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Molteni F, Wissel J, Fheodoroff K, Munin MC, Patel AT, Althaus M, Comes G, Dekundy A, Pulte I, Scheschonka A, Vacchelli M, Santamato A. Improvement in Quality-of-Life-Related Outcomes Following Treatment with IncobotulinumtoxinA in Adults with Limb Spasticity: A Pooled Analysis. Toxins (Basel) 2023; 16:19. [PMID: 38251237 PMCID: PMC10821091 DOI: 10.3390/toxins16010019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 12/05/2023] [Accepted: 12/16/2023] [Indexed: 01/23/2024] Open
Abstract
A strong correlation has been reported between patient-reported quality of life (QoL) and the investigator-rated Disability Assessment Scale (DAS) in patients with spasticity. The current analysis evaluates the effect of incobotulinumtoxinA on QoL-related outcomes (limb position abnormality, as well as dressing- and hygiene-related disability, measured with the DAS) in adults with upper limb spasticity, using pooled data from six studies. Separate analyses for each DAS domain were performed using data from patients with disabilities for that domain (DAS score ≥1). Results showed that a significantly greater proportion of incobotulinumtoxinA-treated compared with placebo-treated patients achieved a ≥1-point reduction from baseline in each of the DAS domains (improvement) 4 weeks after the first injection. The benefits of incobotulinumtoxinA were observed regardless of the baseline severity of DAS impairment and of the time elapsed since stroke. The effects of incobotulinumtoxinA 4 weeks after injection were maintained or enhanced over multiple injection cycles for all three DAS domains, supporting the use of repeated injection cycles to provide sustained QoL benefit. IncobotulinumtoxinA represents an important treatment option to achieve better QoL-related outcomes for patients with upper limb spasticity, irrespective of the duration of their condition.
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Affiliation(s)
- Franco Molteni
- Department of Rehabilitation, Valduce Villa Beretta Hospital, 23845 Costa Masnaga, Italy
| | - Jörg Wissel
- Department of Neurorehabilitation and Physical Therapy, Vivantes Hospital Spandau, 13585 Berlin, Germany
| | | | - Michael C. Munin
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Atul T. Patel
- Kansas City Bone and Joint Clinic, Overland Park, KS 66211, USA
| | - Michael Althaus
- Merz Therapeutics GmbH, 60318 Frankfurt am Main, Germany; (M.A.); (G.C.)
| | - Georg Comes
- Merz Therapeutics GmbH, 60318 Frankfurt am Main, Germany; (M.A.); (G.C.)
| | - Andrzej Dekundy
- Merz Therapeutics GmbH, 60318 Frankfurt am Main, Germany; (M.A.); (G.C.)
| | - Irena Pulte
- Merz Therapeutics GmbH, 60318 Frankfurt am Main, Germany; (M.A.); (G.C.)
| | - Astrid Scheschonka
- Merz Therapeutics GmbH, 60318 Frankfurt am Main, Germany; (M.A.); (G.C.)
| | - Matteo Vacchelli
- Merz Therapeutics GmbH, 60318 Frankfurt am Main, Germany; (M.A.); (G.C.)
| | - Andrea Santamato
- Unit of Spasticity and Movement Disorders, Division of Physical Medicine and Rehabilitation, University Hospital of Foggia, 71100 Foggia, Italy
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Ho WWS, Chan L, Corduff N, Lau WT, Martin MU, Tay CM, Wang S, Wu R. Addressing the Real-World Challenges of Immunoresistance to Botulinum Neurotoxin A in Aesthetic Practice: Insights and Recommendations from a Panel Discussion in Hong Kong. Toxins (Basel) 2023; 15:456. [PMID: 37505725 PMCID: PMC10467074 DOI: 10.3390/toxins15070456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/01/2023] [Accepted: 07/03/2023] [Indexed: 07/29/2023] Open
Abstract
With increasing off-label aesthetic indications using higher botulinum neurotoxin A (BoNT-A) doses and individuals starting treatment at a younger age, particularly in Asia, there is a greater risk of developing immunoresistance to BoNT-A. This warrants more in-depth discussions by aesthetic practitioners to inform patients and guide shared decision-making. A panel comprising international experts and experienced aesthetic practitioners in Hong Kong discussed the implications and impact of immunoresistance to BoNT-A in contemporary aesthetic practice, along with practical strategies for risk management. Following discussions on a clinical case example and the results of an Asia-Pacific consumer study, the panel concurred that it is a priority to raise awareness of the possibility and long-term implications of secondary non-response due to immunoresistance to BoNT-A. Where efficacy and safety are comparable, a formulation with the lowest immunogenicity is preferred. The panel also strongly favored a thorough initial consultation to establish the patient's treatment history, explain treatment side effects, including the causes and consequences of immunoresistance, and discuss treatment goals. Patients look to aesthetic practitioners for guidance, placing an important responsibility on practitioners to adopt risk-mitigating strategies and adequately communicate important risks to patients to support informed and prudent BoNT-A treatment decisions.
