Botox Treatment Technical Information

Botox Technical Information

Recommended dose:

The exact dosage and number of injection sites may be tailored to the individual based on the size, number and location of muscles involved, the severity of spasticity, the presence of local muscle weakness, and the patient response to previous treatment.

The following doses are recommended:

Muscle

Total Dosage;

Number of Sites

Flexor digitorum profundus

15 - 50 Units; 1-2 sites

Flexor digitorum sublimis

15 - 50 Units; 1-2 sites

Flexor carpi radialis

15 - 60 Units; 1-2 sites

Flexor carpi ulnaris

10 - 50 Units; 1-2 sites

Adductor Pollicis

20 Units; 1-2 sites

Flexor Pollicis Longus

20 Units; 1-2 sites

Maximum dose:

Between 200 and 240 Units divided among selected muscles.

Additional information:

If it is deemed appropriate by the treating physician, the patient should be considered for re-injection when the clinical effect of the previous injection has diminished. Re-injections should occur no sooner than 12 weeks after the previous injection. The degree and pattern of muscle spasticity at the time of re-injection may necessitate alterations in the dose of BOTOX and muscles to be injected. The lowest effective dose should be used.

Focal lower limb spasticity associated with stroke

Recommended needle:

Sterile 25, 27 or 30 gauge needle. Needle length should be determined based on muscle location and depth.

Administration guidance:

Localisation of the involved muscles with techniques such as electromyographic guidance, nerve stimulation, or ultrasound is recommended. Multiple injection sites may allow BOTOX to have more uniform contact with the innervation areas of the muscle and are especially useful in larger muscles.

Recommended dose:

300 Units to 400 Units divided among up to 6 muscles, as listed in the following table.

Muscle

Recommended Dose

Total Dosage; Number of Sites

Gastrocnemius

Medial head

Lateral head

75 Units; 3 sites

75 Units; 3 sites

Soleus

75 Units; 3 sites

Tibialis Posterior

75 Units; 3 sites

Flexor hallucis longus

50 Units; 2 sites

Flexor digitorum longus

50 Units; 2 sites

Flexor digitorum brevis

25 Units; 1 site

Maximum dose:

400 Units in total

Additional information:

If it is deemed appropriate by the treating physician, the patient should be considered for re-injection when the clinical effect of the previous injection has diminished, no sooner than 12 weeks after the previous injection.

Blepharospasm/hemifacial spasm

Recommended needle:

Sterile, 27-30 gauge/0.40-0.30 mm needle.

Administrative guidance:

Electromyographic guidance is not necessary.

Recommended dose:

The initial recommended dose is 1.25-2.5 Units (0.05-0.1 ml volume at each site) injected into the medial and lateral orbicularis oculi of the upper lid and the lateral orbicularis oculi of the lower lid. Additional sites in the brow area, the lateral orbicularis and in the upper facial area may also be injected if spasms here interfere with vision.

The following diagrams indicate the possible injection sites:

Maximum dose:

The initial dose should not exceed 25 Units per eye. In the management of blepharospasm total dosing should not exceed 100 Units in total every 12 weeks.

Additional information:

Avoiding injection near levator palpebrae superioris may reduce the complication of ptosis. Avoiding medial lower lid injections, and thereby reducing diffusion into the inferior oblique, may reduce the complication of diplopia.

In general, the initial effect of the injections is seen within three days and reaches a peak at one to two weeks post-treatment. Each treatment lasts approximately three months, following which the procedure can be repeated indefinitely. Normally no additional benefit is conferred by treating more frequently than every three months.

At repeat treatment sessions, the dose may be increased up to two-fold if the response from the initial treatment is considered insufficient - usually defined as an effect that does not last longer than two months. However, there appears to be little benefit obtainable from injecting more than 5 Units per site.

Patients with hemifacial spasm or VIIth nerve disorders should be treated as for unilateral blepharospasm, with other affected facial muscles being injected as needed. Electromyographic control may be necessary to identify affected small circumoral muscles.

Cervical dystonia

Recommended needle:

A 25, 27 or 30 gauge/0.50-0.30 mm needle may be used for superficial muscles, and a 22 gauge needle may be used for deeper musculature.

