged that suggests multiple antinociceptive mechanisms for botulinum toxins in a variety of painful disorders, including: chronic musculoskeletal, neurological, pelvic, perineal, osteoarticular, and some headache conditions.
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Affiliation(s)
- Anthony Wheeler
- The Neurological Institute, 2219 East 7th Street, Charlotte, NC 28204, United States.
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8
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Dressler D. Clinical applications of botulinum toxin. Curr Opin Microbiol 2012; 15:325-36. [PMID: 22770659 DOI: 10.1016/j.mib.2012.05.012] [Citation(s) in RCA: 115] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Accepted: 05/22/2012] [Indexed: 01/14/2023]
Affiliation(s)
- Dirk Dressler
- Movement Disorders Section, Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany.
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Eleopra R, Tugnoli V, Quatrale R, Rossetto O, Montecucco C, Dressler D. Clinical use of non-A botulinum toxins: botulinum toxin type C and botulinum toxin type F. Neurotox Res 2006; 9:127-31. [PMID: 16785109 DOI: 10.1007/bf03033930] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Botulinum neurotoxin (BoNT) serotype A is commonly used in the treatment of focal dystonia, but some patients are primarily or become secondarily resistant to it. Consequently, other serotypes have to be used when immuno-resistance is proven. In the literature, patients with focal dystonia have been treated with BoNT serotype F with clinical benefit but with short lasting effects. Recently, BoNT serotype C has been used with positive clinical outcome. An update on the clinical use of BoNT serotype F and BoNT serotype C is provided.
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Affiliation(s)
- R Eleopra
- Clinical Neuroscience Department, Neurology Section, Umberto I Hospital, Venice, Italy.
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10
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Tugnoli V, Eleopra R, Montecucco C, De Grandis D. The therapeutic use of botulinum toxin. Expert Opin Investig Drugs 2005; 6:1383-94. [PMID: 15989508 DOI: 10.1517/13543784.6.10.1383] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Since Alan Scott's research, botulinum toxin (BoNT) has been used in several diseases or conditions characterised by muscular overactivity. BoNT acts on either neuromuscular or autonomic cholinergic junctions. Seven different serotypes are known, with antigenic specificity and different therapeutic profiles. BoNT is made up of a heavy chain, involved in binding and membrane translocation, and a light chain, involved in blocking neuroexcytosis. Each serotype shares a specific acceptor on the presynaptic membrane of a cholinergic junction. The available BoNT preparations differ in toxicity, purity and stability. Injection of the neurotoxin produces several modifications at a neuromuscular junction. Axonal sprouting, muscular fibre atrophy, and new end-plates are the most evident histological events after BoNT treatment. They appear to be reversible in untreated muscles. Diffusion can occur at first by haematogeneous or local BoNT spread. Several factors, such as dose, volume, site of injection, muscle size, and muscular fascia, can influence the amount of diffusion and possible side-effects. After prolonged BoNT treatment patients can become unresponsive. Antibodies directed against BoNT have been observed with ELISA or mouse bioassay. Different serotypes have been used to treat non-responder patients. Novel toxins with lower immunogenicity and prolonged clinical efficacy are required for more effective treatment.
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Affiliation(s)
- V Tugnoli
- Neurological Department, St Anna Hospital, Corso Giovecca 203, 44100 Ferrara, Italy
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Abstract
BACKGROUND Botulism caused by type F botulinum toxin accounts for less than 0.1% of all human botulism cases and is rarely reported in the literature. CASE REPORT A 45-year-old woman presented to an emergency department complaining of blurred vision, difficulty focusing, and dysphagia. The treating physician initially considered the possibility of paralytic shellfish poisoning due to a report of shellfish ingestion, which was later determined to be frozen shrimp and a can of tuna, but no gastroenteritis or paresthesias were present. During the emergency department observation, the patient developed respiratory distress with hypercapnea and required intubation and mechanical ventilation. Within hours, ptosis, mydriasis, and weakness in the arms and legs developed. Bivalent (A, B) botulinum antitoxin was administered approximately 24 h from the onset of initial symptoms, but over the next two days complete paralysis progressed to the upper and lower extremities. Shortly thereafter a stool toxin assay demonstrated the presence of type F botulinum toxin. The patient subsequently received an experimental heptavalent botulinum antitoxin on hospital day 7 but paralysis was already complete. Her three-week hospital course was complicated by nosocomial pneumonia and a urinary tract infection, but she gradually improved and was discharged to a rehabilitation facility. Anaerobic cultures and toxin assays have yet to elucidate the source of exposure. CONCLUSION We report a rare case of type F botulism believed to be foodborne in etiology. Administration of bivalent botulinum antitoxin did not halt progression of paralysis.