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Affiliation(s)
- Wilson W. S. Ho
- The Specialists: Lasers, Aesthetic and Plastic Surgery, Central, Hong Kong
| | - Lisa Chan
- EverKeen Medical Centre, Tin Hau, Hong Kong;
| | - Niamh Corduff
- Cosmetic Refinement Clinic, Geelong, VIC 3220, Australia;
| | | | | | | | - Sandy Wang
- Independent Researcher, Causeway Bay, Hong Kong;
| | - Raymond Wu
- Asia Pacific Aesthetic Academy, Kowloon, Hong Kong;
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Erro R, Picillo M, Pellecchia MT, Barone P. Improving the Efficacy of Botulinum Toxin for Cervical Dystonia: A Scoping Review. Toxins (Basel) 2023; 15:391. [PMID: 37368692 DOI: 10.3390/toxins15060391] [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: 04/24/2023] [Revised: 05/18/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023] Open
Abstract
Cervical dstonia (CD) is a chronic disorder with a significant detrimental impact on quality of life, requiring long-term treatment. Intramuscular injections of botulinum neurotoxin (BoNT) every 12 to 16 weeks have become the first-line option for CD. Despite the remarkable efficacy of BoNT as a treatment for CD, a significantly high proportion of patients report poor outcomes and discontinue the treatment. The reasons that drive sub-optimal response or treatment failure in a proportion of patients include but are not limited to inappropriate muscle targets and/or BoNT dosing, improper method of injections, subjective feeling of inefficacy, and the formation of neutralizing antibodies against the neurotoxin. The current review aims to complement published research focusing on the identification of the factors that might explain the failure of BoNT treatment in CD, highlighting possible solutions to improve its outcomes. Thus, the use of the new phenomenological classification of cervical dystonia known as COL-CAP might improve the identification of the muscle targets, but more sensitive information might come from the use of kinematic or scintigraphic techniques and the use of electromyographic or ultrasound guidance might ensure the accuracy of the injections. Suggestions are made for the development of a patient-centered model for the management of cervical dystonia and to emphasize that unmet needs in the field are to increase awareness about the non-motor spectrum of CD, which might influence the perception of the efficacy from BoNT injections, and the development of dedicated rehabilitation programs for CD that might enhance its effectiveness.
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Affiliation(s)
- Roberto Erro
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Neuroscience Section, University of Salerno, Via Allende 43, 84081 Baronissi, SA, Italy
| | - Marina Picillo
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Neuroscience Section, University of Salerno, Via Allende 43, 84081 Baronissi, SA, Italy
| | - Maria Teresa Pellecchia
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Neuroscience Section, University of Salerno, Via Allende 43, 84081 Baronissi, SA, Italy
| | - Paolo Barone
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Neuroscience Section, University of Salerno, Via Allende 43, 84081 Baronissi, SA, Italy
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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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Safety Profile and Lack of Immunogenicity of IncobotulinumtoxinA in Pediatric Spasticity and Sialorrhea: A Pooled Analysis. Toxins (Basel) 2022; 14:toxins14090585. [PMID: 36136523 PMCID: PMC9505819 DOI: 10.3390/toxins14090585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/16/2022] [Accepted: 08/19/2022] [Indexed: 11/16/2022] Open
Abstract
IncobotulinumtoxinA, a pure botulinumtoxinA formulation, is free of accessory proteins. This analysis provides pooled safety data from phase 3 trials of children/adolescents (2–17 years), investigating incobotulinumtoxinA for the treatment of spasticity associated with cerebral palsy (at doses ≤20 U/kg (max. 500 U) per injection cycle (IC) for ≤6 ICs; three trials) or sialorrhea associated with neurologic disorders (at total doses of 20–75 U per IC for ≤4 ICs; one trial) for ≤96 weeks. Safety endpoints included the incidences of different types of treatment-emergent adverse events (TEAEs) and immunogenicity. IncobotulinumtoxinA dose groups were combined. Of 1159 patients (mean age 7.3 years, 60.4% males) treated with incobotulinumtoxinA, 3.9% experienced treatment-related TEAEs, with the most common being injection site reactions (1.3%) (both indications), muscular weakness (0.7%) (spasticity), and dysphagia (0.2%) (sialorrhea). Two patients (0.2%) experienced a treatment-related treatment-emergent serious adverse event, and 0.3% discontinued the study due to treatment-related TEAEs. No botulinumtoxinA-naïve patients developed neutralizing antibodies (NAbs) after incobotulinumtoxinA. All children/adolescents with known pre-treatment status and testing positive for Nabs at final visit (n = 7) were previously treated with a botulinumtoxinA other than incobotulinumtoxinA. IncobotulinumtoxinA was shown to be safe, with very few treatment-related TEAEs in a large, diverse cohort of children/adolescents with chronic conditions requiring long-term treatment and was without new NAb formation in treatment-naïve patients.