Administrative guidance:

The treatment of cervical dystonia typically may include injection of BOTOX into the sternocleidomastoid, levator scapulae, scalene, splenius capitis, semispinalis, longissimus and/or the trapezius muscle(s). This list is not exhaustive as any of the muscles responsible for controlling head position may be involved and therefore require treatment. The muscle mass and the degree of hypertrophy are factors to be taken into consideration when selecting the appropriate dose. Muscle activation patterns can change spontaneously in cervical dystonia without a change in the clinical presentation of dystonia.

In case of any difficulty in isolating the individual muscles, injections should be made under electromyographic assistance.

Multiple injection sites allow BOTOX to have more uniform contact with the innervation areas of the dystonic muscle and are especially useful in larger muscles. The optimal number of injection sites is dependent upon the size of the muscle to be chemically denervated.

Recommended dose:

Dosing must be tailored to the individual patient based on the patient's head and neck position, location of pain, muscle hypertrophy, patient's body weight, and patient response.

Initial dosing in a naïve patient should begin at the lowest effective dose.

To minimise the incidence of dysphagia, the sternomastoid should not be injected bilaterally.

The following doses are recommended:

Type I

Head rotated toward side of shoulder elevation

Sternomastoid

Levator scapulae

Scalene

Splenius capitis

Trapezius

50 - 100 Units; at least 2 sites

50 Units; 1 - 2 sites

25 - 50 Units; 1 - 2 sites

25 - 75 Units; 1 - 3 sites

25 - 100 Units; 1 - 8 sites

Type II

Head rotation only

Sternomastoid

25 - 100 Units; at least 2 sites if >25 Units given

Type III

Head tilted toward side of shoulder elevation

Sternomastoid

Levator scapulae

Scalene

Trapezius

25 - 100 Units at posterior border; at least 2 sites if >25 Units given

25 - 100 Units; at least 2 sites

25 - 75 Units; at least 2 sites

25 - 100 Units; 1 - 8 sites

Type IV

Bilateral posterior cervical muscle spasm with elevation of the face

Splenius capitis and cervicis

50 - 200 Units; 2 - 8 sites, treat bilaterally

(This is the total dose and not the dose for each side of the neck)

Maximum dose:

No more than 50 Units should be given at any one injection site.

No more than 100 Units should be given to the sternomastoid.

No more than 200 Units in total should be injected for the first course of therapy, with adjustments made in subsequent courses dependent on the initial response, up to a maximum total dose of 300 Units.

Additional information:

Treatment intervals of less than 10 weeks are not recommended.

Chronic migraine

Recommended needle:

Sterile 30 gauge, 0.5 inch needle.

A 1 inch needle may be needed in the neck region for patients with extremely thick neck muscles.

Administration guidance:

Injections should be divided across 7 specific head/neck muscle areas as specified in the diagrams below. With the exception of the procerus muscle, which should be injected at 1 site (midline), all muscles should be injected bilaterally with half the number of injection sites administered to the left, and half to the right side of the head and neck.

If there is a predominant pain location(s), additional injections to one or both sides may be administered in up to 3 specific muscle groups (occipitalis, temporalis and trapezius), up to the maximum dose per muscle as indicated in the table below.

Recommended dose:

155 Units to 195 Units administered intramuscularly as 0.1 ml (5 Units) injections to 31 and up to 39 sites.

Recommended Dose

Head/Neck Area

Total Dosage (number of sitesa)

Corrugatorb

10 Units (2 sites)

Procerus

5 Units (1 site)

Frontalisb

20 Units (4 sites)

Temporalisb

40 Units (8 sites) up to 50 Units (up to 10 sites)

Occipitalisb

30 Units (6 sites) up to 40 Units (up to 8 sites)

Cervical Paraspinal Muscle Groupb

20 Units (4 sites)

Trapeziusb

30 Units (6 sites) up to 50 Units (up to 10 sites)

Total Dose Range:

155 Units to 195 Units

31 to 39 sites

a1 IM injection site = 0.1 ml = 5 Units BOTOX

bDose distributed bilaterally

Additional information:

The recommended re-treatment schedule is every 12 weeks.

BLADDER DISORDERS

Overactive bladder

Recommended needle:

The injection needle should be filled (primed) with approximately 1 ml of the reconstituted BOTOX solution prior to the start of the injections (depending on the needle length) to remove any air.

