Efficacy, patient-reported outcomes and safety profile of ATX-101 (deoxycholic acid), an injectable drug for the reduction of unwanted submental fat: results from a phase III, randomized, placebo-controlled study

Background

Unwanted submental fat (SMF) may result in an unattractive chin profile and dissatisfaction with appearance. An approved and rigorously tested non-surgical method for SMF reduction is lacking.

Objective

To evaluate the efficacy and safety of ATX-101 for the pharmacological reduction of unwanted SMF in a phase III randomized, double-blind, placebo-controlled study.

Methods

Patients (n = 360) with moderate or severe SMF were randomized to receive ATX-101 1 or 2 mg/cm² or placebo injected into their SMF for up to four treatments ∼28 days apart, with a 12-week follow-up. Coprimary efficacy endpoints were the proportions of treatment responders, defined as a ≥1-point reduction in SMF on the Clinician-Reported Submental Fat Rating Scale (CR-SMFRS), and those satisfied with their appearance in association with their face and chin after treatment on the Subject Self-Rating Scale (SSRS score ≥4). Secondary efficacy endpoints included a ≥1-point improvement in SMF on the Patient-Reported Submental Fat Rating Scale (PR-SMFRS) and changes in the Patient-Reported Submental Fat Impact Scale (PR-SMFIS). Additional patient-reported outcomes and changes in the Skin Laxity Rating Scale were recorded. Adverse events (AEs) and laboratory test results were monitored.

Results

Compared with placebo, a greater proportion of patients treated with ATX-101 1 and 2 mg/cm² showed a ≥1-point improvement in CR-SMFRS (58.3% and 62.3%, respectively, vs. 34.5% with placebo; P < 0.001) and patient satisfaction (SSRS score ≥4) with the appearance of their face and chin (68.3% and 64.8%, respectively, vs. 29.3%; P < 0.001). Patient-reported secondary efficacy endpoints showed significant improvements in SMF severity (PR-SMFRS; P = 0.009 for ATX-101 1 mg/cm², P < 0.001 for ATX-101 2 mg/cm² vs. placebo) and emotions and perceived self-image (PR-SMFIS; P < 0.001). No overall worsening of skin laxity was observed. AEs were mostly transient, mild to moderate in intensity and localized to the treatment area.

Conclusion

ATX-101 was effective and well tolerated, and may be an alternative to surgery for patients desiring improvement of their submental profile.

Treatment of glabellar lines with botulinum toxin type A (Speywood Unit): a clinical overview

Azzalure (Galderma) is a newly approved European botulinum neurotoxin type A (BoNT-A) specifically designed for aesthetic usages. It is sourced from Dysport (Ipsen Ltd.), which has a 20-year product consistency and has been used widely for various therapeutic and aesthetic applications. Azzalure and Dysport are collectively referred to as BoNT-A (Speywood Unit; s.U) (or abobotulinumtoxinA in the U.S.) after their biological activity unit, which is unique and not interchangeable with units of other commercial BoNT-A preparations. Azzalure is approved for the treatment of moderate-to-severe glabellar lines, with a total dose of 50 s.U distributed evenly among 5 injection points. To ensure optimal treatment outcomes with BoNT-A (s.U), it is crucial for injectors to adopt proper methods of reconstitution and injection, which can be acquired through training. We review here the method of reconstitution for BoNT-A (s.U), as well as the injection dose, points and techniques for glabellar line treatment. We also review the efficacy and safety results of BoNT-A (s.U) demonstrated in 11 clinical studies, most of which were randomized, double-blind and placebo-controlled. The studies included assessments after single injections as well as after up to 6 repeated treatment sessions. We summarize the clinical efficacy results, which include the responder rate 1 month post-injection, onset of response and duration of action, as well as safety results, which include incidence of treatment-emergent adverse events and specifically eyelid ptosis. The efficacy and safety profiles reported here are unique to BoNT-A (s.U) and cannot be generalized to other BoNT-A products.

[Treatment of HIV facial lipoatrophy with a submalar porous polyethylene implant (Medpor)]

Human immunodeficiency virus associated facial lipoatrophy is becoming epidemic and is a distressing sign for patients. Non permanent fillers provide only temporary results and cannot be the solution for severe cases. Lipodystrophy makes the lipofilling difficult to perform with a fibrous low quality fat difficult to harvest. We propose another solution using porous polyethylene implants (Medpor). Eight patients underwent submalar augmentation through an upper gingivobuccal sulcus incision that allows a subperiosteal dissection. The implants are carved to provide the desired augmentation. Overall, eight patients had good or very good aesthetic postoperative outcomes as determined by the patient and the surgeon. No complications occurred and results remain natural. Porous polyethylene implant (Medpor) is our treatment of choice for mild to severe facial lipoatrophy. Besides these implants could be removed easily later if needed.

[Soft tissue filling with hyaluronic acid]

PHYSIOLOGY AND PHARMACOLOGY: Hyaluronan was discovered by Karl Meyer in 1934 in the vitreous humor of cattle eye. Hyaluronic acid, (AH), is a natural polysaccharide and a ubiquitous component of the extra cellular matrix. It is largely biocompatible and has a short half life. In the early 1990's, preceded by the use of bovine collagen, AH started to be employed in the fields of Dermatology and Plastic Surgery; currently it is a major intervention product in both soft tissue augmentation and facial volume loss treatments. Often well tolerated, AH, has high water retention properties and is an effective tissue volumizer. Industry first attempted to extract AH from rooster comb, then through bacterial fermentation and succeeded in increasing its lifespan by cross linking. However, industrially produced AH can contain residues from the manufacturing process. It thus appears critical to us to be informed of the process used in manufacturing AH including the reticulant utilized. Manufacturers should be legally required to publish this data as well as to conduct physiochemical follow-up studies over the short, mid and long terms.

