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      Considerations on patient-related outcomes with the use of botulinum toxins: is switching products safe?

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          Botulinum toxin (BoNT) is the treatment of choice for many neurologic movement disorders, including blepharospasm, hemifacial spasm, and cervical dystonia. There are two serotypes approved for use by the US Food and Drug Administration: three brands of serotype A and one of serotype B. Many attempts have been made at establishing dose conversion ratios between brands and serotypes. This review focuses on the existing data comparing different formulations of the same BoNT serotypes as well as that comparing different serotypes with one another. We focus on existing data regarding switching from one formulation or serotype to another and will also discuss the issue of immunogenicity of BoNT. With this information as a foundation, recommendations on safety of switching agents are addressed.


          Literature review searching PubMed and Google Scholar using the search terms “switching botox”, “dosing equivalency in botox”, and “comparing botox”.


          Overall, there are many studies that demonstrate the efficacy and safety of each of the brands of BoNTs used in clinical practice. However, determination of dosing equivalencies among these brands and serotypes is complex with inconsistencies among the studies. When switching from one brand to another, the clinician should be aware of these issues, and not make the assumption that such ratios exist. Tailoring the dosage of each brand of BoNT to the clinical situation is the most prudent treatment strategy rather than focusing closely on conversion factors and concerns for immunogenicity.

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          Most cited references 24

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          Botulinum toxin type A and other botulinum toxin serotypes: a comparative review of biochemical and pharmacological actions.

           K. Aoki,  B. Guyer (2001)
          Botulinum toxin type A is an important therapeutic agent for the treatment of movement and other disorders. As the clinical uses of botulinum toxin type A expand, it is increasingly important to understand the biochemical and pharmacological actions of this toxin, as well as those of other botulinum toxin serotypes (B-G). Botulinum neurotoxin serotypes exhibit differences in neurotoxin complex protein size, percentage of neurotoxin in the activated or nicked form, intracellular protein target, and potency. These properties differ even between preparations that contain the same botulinum toxin serotype due to variations in product formulations. As demonstrated in preclinical and clinical studies, these differences result in a unique combination of efficacy, duration of action, safety, and antigenic potential for each botulinum neurotoxin preparation.
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            Respective potencies of Botox and Dysport: a double blind, randomised, crossover study in cervical dystonia.

            Botulinum toxin type A is a potent neuromuscular paralyzing agent used in various disorders including cervical dystonia. Two preparations of botulinum toxin are now commercially available ( Dysport and Botox), but much controversy remains about their respective potencies. The aim of the study was to compare the efficacy of Botox with two different ratios of Dysport. A double blind, randomised, three period cross over study involving 54 patients with cervical dystonia was performed. The patients received the following treatments in a randomised order: Botox at the usually effective dose, Dysport at a dose of 1:3 (conversion factor of 3 between Botox and Dysport units-that is, one Botox unit=three Dysport units) and at a dose of 1:4 (conversion factor of four). The improvement of the Tsui (primary outcome criteria) and of the TWSTRS pain scales between baseline and a control visit 1 month after each of the three injections, as well as the incidence of adverse events, were assessed. Comparison of the Tsui scores and of the TWSTRS pain scores showed a better effect on impairment and pain with Dysport 1:3 (p=0.02 and 0.04, respectively) and 1:4 (p=0.01 and 0.02, respectively) than with Botox. The number of adverse events was higher with both Dysport treatments. The most frequent adverse event was dysphagia, found in 3%, 15.6%, and 17.3% (Botox, Dysport 1:3 and 1:4, respectively) of the patients. No adverse event required withdrawal of therapy or specific management. Dysport 1:3 (and Dysport 1:4 to a greater extent) is more efficient than Botox for both impairment and pain in cervical dystonia although with a somewhat higher incidence of minor adverse effects. This strongly suggests that the most appropriate conversion factor between Botox and Dysport units is less than 3 in cervical dystonia.
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              Neutralizing antibodies and secondary therapy failure after treatment with botulinum toxin type A: much ado about nothing?

              As the indications and duration of treatment of botulinum toxin type A (BoNT-A) increase, so do reports of patients who fail therapy after initially responding well. Although a loss of efficacy is commonly thought to be associated with neutralizing antibodies (NAbs), this relationship is not strongly correlated, and other factors may play a significant role. To explore this issue, we evaluated levels of NAbs in a large selected cohort of secondary nonresponders to BoNT-A using the highly sensitive mouse phrenic nerve-hemidiaphragm assay. Serum samples from 503 patients treated with BoNT-A who had a variety of diagnoses were tested for the presence of NAbs. Fewer than half of the patients (n = 224, 44.5%) were found to be NAb-positive, indicating that in more than half of the secondary nonresponders, lack of efficacy is not due to NAb formation. The proportion of secondary nonresponders with NAbs was greater for higher dose indications (focal spasticity and spasmodic torticollis) than for lower dose indications (blepharospasm and hemifacial spasm) and increased with shorter injection intervals. Neutralizing antibody development was independent of the commercial preparation used. Our results indicate that although NAb formation does play a role in secondary treatment failure with BoNT-A, this is not the cause in all patients, and the influence of other factors needs to be investigated. Gaining a better understanding of the underlying mechanisms for secondary treatment failure may help in the prediction, diagnosis, management, and prevention of this problem.

                Author and article information

                Ther Clin Risk Manag
                Ther Clin Risk Manag
                Therapeutics and Clinical Risk Management
                Therapeutics and Clinical Risk Management
                Dove Medical Press
                05 February 2016
                : 12
                : 147-154
                [1 ]Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA
                [2 ]Section of Movement Disorders, Rush University Medical Center, Chicago, IL, USA
                Author notes
                Correspondence: Avram Fraint, Department of Neurological Sciences, Rush University Medical Center, 1725 W Harrison St, Suite 1118, Chicago, IL 60612, USA, Email avram_fraint@ 123456rush.edu
                © 2016 Fraint et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.



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