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Lapostolle A, Houot M, Mongin M, Degos B. Comparison of Botulinum neurotoxin efficiency in dystonia associated with Parkinson's disease and atypical parkinsonism: a retrospective study with a self-reported improvement scale. J Neurol 2022; 269:6021-6028. [PMID: 35854137 DOI: 10.1007/s00415-022-11280-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 06/07/2022] [Accepted: 07/09/2022] [Indexed: 11/25/2022]
Abstract
Botulinum neurotoxin (BoNT) is a useful therapeutic option to treat dystonic manifestations. Data on its efficiency on dystonia associated with Parkinson's disease (PD) or atypical parkinsonism (AP) are scarce and no comparison of the efficiency of BoNT has been performed between these diseases and between the different localizations of dystonia in these pathologies. We retrospectively collected from patients' medical records the result of 611 BoNT injections in 63 dystonic parkinsonian patients (44 PD and 19 AP) using a self-reported clinical improvement scale and duration of effect. Using these data, we modeled the degree of improvement and its duration after BoNT treatment with a linear mixed model. This allowed us to assess the influence of clinical parameters on the reported treatment efficiency. On a scale from 0 to 100, patients with PD and AP, respectively, report a mean improvement of 69% and 55% after BoNT injection and it is similar regarding the different localizations of dystonia. Duration of effect is, however, longer in PD compared to AP (P = 0.023). Patients' demographic and clinical characteristics had no effect on the degree of improvement or duration of effect. Overall, our results support the use of BoNT in the various dystonic phenomena associated with degenerative parkinsonian syndromes. Shorter delays between injection sessions should be considered in AP compared to PD.Trial registration: This study was registered on Clinicaltrial.gov (NCT04948684).
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Affiliation(s)
- Arnaud Lapostolle
- Service de Neurologie, AP-HP, Hôpital Avicenne, Hôpitaux Universitaires de Paris - Seine Saint Denis, Sorbonne Paris Nord, NS-PARK/FCRIN network, Bobigny, France.,Sorbonne Université, UPMC, Paris, France
| | - Marion Houot
- Center of Excellence of Neurodegenerative Disease (CoEN), AP-HP, Pitié-Salpêtrière Hospital, Paris, France.,Clinical Investigation Centre, Institut du Cerveau et de la Moelle épinière (ICM), Pitié-Salpêtrière Hospital, Paris, France.,Department of Neurology, Institute of Memory and Alzheimer's Disease (IM2A), AP-HP, Pitié-Salpêtrière Hospital, Paris, France
| | - Marie Mongin
- Service de Neurologie, AP-HP, Hôpital Avicenne, Hôpitaux Universitaires de Paris - Seine Saint Denis, Sorbonne Paris Nord, NS-PARK/FCRIN network, Bobigny, France
| | - Bertrand Degos
- Service de Neurologie, AP-HP, Hôpital Avicenne, Hôpitaux Universitaires de Paris - Seine Saint Denis, Sorbonne Paris Nord, NS-PARK/FCRIN network, Bobigny, France. .,Dynamics and Pathophysiology of Neuronal Networks Team, Center for Interdisciplinary Research in Biology, Collège de France, CNRS UMR7241/INSERM U1050,, Université PSL, 75005, Paris, France.