Administration guidance:

The reconstituted solution of BOTOX (100 Units/10 ml) is injected via a flexible or rigid cystoscope, avoiding the trigone and base. The bladder should be instilled with enough saline to achieve adequate visualisation for the injections and avoid backflow of the product, but over-distension should be avoided.

The needle should be inserted approximately 2 mm into the detrusor, and 20 injections of 0.5 ml each (total volume 10 ml) should be spaced approximately 1 cm apart (see figure below). For the final injection, approximately 1 ml of sterile unpreserved normal saline (0.9% sodium chloride for injection) should be injected so the full dose is delivered.

Recommended dose:

The recommended dose is 100 Units of BOTOX, as 0.5 ml (5 Units) injections across 20 sites in the detrusor muscle.

Additional information:

For the patient preparation and monitoring, see section 4.4.

After the injections are given, the saline used for bladder wall visualisation should not be drained so that the patients can demonstrate their ability to void prior to leaving the clinic. The patient should be observed for at least 30 minutes post-injection and until a spontaneous void has occurred.

Patients should be considered for reinjection when the clinical effect of the previous injection has diminished but no sooner than 3 months from the prior bladder injection.

Urinary incontinence due to neurogenic detrusor overactivity

Recommended needle:

The injection needle should be filled (primed) with approximately 1 ml of the reconstituted BOTOX solution prior to the start of the injections (depending on the needle length) to remove any air.

Administration guidance:

The reconstituted solution of BOTOX (200 Units/30 ml) is injected via a flexible or rigid cystoscope, avoiding the trigone and base. The bladder should be instilled with enough saline to achieve adequate visualisation for the injections and avoid backflow of the product, but over-distension should be avoided.

The needle should be inserted approximately 2 mm into the detrusor, and 30 injections of 1 ml each (total volume 30 ml) should be spaced approximately 1 cm apart (see figure above). For the final injection, approximately 1 ml of sterile unpreserved normal saline (0.9% sodium chloride for injection) should be injected so the full dose is delivered. After the injections are given, the saline used for bladder wall visualisation should be drained.

Recommended dose:

The recommended dose is 200 Units of BOTOX, as 1 ml (~6.7 Units) injections across 30 sites in the detrusor muscle.

Additional information:

For the patient preparation and monitoring, see section 4.4.

Patients should be considered for reinjection when the clinical effect of the previous injection has diminished, but no sooner than 3 months from the prior bladder injection.

No urodynamic data beyond 2 treatments and no histopathological data after repeated treatment are currently available.

Patients should not receive multiple treatments in the event of limited symptomatic improvement.

SKIN AND SKIN APPENDAGE DISORDERS

Primary hyperhidrosis of the axillae

Recommended needle:

Sterile 30 gauge needle.

Administration guidance:

The hyperhidrotic area to be injected may be defined by using standard staining techniques, e.g. Minor´s iodine-starch test.

Recommended dose:

50 Units of BOTOX is injected intradermally to each axilla, evenly distributed in multiple sites approximately 1-2 cm apart.

The recommended injection volume for intradermal injection is 0.1-0.2 ml.

Maximum dose:

Doses other than 50 Units per axilla cannot be recommended.

Additional information:

Clinical improvement generally occurs within the first week after injection and persists for 4-7 months.

Repeat injection of BOTOX can be administered when the clinical effect of a previous injection diminishes and the treating physician deems it necessary. Injections should not be repeated more frequently than every 16 weeks.

Glabellar lines seen at maximum frown

Recommended needle:

Sterile 30 gauge needle.

Administration guidance:

Before injection, the thumb or index finger is to be placed firmly below the orbital rim in order to prevent extravasation below the orbital rim. The needle should be oriented superiorly and medially during the injection. In addition, injections near the levator palpebrae superioris muscle must be avoided, particularly in patients with larger brow-depressor complexes (depressor supercilii). Injections in the corrugator muscle must be done in the central part of that muscle, a distance of at least 1 cm above the arch of the eyebrows (see figure).

Care should be taken to ensure that BOTOX is not injected into a blood vessel when it is injected in the glabellar lines seen at maximum frown, see section 4.4.

Recommended dose:

A volume of 0.1 ml (4 Units) is administered in each of the 5 injection sites (see Figure): 2 injections in each corrugator muscle and 1 injection in the procerus muscle for a total dose of 20 Units.

