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)

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