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Emerging Trends in Botulinum Neurotoxin A Resistance: An International Multidisciplinary Review and Consensus. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4407. [PMID: 35747253 PMCID: PMC9208887 DOI: 10.1097/gox.0000000000004407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 05/11/2022] [Indexed: 11/26/2022]
Abstract
Botulinum neurotoxin A (BoNT-A) injection is the most widely performed aesthetic procedure and a first-line therapeutic option for various medical conditions. The potential for BoNT-A immunoresistance and secondary nonresponse related to neutralizing antibody (NAb) formation warrants attention as the range of BoNT-A aesthetic applications continues to expand. Methods An international multidisciplinary panel reviewed published evidence on BoNT-A immunoresistance in aesthetic and therapeutic applications and discussed best practices integrating clinical, ethical, and aesthetic considerations. Consensus statements relating to awareness, assessment, and management of the risk of NAb-related secondary nonresponse in aesthetic practice were developed. Results There was a consensus that, as doses used in aesthetic practice become like those in therapeutics, rates of NAb formation may be expected to increase. However, the true extent of NAb formation in aesthetics is likely underestimated due to limitations of published evidence and variability in treatment patterns of aesthetic patients. Since BoNT-A therapy is often lifelong, practitioners need to recognize immunogenicity as a potential complication that might affect future therapeutic use and strive to minimize modifiable risk factors. The selection and use of a BoNT-A product with the least immunogenic potential from the beginning may thus be advantageous, especially when treatment with high doses is planned. Conclusions In view of current trends in BoNT-A aesthetic use, it is essential for practitioners to conduct thorough clinical assessments, inform patients of treatment risks, and develop BoNT-A treatment plans to minimize immunogenicity. This can help preserve the option of continued or future BoNT-A treatment with satisfactory outcomes.
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Botulinum Toxin Type A for Treatment of Forehead Hyperhidrosis: Multicenter Clinical Experience and Review from Literature. Toxins (Basel) 2022; 14:toxins14060372. [PMID: 35737033 PMCID: PMC9231294 DOI: 10.3390/toxins14060372] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 05/22/2022] [Accepted: 05/24/2022] [Indexed: 12/04/2022] Open
Abstract
Among the forms of idiopathic hyperhidrosis, those involving the forehead have the greatest impact on patients’ quality of life, as symptoms are not very controllable and are difficult to mask for patients. Although the local injection therapy with Incobotulinum toxin type A (IncoBTX-A therapy) can be considered a rational treatment, data from the literature describing both efficacy and safety of the treatment over the long term are poor. The aim of this report is to describe the single-center experience of five patients seeking treatment, for forehead hyperhidrosis with IncoBTX-A. To evaluate the benefits, safety profile and duration of anhidrosis, patients were treated following a standardized procedure and then followed until clinical relapse. The amount of sweating was measured by gravimetric testing, the extension of hyperhidrosis area was measured through Minor’s iodine starch test, and response to the treatment was evaluated using the Hyperhidrosis Disease Severity Scale (HDSS) and the Dermatology Life Quality Index (DLQI). In all treated patients, a significant anhidrotic effect was observed 4 weeks after the treatment and lasted for approximately 36 weeks. The reduction in sweat production was associated with significant amelioration of symptoms and quality of life for all treated patients. No serious side effects occurred; one patient complained of a mild transient bilateral ptosis. Although further wider studies are required, our preliminary results seem to encourage the use of IncoBTX-A in forehead hyperhidrosis.