Maximum dose:

In order to reduce the risk of eyelid ptosis, the maximum dose of 4 Units for each injection site as well as the number of injection sites should not be exceeded.

Additional Information

Treatment intervals should not be more frequent than every three months. In the event of treatment failure or diminished effect following repeat injections, alternative treatment methods should be employed.

In case of insufficient dose a second treatment session should be initiated by adjusting the total dose up to 40 or 50 Units, taking into account the analysis of the previous treatment failure (see information in All indications).

The efficacy and safety of repeat injections of BOTOX for the treatment of glabellar lines beyond 12 months has not been evaluated.

Crow's feet lines seen at maximum smile

Recommended needle:

Sterile 30 gauge needle.

Administration guidance:

Injections should be given with the needle tip bevel up and oriented away from the eye. The first injection (A) should be made approximately 1.5 to 2.0 cm temporal to the lateral canthus and just temporal to the orbital rim. If the lines in the crow's feet region are above and below the lateral canthus, inject as shown in Figure 1. Alternatively, if the lines in the crow's feet region are primarily below the lateral canthus, inject as shown in Figure 2.

In order to reduce the risk of eyelid ptosis, injections should be made temporal to the orbital rim, thereby maintaining a safe distance from the muscle controlling eyelid elevation.

Care should be taken to ensure that BOTOX is not injected into a blood vessel when it is injected in the crow's feet lines seen at maximum smile (see section 4.4).

Recommended dose:

A volume of 0.1 ml (4 Units) is administered in each of the 3 injection sites per side (total of 6 injection sites) in the lateral orbicularis oculi muscle, for a total dose of 24 Units in a total volume of 0.6 ml (12 Units per side).

For simultaneous treatment with glabellar lines seen at maximum frown, the dose is 24 Units for crow's feet lines seen at maximum smile and 20 Units for glabellar lines (see Administration guidance for glabellar lines) for a total dose of 44 Units in a total volume of 1.1 ml.

Maximum dose:

In order to reduce the risk of eyelid ptosis, the maximum dose of 4 Units for each injection site as well as the number of injection sites should not be exceeded.

Additional information:

Treatment intervals should not be more frequent than every 3 months.

The efficacy and safety of repeat injections of BOTOX for the treatment of crow's feet lines beyond 12 months has not been evaluated.

Forehead Lines seen at maximum eyebrow elevation

Recommended needle:

Sterile 30 gauge needle.

Administration guidance:

To identify the location of the appropriate injection sites in the frontalis muscle, assess the overall relationship between the size of the subject's forehead, and the distribution of frontalis muscle activity should be assessed.

The following horizontal treatment rows should be located by light palpation of the forehead at rest and maximum eyebrow elevation:

• Superior Margin of Frontalis Activity: approximately 1 cm above the most superior forehead crease

• Lower Treatment Row: midway between the superior margin of frontalis activity and the eyebrow, at least 2 cm above the eyebrow

• Upper Treatment Row: midway between the superior margin of frontalis activity and lower treatment row

The 5 injections should be placed at the intersection of the horizontal treatment rows with the following vertical landmarks:

• On the lower treatment row at the midline of the face, and 0.5 – 1.5 cm medial to the palpated temporal fusion line (temporal crest); repeat for the other side.

• On the upper treatment row, midway between the lateral and medial sites on the lower treatment row; repeat for the other side.

Care should be taken to ensure that BOTOX is not injected into a blood vessel when it is injected in the forehead lines seen at maximum eyebrow elevation (see section 4.4).

Recommended dose:

A volume of 0.1 ml (4 Units) is administered in each of the 5 injection sites in the frontalis muscle, for a total dose of 20 Units in a total volume of 0.5 ml (see Figure 3).

The total dose for treatment of forehead lines (20 Units) in conjunction with glabellar lines (20 Units) is 40 Units/1.0 mL.

For simultaneous treatment with glabellar lines and crow's feet lines, the total dose is 64 Units, comprised of 20 Units for forehead lines, 20 Units for glabellar lines (see Recommended dose for Glabellar Lines and Figure), and 24 Units for crow's feet lines (see Recommended dose for Crow's Feet Lines and Figures 1 and 2).

Additional information:

Treatment intervals should not be more frequent than every 3 months.