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Affiliation(s)
- William H Richardson
- California Poison Control System, San Diego Division, San Diego, California, USA.
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Rajkumar GN, Conn IG. Botulinum toxin: a new dimension in the treatment of lower urinary tract dysfunction. Urology 2004; 64:2-8. [PMID: 15245922 DOI: 10.1016/j.urology.2004.03.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2003] [Accepted: 03/01/2004] [Indexed: 11/30/2022]
Affiliation(s)
- G N Rajkumar
- Department of Urology, Southern General Hospital, Glasgow, Scotland, United Kingdom
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Abstract
Since the commercial launch of Dysport in 1991, after 10 years of clinical studies on its predecessor formulations, this BTX-A product has shown great therapeutic promise with a good safety profile and low incidence of treatment failures. As with all BTX products, Dysport should not be seen as a generic equivalent but as a specific product with individual unit dosing requirements and side effect profiles. Its role as an important BTX-A molecule looks set to expand as new indications for botulinum toxin arise, and as the cosmetic usage of Dysport is approved in countries outside of South America.
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Affiliation(s)
- Andrew C Markey
- St. John's Institute of Dermatology, St. Thomas' Hospital, London SE17EH, UK.
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Abstract
Botulinum toxins are among the most potent neurotoxins known to humans. In the past 25 years, botulinum toxin has emerged as both a potential weapon of bioterrorism and as a powerful therapeutic agent, with growing applications in neurological and non-neurological disease. Botulinum toxin is unique in its ability to target peripheral cholinergic neurons, preventing the release of acetylcholine through the enzymatic cleavage of proteins involved in membrane fusion, without prominent central nervous system effects. There are seven serotypes of the toxin, each with a specific activity at the molecular level. Currently, serotypes A (in two preparations) and B are available for clinical use, and have been shown to be safe and effective for the treatment of dystonia, spasticity, and other disorders in which muscle overactivity gives rise to symptoms. This review focuses on the pharmacology, electrophysiology, immunology, and application of botulinum toxin in selected neurological disorders.
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Affiliation(s)
- Cynthia L Comella
- Department of Neurological Sciences, Rush University Medical Center, 1725 West Harrison, Chicago, Illinois 60612, USA.
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Billante CR, Zealear DL, Billante M, Reyes JH, Sant'Anna G, Rodriguez R, Stone RE. Comparison of neuromuscular blockade and recovery with botulinum toxins A and F. Muscle Nerve 2002; 26:395-403. [PMID: 12210370 DOI: 10.1002/mus.10213] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Intramuscular injection of botulinum toxin A is used to treat focal dystonias. Because immunoresistance has been documented in some patients, other molecular forms of the toxin have been evaluated clinically. The present investigation compared the time course and extent of neuromuscular blockade and recovery of botulinum toxin types A and F using an electromyographic monitoring system implanted in the rat hindlimb. For a given dose, the degree and duration of blockade was more complete with type A toxin. Delayed onset of recovery in animals that received high doses of type A toxin allowed time for denervative changes to prevent a full return to baseline, as confirmed histologically. Conversely, animals receiving type F toxin fully recovered within 30 days at all dose levels. The rapid recovery with type F toxin suggested that neuromuscular transmission was restored via the original terminals rather than through functional collateral sprouting. The reversible nature of blockade with this molecular species puts in question its future clinical utility.