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Mueller J, Langbein T, Mishra A, Baum RP. Safety of High-Dose Botulinum Toxin Injections for Parotid and Submandibular Gland Radioprotection. Toxins (Basel) 2022; 14:toxins14010064. [PMID: 35051042 PMCID: PMC8781970 DOI: 10.3390/toxins14010064] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 01/07/2022] [Accepted: 01/10/2022] [Indexed: 01/10/2023] Open
Abstract
Botulinum Toxin injections into salivary glands (SG) up to a total dose of 100 units IncobotulinumtoxinA (IncoA) represent the treatment of choice for sialorrhea. However, BTX might also protect SG against sialotoxic radioligand cancer therapies. The radioligand Actinium-225-PSMA effectively targets Prostate Cancer (PCa) metastases but inevitably destroys SG due to unintended gland uptake. A preliminary case series with regular-dose IncoA failed to reduce SG PSMA-radioligand uptake. We therefore increased IncoA dosage in combination with transdermal scopolamine until a clinically relevant SG PSMA-radioligand uptake reduction was achieved. Ten consecutive men with metastasized PCa refractory to all other cancer therapies received gradually increasing IncoA dosages as part of a compassionate use PSMA-radioligand-therapy trial. The parotid gland received six and the submandibular gland three injection points under ultrasound control, up to a maximum of 30 units IncoA per injection point. A maximum total dose of 250 units IncoA was applied with up to 170 units per parotid and 80 units per submandibular gland. Treatment was well tolerated and all side-effects were non-serious. The most frequent side-effect was dry mouth of mild severity. No dysphagia, facial weakness, chewing difficulties or systemic side-effects were observed. SG injections with IncoA up to a total dose of 250 units are safe when distributed among several injection-points under ultrasound control by an experienced physician. These preliminary findings lay the basis for future trials including BTX as major component for SG protection in established as well as newly emerging radioligand cancer therapies.
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Affiliation(s)
- Joerg Mueller
- Department of Neurology, Vivantes Klinikum Spandau, Neue Bergstrasse 6, D-13585 Berlin, Germany
- Correspondence:
| | - Thomas Langbein
- Department of Nuclear Medicine, Technical University of Munich, Klinikum rechts der Isar, Ismaninger Strasse 22, D-81675 München, Germany;
| | - Aditi Mishra
- Department of Nuclear Medicine, Curanosticum Wiesbaden, Deutsche Klinik für Diagnostik, Aukammallee 33, D-65191 Wiesbaden, Germany; (A.M.); (R.P.B.)
| | - Richard P. Baum
- Department of Nuclear Medicine, Curanosticum Wiesbaden, Deutsche Klinik für Diagnostik, Aukammallee 33, D-65191 Wiesbaden, Germany; (A.M.); (R.P.B.)
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The Use of High Initial Doses of Botulinum Toxin Therapy for Cervical Dystonia Is a Risk Factor for Neutralizing Antibody Formation-A Monocentric Cross-Sectional Pilot Study. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58010088. [PMID: 35056396 PMCID: PMC8779899 DOI: 10.3390/medicina58010088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 12/30/2021] [Accepted: 01/04/2022] [Indexed: 11/17/2022]
Abstract
Background and Objectives: The present study aims to analyze the complex patient/treating physician interaction at onset of botulinum toxin (BoNT) therapy in patients with idiopathic cervical dystonia (CD) and the influence of high initial doses on long-term outcomes. Materials and Methods: A total of 74 CD patients with well-documented courses of BoNT treatment were consecutively recruited after written informed consent. Patients had to rate the amount of improvement of CD in percent of severity of CD at onset of BoNT therapy. They had to draw the course of disease severity (CoD) of CD from the onset of symptoms until the onset of BoNT therapy and from the onset of BoNT therapy until recruitment. The remaining severity of CD was estimated by the treating physician using the TSUI score. Demographic- and treatment-related data were extracted from the charts of the patients. Seventeen patients with suspected secondary treatment failure (STF) were tested for the presence of antibodies. Results: Depending on the CoD before BoNT therapy, three patient subgroups could be distinguished: rapid onset, continuous onset and delayed onset groups. Time to BoNT therapy, increase in dose and improvement were significantly different between these three groups. In the rapid onset group, with the highest initial doses, the best improvement was reported, but the highest number of patients with an STF and with neutralizing antibodies was also observed. Conclusion: The use of high initial doses in the BoNT therapy of CD is associated with a rapid response and quick success; however, it leads to an elevated risk for the development of a secondary treatment failure and induction of neutralizing antibodies.