The efficacy and safety of repeat injections of BOTOX for the treatment of forehead lines beyond 12 months has not been evaluated.

ALL INDICATIONS:

In case of treatment failure after the first treatment session, i.e. absence, at one month after injection, of significant clinical improvement from baseline, the following actions should be taken:

- Clinical verification, which may include electromyographic examination in a specialist setting, of the action of the toxin on the injected muscle(s);

- Analysis of the causes of failure, e.g. bad selection of muscles to be injected, insufficient dose, poor injection technique, appearance of fixed contracture, antagonist muscles too weak, formation of toxin-neutralising antibodies;

- Re-evaluation of the appropriateness of treatment with botulinum toxin type A;

- In the absence of any undesirable effects secondary to the first treatment session, instigate a second treatment session as following: i) adjust the dose, taking into account the analysis of the earlier treatment failure; ii) use EMG; and iii) maintain a three-month interval between the two treatment sessions.

In the event of treatment failure or diminished effect following repeat injections alternative treatment methods should be employed.

When treating adult patients for multiple indications, the maximum cumulative dose should not exceed 400 Units in a 12-week interval.

4.3 Contraindications
-known hypersensitivity to botulinum toxin type A or to any of the excipients listed in section 6.1;

-presence of infection at the proposed injection site(s).

For the management of bladder disorders:

-urinary tract infection at the time of treatment;

-acute urinary retention at the time of treatment, in patients who are not routinely catheterising;

-patients who are not willing and/or able to initiate catheterisation post-treatment if required;

-presence of bladder calculi.

4.4 Special warnings and precautions for use
The recommended dosages and frequencies of administration of BOTOX should not be exceeded due to the potential for overdose, exaggerated muscle weakness, distant spread of toxin and the formation of neutralising antibodies. Initial dosing in treatment naïve patients should begin with the lowest recommended dose for the specific indication.

Prescribers and patients should be aware that side effects can occur despite previous injections being well tolerated. Caution should therefore be exercised on the occasion of each administration.

Side effects related to spread of toxin distant from the site of administration have been reported (see section 4.8), sometimes resulting in death, which in some cases was associated with dysphagia, pneumonia and/or significant debility.

The symptoms are consistent with the mechanism of action of botulinum toxin and have been reported hours to weeks after injection. The risk of symptoms is probably greatest in patients who have underlying conditions and comorbidities that would predispose them to these symptoms, including children and adults treated for spasticity, and are treated with high doses.

Patients treated with therapeutic doses may also experience exaggerated muscle weakness.

Elderly and debilitated patients should be treated with caution. Generally, clinical studies of BOTOX did not identify differences in responses between the elderly and younger patients except for facial lines (see section 5.1). Dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range.

Consideration should be given to the risk-benefit implications for the individual patient before embarking on treatment with BOTOX.

Dysphagia has also been reported following injection to sites other than the cervical musculature (see section 4.4 'Cervical Dystonia').

BOTOX should only be used with extreme caution and under close supervision in patients with subclinical or clinical evidence of defective neuromuscular transmission e.g. myasthenia gravis or Lambert-Eaton Syndrome in patients with peripheral motor neuropathic diseases (e.g. amyotrophic lateral sclerosis or motor neuropathy) and in patients with underlying neurological disorders. Such patients may have an increased sensitivity to agents such as BOTOX, even at therapeutic doses, which may result in excessive muscle weakness and an increased risk of clinically significant systemic effects including severe dysphagia and respiratory compromise. The botulinum toxin product should be used under specialist supervision in these patients and should only be used if the benefit of treatment is considered to outweigh the risk. Patients with a history of dysphagia and aspiration should be treated with extreme caution.

Patients or caregivers should be advised to seek immediate medical care if swallowing, speech or respiratory disorders arise.

As with any treatment with the potential to allow previously-sedentary patients to resume activities, the sedentary patient should be cautioned to resume activity gradually.

The relevant anatomy, and any alterations to the anatomy due to prior surgical procedures, must be understood prior to administering BOTOX and injection into vulnerable anatomic structures must be avoided.

Pneumothorax associated with injection procedure has been reported following the administration of BOTOX near the thorax.

Caution is warranted when injecting in proximity to the lung (particularly the apices) or other vulnerable anatomic structures.