LEGAL CONSIDERATIONS

In Europe, CE marking is a prerequisite to market injectable products. However, a CE marking does not necessarily imply that the product's efficacy and side effects have been assessed objectively in clinical studies. However, this marking is expected to fall into line with the US legislation, where the marketing of any medicinal product is subject to FDA approval, based on comprehensive animal and clinical studies and on more systematic and better centralised side effect reporting. We have examined most of the products used in Europe and internationally in 2004, whether of animal or bacterial origin, reticulated or non-reticulated, and used to restore, increase volume or as a product vector. Before injecting these products, it is essential to have a thorough understanding of their absolute and relative contraindications and anaesthetic requirements, differences between types of wrinkles to fill in and indicated techniques, differences between concerned regions or tissues, and the impact of associated cosmetic treatments. These resorbable injectable products have mild and, more importantly, short-lived side effects. However, in patients with a relative contraindication, a double test is justified, as allergic reactions are known to occur in 1 to 3% of patients. It is also advisable not to inject HA in a site previously injected with a non-resorbable product. More precise statistics on results and side effects based on double-blind randomised studies are still wanting, due to the lack of legal requirement and effective centralisation of data. Therefore, all side effects must be reported to improve our knowledge as well as the safety of injections.

CONCLUSION

Although their duration of effect is limited, HA products are the most commonly used fillers, before collagens. Many questions have yet to be answered, but they produce very significant results in filling procedures. Both clinicians and patients praise these products for their tolerance, resorbable nature, and limited side effects.

[Botulinum toxin and wrinkles: few side effects and effective combining procedures with other treatments]

Chemical denervation, through the biologic effect of botulinum toxin, provides a very effective, low risk, lasting treatment for hyperkinetic wrinkles, mainly of the upper face. Patients with such rhytides, when treated with surgical myotomies or other alternative medical treatments, are at greater risk and with potentially less lasting results. Botulinum toxin has been widely used for the last 20 years in many areas of medicine. It has been used for 13 years in dermatology and plastic surgery, without important complications or sequellae. Any complications appear to be reversible. In these two specialties, with the minute quantities (units) and volume of material injected, complications are infrequent; some of them are now anecdotal. The only main complication from a cosmetic point of view is blepharoptosis, which is more and more rare. Because of a better anatomical knowledge of the affected muscles, and our improved technique, risks are greatly reduced. In our two latest multicenter studies on glabellar wrinkles, between 2002 and 2004, we saw no blepharoptosis. Conversely, in case of dynamic wrinkles associated with muscle, fat, and skin relapse, and/or deep furrows, only surgical procedures and/or other surface treatments are effective. Botulinum toxin injections are not meant to replace upper, mid, or mandibular face and neck lifts; indeed, botulinum toxin injections may optimize results from these surgical procedures. These injections play a fundamental process in producing long lasting results. The current and future evolution, in cosmetic surgery, is toward full achieved, but focused, natural, and minimally invasive surgical procedures in combination with effective and minimal risk techniques such as the botulinum toxin injections. To optimize the effect of the medical procedures, botulinum toxin should be injected three weeks before surgery. In addition botulinum toxin injections may optimize and prolong the effect of the surface procedures, as lasers, peels and fillers. This medicosurgical combination is one of the examples that best describes the evolution of plastic and aesthetic surgery in 2004.

[Botulinum toxin in the treatment of frontoglabellar and periorbital wrinkles. An initial study]

Glabellar frown lines and crow's feet are wrinkles of facial expression related to an underlying muscular activity, which is particularly strong during facial expression. Classic treatments of these wrinkles only give partially satisfactory are associated with results, and secondary effects, whether they involve skin and muscle lifting, surgical section of muscles, dermal stimulation by thread or injectable fillers, chemical or mechanical abrasion, transient or permanent soft tissue augmentation with various materials. The authors studied the efficacy and safety of intramuscular injections botulinum A Exotoxin in glabellar and crow's feet areas in 19 well-informed and consenting patients. Botulinum toxin injections have been used since 1980 in the treatment of focal dystonia (blepharospasm, oromandibular dystonia, spasmodic torticollis, spasmodic dysphonia and writer's cramp) and safety hemifacial spasm. Their wide use in these indications has highlighted their excellent and efficacy, and the need to repeat injections every 3 to 4 months. The dose required was progressively adjusted around glabellar and orbital areas, while injections of the peri-buccal and forehead areas are still being evaluated. The 19 patients were examined clinically, filmed and photographed every month over a period of 12 to 24 months, and skin prints were performed. Evaluation criteria included the percentage improvement as assessed by the patients themselves, and also evaluation by the investigators of the data of clinical examination, and blind comparison of photographic, videoscopic, and prints. The authors obtained a significant decrease of wrinkles of the areas studied, with a "smoothing" effect during the period of activity of the toxin, which lased an average of 3 to 4 months at the beginning, and 6 to 9 months after several injections. No secondary effects, either general or local, were observed. The product's specificity means that the operator must have a complete mastery of the injection technique and a thorough knowledge of its pharmacology.