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Significant Long-Lasting Improvement after Switch to Incobotulinum Toxin in Cervical Dystonia Patients with Secondary Treatment Failure. Toxins (Basel) 2022; 14:toxins14010044. [PMID: 35051021 PMCID: PMC8779547 DOI: 10.3390/toxins14010044] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/17/2021] [Accepted: 01/01/2022] [Indexed: 11/17/2022] Open
Abstract
Under continuous long-term treatment with abo- or onabotulinum toxin type A (BoNT/A), ~10 to 15% of patients with cervical dystonia (CD) will develop neutralizing antibodies and reduced responsiveness over an ~10-year treatment period. Among the botulinum neurotoxin type A preparations so far licensed for CD, incobotulinum toxin A (incoBoNT/A; Xeomin®) is the only one without complex proteins. Whether CD patients with treatment failure under abo- or onaBoNT/A may still respond to incoBoNT/A is unknown. In this cross-sectional, retrospective study, 64 CD patients with secondary treatment failure after abo- or onaBoNT/A therapy who were switched to incoBoNT/A were compared to 34 CD patients exclusively treated with incoBoNT/A. The initial clinical severity of CD, best outcome during abo- or onaBoNT/A therapy, severity at the time of switching to incoBoNT/A and severity at recruitment, as well as all corresponding doses, were analyzed. Furthermore, the impact of neutralizing antibodies (NABs) on the long-term outcome of incoBoNT/A therapy was evaluated. Patients significantly improved after the switch to incoBoNT/A (p < 0.001) but did not reach the improvement level obtained before the development of partial secondary treatment failure or that of patients who were exclusively treated with incoBoNT/A. No difference between abo- and onaBoNT/A pretreatments or between the long-term outcomes of NAB-positive and NAB-negative patients was found. The present study demonstrates significant long-term improvement after a switch to incoBoNT/A in patients with preceding secondary treatment failure after abo- or onaBoNT/A therapy and confirms the low antigenicity of incoBoNT/A.
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Hong JY, Kim JH, Jin JE, Shin SH, Park KY. Practical Application of Novel Test Methods to Evaluate the Potency of Botulinum Toxin: A Comparison Analysis among Widely Used Products in Korea. Toxins (Basel) 2021; 13:toxins13120833. [PMID: 34941671 PMCID: PMC8707463 DOI: 10.3390/toxins13120833] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/18/2021] [Accepted: 11/22/2021] [Indexed: 11/29/2022] Open
Abstract
The safe and effective dosing of botulinum neurotoxins (BoNTs) requires accurate and reliable methods to measure their potency. Several novel methods have been introduced over the past decade; however, only few studies have compared the potency of BoNT products with that of the LD50 and other alternative assays. Therefore, the objective of this study was to comparatively evaluate widely used BoNT products using various test methods. Four types of BoNTs (prabotulinumtoxin A, onabotulinumtoxin A, neubotulinumtoxin A, and letibotulinumtoxin A) were used in this study. The estimated potency was assessed using the LD50 assay, and the total BoNT type A protein levels were measured using the enzyme-linked immunosorbent assay (ELISA). The in vitro efficacy of the BoNTs was determined using fluorescence resonance energy transfer (FRET) and surface plasmon resonance (SPR) assays. The results showed differences in the total amount of BoNT protein and the cleavage activity of SNAP-25 within all types of BoNTs. The SPR study seemed to be useful for evaluating the potency by specifically measuring intact 19S neurotoxin, and these results provide new insights for assessing different BoNT products.
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Affiliation(s)
- Ji-Yeon Hong
- Department of Dermatology, Chungnam National University Sejong Hospital, Sejong 30099, Korea;
| | - Jong-Hee Kim
- NABOTA Research and Development Team, Daewoong Pharmaceuticals, Seoul 06973, Korea; (J.-H.K.); (J.-E.J.)
| | - Jung-Eun Jin
- NABOTA Research and Development Team, Daewoong Pharmaceuticals, Seoul 06973, Korea; (J.-H.K.); (J.-E.J.)