Serious adverse events including fatal outcomes have been reported in patients who had received off-label injections of BOTOX directly into salivary glands, the oro-lingual-pharyngeal region, oesophagus and stomach. Some patients had pre-existing dysphagia or significant debility.

Serious and/or immediate hypersensitivity reactions have been rarely reported including anaphylaxis, serum sickness, urticaria, soft tissue oedema, and dyspnoea. Some of these reactions have been reported following the use of BOTOX either alone or in conjunction with other products associated with similar reactions. If such a reaction occurs further injection of BOTOX should be discontinued and appropriate medical therapy, such as epinephrine, immediately instituted. One case of anaphylaxis has been reported in which the patient died after being injected with BOTOX inappropriately diluted with 5 ml of 1% lidocaine.

As with any injection, procedure-related injury could occur. An injection could result in localised infection, pain, inflammation, paraesthesia, hypoaesthesia, tenderness, swelling, erythema, and/or bleeding/bruising. Needle-related pain and/or anxiety may result in vasovagal responses, e.g. syncope, hypotension, etc.

Caution should be used when BOTOX is used in the presence of inflammation at the proposed injection site(s) or when excessive weakness or atrophy is present in the target muscle. Caution should also be exercised when BOTOX is used for treatment of patients with peripheral motor neuropathic diseases (e.g., amyotrophic lateral sclerosis or motor neuropathy).

There have been reports of adverse events following administration of BOTOX involving the cardiovascular system, including arrhythmia and myocardial infarction, some with fatal outcomes. Some of these patients had risk factors including pre-existing cardiovascular disease.

New onset or recurrent seizures have been reported, typically in patients who are predisposed to experiencing these events. The exact relationship of these events to botulinum toxin injection has not been established. The reports in children were predominantly from cerebral palsy patients treated for spasticity.

Formation of neutralising antibodies to botulinum toxin type A may reduce the effectiveness of BOTOX treatment by inactivating the biological activity of the toxin. Results from some studies suggest that BOTOX injections at more frequent intervals or at higher doses may lead to greater incidence of antibody formation. When appropriate, the potential for antibody formation may be minimised by injecting with the lowest effective dose given at the longest clinically indicated intervals between injections.

Clinical fluctuations during the repeated use of BOTOX (as with all botulinum toxins) may be a result of different vial reconstitution procedures, injection intervals, muscles injected and slightly differing potency values given by the biological test method used.

Paediatric use

The safety and efficacy of BOTOX in indications other than those described for the paediatric population in section 4.1 has not been established. Post-marketing reports of possible distant spread of toxin have been very rarely reported in paediatric patients with comorbidities, predominantly with cerebral palsy. In general the dose used in these cases was in excess of that recommended (see section 4.8).

There have been rare spontaneous reports of death sometimes associated with aspiration pneumonia in children with severe cerebral palsy after treatment with botulinum toxin, including following off-label use (e.g. neck area). Extreme caution should be exercised when treating paediatric patients who have significant neurologic debility, dysphagia, or have a recent history of aspiration pneumonia or lung disease.

Treatment in patients with poor underlying health status should be administered only if the potential benefit to the individual patient is considered to outweigh the risks.

NEUROLOGIC DISORDERS

Focal spasticity associated with paediatric cerebral palsy and focal spasticity of the ankle and foot, hand and wrist in adult post-stroke patients

BOTOX is a treatment of focal spasticity that has only been studied in association with usual standard of care regimens, and is not intended as a replacement for these treatment modalities. BOTOX is not likely to be effective in improving range of motion at a joint affected by a fixed contracture.

BOTOX should only be used for the treatment of focal spasticity in adult post-stroke patients if muscle tone reduction is expected to result in improved function (e.g. improvements in gait), or improved symptoms (e.g. reduction in muscle spasms or pain), and/or to facilitate care. Improvement in active function may be limited if BOTOX treatment is initiated longer than 2 years post-stroke or in patients with Modified Ashworth Scale (MAS) < 3.

Caution should be exercised when treating adult patients with post-stroke spasticity who may be at increased risk of fall.

There have been post-marketing reports of death (sometimes associated with aspiration pneumonia) and of possible distant spread of toxin in children with co-morbidities, predominantly cerebral palsy following treatment with botulinum toxin. See warnings under section 4.4, 'Paediatric use'.