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Affiliation(s)
- Cheryl R Billante
- Department of Otolaryngology, Vanderbilt Voice Center, 1500 21st Avenue South, Suite 2700, Nashville, TN 37212, USA.
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Abstract
An open-label study and 2 double-blind, placebo-controlled studies have provided supporting evidence of botulinum toxin type A (BTX-A) as an effective, well-tolerated treatment for migraine. Observed durations of benefit were consistent with known properties of BTX-A. Findings suggest that response may vary by features of preinjection headaches, such as migraine frequency. The precise mechanism by which BTX-A provides pain relief is hypothesized to be related not only to acetylcholine inhibition but also to a blocking action on the parasympathetic nervous system. Additional studies that control factors likely to be related to response may lead to better understanding of the BTX-A effect on migraine and an optimal treatment protocol.
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Abstract
Dystonia is a syndrome of sustained involuntary muscle contractions, frequently causing twisting and repetitive movements or abnormal posturing. Cervical dystonia (CD) is a form of dystonia that involves neck muscles. However, CD is not the only cause of neck rotation. Torticollis may be caused by orthopaedic, musculofibrotic, infectious and other neurological conditions that affect the anatomy of the neck, and structural causes. It is estimated that there are between 60,000 and 90,000 patients with CD in the US. The majority of the patients present with a combination of neck rotation (rotatory torticollis or rotatocollis), flexion (anterocollis), extension (retrocollis), head tilt (laterocollis) or a lateral or sagittal shift. Neck posturing may be either tonic, clonic or tremulous, and may result in permanent and fixed contractures. Sensory tricks ('geste antagonistique') often temporarily ameliorate dystonic movements and postures. Commonly used sensory tricks by patients with CD include touching the chin, back of the head or top of the head. Patients with CD are classified according to aetiology into two groups: primary CD (idiopathic--may be genetic or sporadic) or secondary CD (symptomatic). Patients with primary CD have no evidence by history, physical examination or laboratory studies (except primary dystonia gene) of any secondary cause for the dystonic symptoms. CD is a part of either generalised or focal dystonic syndrome which may have a genetic basis, with an identifiable genetic association. Secondary or symptomatic CD may be caused by central or peripheral trauma, exposure to dopamine receptor antagonists (tardive), neurodegenerative disease, and other conditions associated with abnormal functioning of the basal ganglia. In the majority of patients with CD, the aetiology is not identifiable and the disorder is often classified as primary. Unless the aetiological investigation reveals a specific therapeutic intervention, therapy for CD is symptomatic. It includes supportive therapy and counselling, physical therapy, pharmacotherapy, chemodenervation [botulinum toxin (BTX), phenol, alcohol], and central and peripheral surgical therapy. The most widely used and accepted therapy for CD is local intramuscular injections of BTX-type A. Currently, both BTX type A and type B are commercially available, and type F has undergone testing. Pharmacotherapy, including anticholinergics, dopaminergic depleting and blocking agents, and other muscle relaxants can be used alone or in combination with other therapeutic interventions. Surgery is usually reserved for patients with CD in whom other forms of treatment have failed.
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Affiliation(s)
- M Velickovic
- Department of Neurology, The Mount Sinai Medical Center, New York, New York, 10029, USA.
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18
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Adler CH, Factor SA, Brin M, Sethi KD. Secondary nonresponsiveness to botulinum toxin type A in patients with oromandibular dystonia. Mov Disord 2002; 17:158-61. [PMID: 11835455 DOI: 10.1002/mds.10001] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Intramuscular injection of botulinum toxin type A is the treatment of choice for most cases of oromandibular dystonia. We report on five patients with oromandibular dystonia that developed secondary nonresponsiveness to botulinum toxin type A following multiple injections over a 6-year period.
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Affiliation(s)
- Charles H Adler
- Parkinson's Disease and Movement Disorders Center, Mayo Clinic Scottsdale, Scottsdale, Arizona, USA.