| | - Sun-Hye Shin
- Department of Dermatology, College of Medicine, Chung-Ang University, Seoul 06973, Korea;
| | - Kui-Young Park
- Department of Dermatology, College of Medicine, Chung-Ang University, Seoul 06973, Korea;
- Correspondence: ; Tel.: +82-2-6299-1544; Fax: +82-2-6299-1718
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Immunogenicity of Botulinum Toxin Formulations: Potential Therapeutic Implications. Adv Ther 2021; 38:5046-5064. [PMID: 34515975 PMCID: PMC8478757 DOI: 10.1007/s12325-021-01882-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 08/02/2021] [Indexed: 12/21/2022]
Abstract
Botulinum neurotoxins (BoNTs) are proteins produced by bacteria of the Clostridium family. Upon oral ingestion, BoNT causes the neuroparalytic syndrome botulism. There are seven serotypes of BoNT (serotypes A-G); BoNT-A and BoNT-B are the botulinum toxin serotypes utilized for therapeutic applications. Treatment with BoNT injections is used to manage chronic medical conditions across multiple indications. As with other biologic drugs, immunogenicity after long-term treatment with BoNT formulations may occur, and repeated use can elicit antibody formation leading to clinical nonresponsiveness. Thus, approaching BoNT treatment of chronic conditions with therapeutic formulations that minimize stimulating the host immune response while balancing patient responsiveness to therapy is ideal. Immunogenicity is a clinical limitation in many settings that use biologic drugs for treatment, and clinically relevant immunogenicity reduction has been achieved through engineering smaller protein constructs and reducing unnecessary formulation components. A similar approach has influenced the evolution of BoNT formulations. Three BoNT-A products and one BoNT-B product have been approved by the Food and Drug Administration (FDA) for therapeutic use: onabotulinumtoxinA, abobotulinumtoxinA, incobotulinumtoxinA, and rimabotulinumtoxinB; a fourth BoNT-A product, daxibotulinumtoxinA, is currently under regulatory review. Additionally, prabotulinumtoxinA is a BoNT-A product that has been approved for aesthetic indications but not therapeutic use. Here, we discuss the preclinical and clinical immunogenicity data that exist within the scientific literature and provide a perspective for considering immunogenicity as a key factor in choice of BoNT formulation.
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Fabi SG, Carruthers J, Joseph J, Cox SE, Yoelin S, Few J, Kaufman-Janette J, Dayan S. High-Dose Neuromodulators: A Roundtable on Making Sense of the Data in Real-World Clinical Practice. Aesthet Surg J Open Forum 2021; 3:ojab036. [PMID: 34708202 PMCID: PMC8545706 DOI: 10.1093/asjof/ojab036] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND For aesthetic treatment with botulinum neurotoxin type A (BoNTA), interest in maximizing treatment duration and efficacy has prompted study of doses higher than those used in registration studies. As data emerge, it is important that physicians understand how to apply study findings to their own practice so that patient demand is satisfied. OBJECTIVES To bring together leading experts in neuromodulators for a roundtable discussion on the implications of high-dose BoNTA studies for patient care. METHODS The authors reviewed and discussed recent data from high-dose BoNTA studies for abobotulinum toxin A, incobotulinum toxin A, and Oonobotulinumtoxin A. RESULTS Discussion focused on the challenges of data interpretation and extrapolation of study findings for real-world patient care. The authors participated in a candid discussion of whether the observed improvements in treatment duration and patient satisfaction warrant treatment with high-dose regimens delivered as high-concentration injections. Safety was also discussed, as well as economic considerations for both practices and patients. Of note, for BoNTA products, the registration dose, when administered in a smaller total volume, appears to give rise to more durable results than those observed in pivotal trials, implicating product concentration as an important consideration. Importantly, at higher doses, extended duration of effect does not appear to be at the expense of natural-looking results. CONCLUSIONS While the authors provide considerations for the development of individual clinical practice, there is no one-size-fits-all recommendation. It may be that "high-dose" BoNTA is in reality the optimal dose; however, important economic considerations may prevent rapid uptake for all patients.
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Affiliation(s)
- Sabrina Guillen Fabi
- Corresponding Author: Dr Sabrina Guillen Fabi, 9339 Genesee Ave Unit 300, San Diego, CA 92121, USA. E-mail:
| | - Jean Carruthers
- Department of Ophthalmology, University of British Columbia, Vancouver, BC, Canada
| | - John Joseph
- Clinical Testing of Beverly Hills, Encino, CA, USA
| | | | | | | | | | - Steven Dayan
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, University of Illinois at Chicago, Chicago, IL, USA
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The Impact of the Course of Disease before Botulinum Toxin Therapy on the Course of Treatment and Long-Term Outcome in Cervical Dystonia. Toxins (Basel) 2021; 13:toxins13070493. [PMID: 34357965 PMCID: PMC8310129 DOI: 10.3390/toxins13070493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/10/2021] [Accepted: 07/13/2021] [Indexed: 12/04/2022] Open
Abstract
This study analyses the influence of the course of the disease of idiopathic cervical dystonia (CD) before botulinum toxin (BoNT) therapy on long-term outcomes. 74 CD-patients who were treated on a regular basis in the botulinum toxin outpatient department of the University of Düsseldorf and had received at least 3 injections were consecutively recruited after written informed consent. Patients were asked to rate the amount of change of CD in relation to the severity of CD at begin of BoNT therapy (IMPQ). Then they had to draw the course of disease of CD from onset of symptoms until initiation of BoNT therapy (CoDB-graph) on a sheet of paper into a square of 10 × 10 cm2 size. Remaining severity of CD was estimated by the treating physician using the TSUI-score. Demographical and treatment related data were extracted from the charts of the patients. Depending on the curvature four different types of CoDB-graphs could be distinguished. Time to BoNT therapy, increase of dose and improvement during BoNT treatment were significantly (p < 0.05) different when patients were split up according to CoDB-graph types. The lower the age at onset of symptoms, the shorter was the time to therapy (p < 0.02). Initial dose (p < 0.04) and actual dose (p < 0.009) were negatively correlated with the age of the patients at recruitment. The course of disease of CD before BoNT therapy has influence on long-term outcome. This has implications on patient management and information on the efficacy of BoNT treatment.
