Updated Guidelines Provide New Evidence for the Use of Botulinum Neurotoxin to Treat Multiple Conditions

The guideline update assessed each formulation separately for each condition
The guideline update assessed each formulation separately for each condition

Based on new research the American Academy of Neurology (AAN) has updated its 2008 guidelines on the uses of botulinum neurotoxin for the treatment of spasticity, cervical dystonia, blepharospasm and migraine headache. The guideline determined that botulinum neurotoxin is generally safe and effective for treating these conditions, according to the author David M. Simpson, MD, with the Icahn School of Medicine at Mount Sinai in New York, NY, and a Fellow of the American Academy of Neurology. Four preparations of botulinum neurotoxin are available in the U.S., and they are not interchangeable. The guideline update assessed each formulation separately for each condition.

For the treatment of blepharospasm:
  • OnabotulinumtoxinA (Botox; Allergan) and incobotulinumtoxinA (Xeomin; Merz) should be considered as treatment options (moderate evidence; Level B)
  • AbobotulinumtoxinA (Dysport; Ispen) may be considered as a treatment option (weak evidence; Level C)
  • Botulinum neurotoxin is considered first-line treatment by most movement disorder specialists
For the treatment of cervical dystonia:
  • AbobotulinumtoxinA and rimabotulinumtoxinB (Myobloc; Neurobloc; US WorldMeds/Solstice Neurosciences) should be offered as options (strong evidence; Level A)
  • OnabotulinumtoxinA and incobotulinumtoxinA should be considered as options (moderate evidence; Level B); lack of additional Class 1 studies 
  • Botulinum neurotoxin is accepted as first-line treatment 
  • Comparative trials show similar efficacy for rimabotulinumtoxinB and onabotulinumtoxinA, and for abobotulinumtoxinA and onabotulinumtoxinA
For the treatment of spasticity in adults:

Upper Extremity Spasticity: 
  • AbobotulinumtoxinA,  incobotulinumtoxinA, and onabotulinumtoxinA should be offered as treatment (strong evidence; Level A)
  • RimabotulinumtoxinB can be considered as an option (moderate evidence; Level B)
  • OnabotulinumtoxinA should be considered as treatment option before tizanidine (moderate evidence; Level B)
Lower Extremity Spasticity:
  • OnabotulinumtoxinA and abobotulinumtoxinA should be offered as treatment (strong evidence; Level A)
  • Insufficient evidence to support or refute benefit of incobotulinumtoxinA or rimabotulinumtoxinB (Level U)

For the treatment of headache:

Chronic Migraine:
  • OnabotulinumtoxinA should be offered as an option for patients with chronic migraine to increase number of headache-free days (strong evidence; Level A)
  • OnabotulinumtoxinA should be considered to reduce impact of headache on health-related quality of life (moderate evidence; Level B)
  • While reduction of headache days was statistically superior in Class I studies, the difference was small
Episodic Migraine:
  • OnabotulinumtoxinA should NOT be offered (strong evidence; Level A)
Tension-type Headaches:
  • Botulinum neurotoxin probably ineffective (Level B; 2008 guidelines)
  • No new studies since 2008 guidelines
Other disorders such as essential tremor, hemifacial spasm and disorders of the voice were not included in this update as there was no new evidence available at the time the guideline update was initiated.

For more information visit AAN.com.

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