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19
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Binder WJ, Brin MF, Blitzer A, Pogoda JM. Botulinum toxin type A (BOTOX) for treatment of migraine. SEMINARS IN CUTANEOUS MEDICINE AND SURGERY 2001; 20:93-100. [PMID: 11474749 DOI: 10.1053/sder.2001.24423] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
An open-label study and 2 double-blind, placebo-controlled studies have provided supporting evidence of botulinum toxin type A (BTX-A) as an effective, well-tolerated treatment for migraine. Observed durations of benefit were consistent with known properties of BTX-A. Findings suggest that response may vary by features of preinjection headaches, such as migraine frequency. The precise mechanism by which BTX-A provides pain relief is hypothesized to be related not only to acetylcholine inhibition but also to a blocking action on the parasympathetic nervous system. Additional studies that control factors likely to be related to response may lead to better understanding of the BTX-A effect on migraine and an optimal treatment protocol.
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Affiliation(s)
- W J Binder
- Department of Head and Neck Surgery, University of California, Los Angeles, USA.
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20
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Isaac AM. Unilateral temporalis muscle hypertrophy managed with botulinum toxin type A. Br J Oral Maxillofac Surg 2000; 38:571-2. [PMID: 11010798 DOI: 10.1054/bjom.2000.0298] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Abstract
Botulinum toxin is the most potent neurotoxin known, and has been in clinical use since the late 1970s. The toxin inhibits the release of acetylcholine from nerve terminals by inhibiting transport of the synaptic vesicles, thus causing functional denervation lasting up to 6 months. Our understanding of the mechanism of action of the toxin and the spectrum of diseases treatable with this agent continues to increase. Efficacy has been demonstrated in hemifacial spasm, dystonia, spasticity, hyperhidrosis and other conditions. Alternative serotypes are used in some centres, generally after the development of immunoresistance to the standard toxin (serotype A), and are likely to be in routine use in the near future. This paper reviews the history, pharmacology and current uses of botulinum toxin.
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Affiliation(s)
- N Mahant
- Department of Neurology, Westmead Hospital, Westmead, NSW, Australia
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22
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Abstract
BACKGROUND Botulinum toxin has a well-defined role among dermatologists for the treatment of facial wrinkling, brow position, and palmar and axillary hyperhidrosis. OBJECTIVE The purpose of this study is to educate dermatologists on the pharmacology of botulinum toxin. METHODS A retrospective review of the literature on botulinum toxin from 1962 to the present was conducted. We examined the clinical applications of botulinum toxin, cholinergic neuromuscular transmission, the toxin's structure and molecular actions, drug and disease interactions at the neuromuscular junction, toxin assays, determinants of clinical response, and adverse side effects. RESULTS Botulinum toxin blocks the release of acetylcholine from the presynaptic terminal of the neuromuscular junction. Several drugs and diseases interfere with the neuromuscular junction and the effects of botulinum toxin. The mouse bioassay, the most sensitive and specific measurement of toxin activity, is the gold standard for botulinum toxin detection and standardization. The major determinants of clinical response to treatment are the toxin preparation, individual patient's anatomy, dose and response relationships, length of toxin storage after reconstitution, and immunogenicity. To minimize potential antibody resistance, one should use the smallest effective dose, utilize treatment intervals of more than 3 months, and avoid booster injections. Uncommon adverse effects include ptosis, ectropion, diplopia, bruising, eyelid drooping, hematoma formation, and temporary headaches. CONCLUSION Botulinum toxin is a safe and effective treatment. Knowledge of the pharmacologic basis of therapy will be useful for standardizing techniques and achieving consistent therapeutic results in the future.