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The Extreme Ends of the Treatment Response Spectrum to Botulinum Toxin in Cervical Dystonia. Toxins (Basel) 2020; 13:toxins13010022. [PMID: 33396548 PMCID: PMC7824374 DOI: 10.3390/toxins13010022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 12/21/2020] [Accepted: 12/28/2020] [Indexed: 11/28/2022] Open
Abstract
Background: The response to BoNT is not uniform; a broad spectrum of responses and side-effects usually occurs. This study aimed to show special cervical dystonia cases with therapy response very different to normal treatment course which indicate the extreme ends of therapy spectrum. Patients: Clinical data and course of treatment of five long-term treated patients with cervical dystonia out of therapy response norms are presented: a patient who was supersensitive to standard dose and has required dose adjustment to lower dose of BoNT; one patient who worsened under a standard dose, but responded excellently to twice the standard dose; one insensitive patient who responded poorly for years to a dose well above the standard dose, but responded when dose was further increased; and two patients with a totally different response pattern to BoNT/A preparation 1, but the development of a neutralizing antibody induced secondary treatment failure in both cases and a totally different response after switch to BoNT/A preparation 2. Conclusions: These five patients indicate that the response of a patient to a BoNT preparation may be unexpected. Therefore, cautious onset of BoNT therapy is recommended as well as consequent dose adjustment later on and even switch to another BoNT/A preparation when a patient has already developed NABs against BoNT/A.
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Hefter H, Samadzadeh S, Moll M. Transient Improvement after Switch to Low Doses of RimabotulinumtoxinB in Patients Resistant to AbobotulinumtoxinA. Toxins (Basel) 2020; 12:toxins12110677. [PMID: 33121133 PMCID: PMC7693617 DOI: 10.3390/toxins12110677] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/24/2020] [Accepted: 10/25/2020] [Indexed: 11/16/2022] Open
Abstract
Botulinum toxin type B (BoNT/B) has been recommended as an alternative for patients who have become resistant to botulinum toxin type A (BoNT/A). This study aimed to compare the clinical effect, within a patient, of four injections with low doses of rimabotulinumtoxinB with the effect of the preceding abobotulinumtoxinA (aboBoNT/A) injections. In 17 patients with cervical dystonia (CD) who had become resistant to aboBoNT/A, the clinical effect of the first four rimabotulinumtoxinB (rimaBoNT/B) injections was compared to the effect of the first four aboBoNT/A injections using a global assessment scale and the TSUI score. After the first two BoNT/B injections, all 17 patients responded well and to a similar extent as to the first two BoNT/A injections, but with more side effects such as dry mouth and constipation. After the next BoNT/B injection, the improvement started to decline. The response to the fourth BoNT/B injection was significant (p < 0.048) lower than the fourth BoNT/A injection. Only three patients developed a complete secondary treatment failure (CSTF) and five patients a partial secondary treatment failure (PSTF) after four BoNT/B injections. In nine patients, the usual response persisted. With the use of low rimaBoNT/B doses, the induction of CSTF and PSTF to BoNT/B could not be avoided but was delayed in comparison to the use of higher doses. In contrast to aboBoNT/A injections, PSTF and CSTF occurred much earlier, although low doses of rimaBoNT/B had been applied.
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Affiliation(s)
- Harald Hefter
- Correspondence: ; Tel.: +49-211-811-7025; Fax: +49-211-810-4903
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