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Affiliation(s)
- W Huang
- Departments of Dermatology and Ophthalmology, Cleveland Clinic Foundation, USA
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Houser MK, Sheean GL, Lees AJ. Further studies using higher doses of botulinum toxin type F for torticollis resistant to botulinum toxin type A. J Neurol Neurosurg Psychiatry 1998; 64:577-80. [PMID: 9598669 PMCID: PMC2170071 DOI: 10.1136/jnnp.64.5.577] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE A previous study of botulinum toxin type F (BTX-F) treatment for torticollis had shown a dose of 520 MU to be effective, but for a much shorter duration than is usual with botulinum toxin type A (BTX-A). The objective was to assess the effect of a higher dose of BTX-F. METHODS Four of the previously treated patients, plus an additional patient, were treated with a higher dose of 780 MU BTX-F. All were secondary nonresponders to BTX-A due to neutralising antibodies. A test injection of 40 MU BTX-F was also given into the extensor digitorum brevis muscle (EDB), to examine the time course of the biological effect of the toxin electrophysiologically. Patients were followed up at two, four, eight, and 12 weeks. RESULTS All patients reported subjective improvement lasting from seven to 11 (mean 8.6) weeks accompanied by a significant reduction in mean clinical severity scores at two weeks. Four patients had pain which was substantially reduced. The electrophysiological studies confirmed biological sensitivity to the toxin in all patients, showing a significant change beginning at two weeks and returning to baseline at 12 weeks. The time course of this effect paralleled roughly that of the clinical response. The four patients who had previously received 520 MU BTX-F reported that the response was better and longer in duration with 780 MU. Dysphagia was more common than reported with the lower dose. CONCLUSION Better results are possible with higher doses of BTX-F but the duration of benefit is still shorter than with BTX-A, seemingly due to a shorter duration of neuromuscular junction blockade.
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Affiliation(s)
- M K Houser
- The National Hospital for Neurology and Neurosurgery, London, UK
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Berardelli A, Abbruzzese G, Bertolasi L, Cantarella G, Carella F, Currà A, De Grandis D, DeFazio G, Galardi G, Girlanda P, Livrea P, Modugno N, Priori A, Ruoppolo G, Vacca L, Manfredi M. Guidelines for the therapeutic use of botulinum toxin in movement disorders. Italian Study Group for Movement Disorders, Italian Society of Neurology. ITALIAN JOURNAL OF NEUROLOGICAL SCIENCES 1997; 18:261-9. [PMID: 9412849 DOI: 10.1007/bf02083302] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Since its introduction in the early '80s the use of botulinum toxin has improved the quality of life of the patients affected by movement disorders. Toxin's neuromuscular blocking action allows a symptomatic treatment of those clinical conditions characterised by excessive muscular activity. Although the dosages used are safe and the side-effects are reversible, a correct use of botulinum toxin depends on the knowledge of its clinical pharmacology and of the anatomy of the body segments to be injected. In addition, the treatment of more complex conditions, i.e. laringeal dystonia, imposes an inter-disciplinary approach and specialised injection techniques. In this review, the Italian Study Group on Movement Disorders presents the consensus guidelines for the therapeutic use of botulinum toxin in movement disorders. The main toxin types, their use and administration modalities, and the training guidelines will be presented.
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Affiliation(s)
- A Berardelli
- Dipartimento di Scienze Neurologiche, Università di Roma La Sapienza, Italy
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Andrade LA, Borges V, Ferraz HB, Azevedo-Silva SM. [Botulinum toxin A: experience in the treatment of 115 patients]. ARQUIVOS DE NEURO-PSIQUIATRIA 1997; 55:553-7. [PMID: 9629404 DOI: 10.1590/s0004-282x1997000400006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Botulinum toxin A is the more efficient therapy of focal dystonias and hemifacial spasm. Our experience with botulinum toxin A injections in 115 patients is reported. Marked or total improvement was achieved in all 45 patients with hemifacial spasm, in 70% of 20 patients with essential blepharospasm and in 71.4% of 14 patients with Meige's syndrome. In 65.2% of 23 patients with cervical dystonia marked but no total improvement was obtained. The worse results were seen in the 6 patients with hand dystonia (writers cramp), in whom marked improvement was obtained in just two. Mild and transient complications occurred in up to 24.4%, eyelid ptosis and eyelid weakness being the most frequent. One patient with Meige's syndrome had an aspiration pneumonia following dysphagia. Our results are in agreement with others, showing that botulinun toxin A is a useful and safe treatment for these conditions.
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Affiliation(s)
- L A Andrade
- Departamento de Neurologia e Neurocirurgia, Universidade Federal de São Paulo, Escola Paulista de Medicina, Brasil
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