Blepharospasm

Reduced blinking following botulinum toxin injection into the orbicularis muscle can lead to corneal exposure, persistent epithelial defect, and corneal ulceration, especially in patients with VII nerve disorders. Careful testing of corneal sensation in eyes previously operated upon, avoidance of injection into the lower lid area to avoid ectropion, and vigorous treatment of any epithelial defect should be employed. This may require protective drops, ointment, therapeutic soft contact lenses, or closure of the eye by patching or other means.

Ecchymosis occurs easily in the soft eyelid tissues. This can be minimised by applying gentle pressure at the injection site immediately after injection.

Because of the anticholinergic activity of botulinum toxin, caution should be exercised when treating patients at risk for angle closure glaucoma, including patients with anatomically narrow angles.

Cervical dystonia

Patients with cervical dystonia should be informed of the possibility of experiencing dysphagia which may be very mild, but could be severe. Dysphagia may persist for two to three weeks after injection, but has been reported to last up to five months post-injection. Consequent to the dysphagia there is the potential for aspiration, dyspnoea and occasionally the need for tube feeding. In rare cases dysphagia followed by aspiration pneumonia and death has been reported.

Limiting the dose injected into the sternocleidomastoid muscle to less than 100 Units may decrease the occurrence of dysphagia. Patients with smaller neck muscle mass, or patients who receive bilateral injections into the sternocleidomastoid muscle, have been reported to be at greater risk of dysphagia. Dysphagia is attributable to the spread of the toxin to the oesophageal musculature. Injections into the levator scapulae may be associated with an increased risk of upper respiratory infection and dysphagia.

Dysphagia may contribute to decreased food and water intake resulting in weight loss and dehydration. Patients with subclinical dysphagia may be at increased risk of experiencing more severe dysphagia following a BOTOX injection.

Chronic migraine

No efficacy has been shown for BOTOX in the prophylaxis of headaches in patients with episodic migraine (headaches on < 15 days per month).

BLADDER DISORDERS

Patient preparation and monitoring

Prophylactic antibiotics should be administered to patients with sterile urine or asymptomatic bacteriuria in accordance with local standard practice.

The decision to discontinue anti-platelet therapy should be subject to local guidance and benefit/risk consideration for the individual patient. Patients on anti-coagulant therapy need to be managed appropriately to decrease the risk of bleeding.

Appropriate medical caution should be exercised when performing the cystoscopy. The patient should be observed for at least 30 minutes post-injection.

In patients who are not regularly practicing catheterisation, post-void residual urine volume should be assessed within 2 weeks post-treatment and periodically as medically appropriate. Patients should be instructed to contact their physician if they experience difficulties in voiding as catheterisation may be required.

Overactive bladder

Prior to injection an intravesical instillation of diluted local anaesthetic, with or without sedation, may be used, per local site practice. If a local anaesthetic instillation is performed, the bladder should be drained and rinsed with sterile saline before the next steps of the injection procedure.

Urinary incontinence due to neurogenic detrusor overactivity

BOTOX injection can be performed under general or local anaesthesia with or without sedation. If a local anaesthetic intravesical instillation is performed, the bladder should be drained and rinsed with sterile saline before the next steps of the injection procedure.

Autonomic dysreflexia associated with the procedure can occur and greater vigilance is required in patients known to be at risk.

SKIN AND SKIN APPENDAGE DISORDERS

Primary hyperhidrosis of the axillae

Medical history and physical examination, along with specific additional investigations as required, should be performed to exclude potential causes of secondary hyperhidrosis (e.g. hyperthyroidism, phaeochromocytoma). This will avoid symptomatic treatment of hyperhidrosis without the diagnosis and/or treatment of underlying disease.

Glabellar lines seen at maximum frown and/or crow's feet lines seen at maximum smile and/or forehead lines seen at maximum eyebrow elevation

It is mandatory that BOTOX is used for one single patient treatment only during a single session. The excess of unused product must be disposed of as detailed in section 6.6. Particular precautions should be taken for product preparation and administration as well as for the inactivation and disposal of the remaining unused solution (see section 6.6).

The use of BOTOX is not recommended in individuals under 18 years. There is limited phase 3 clinical data with BOTOX in patients older than 65 years.

Care should be taken to ensure that BOTOX is not injected into a blood vessel when it is injected in the glabellar seen at maximum frown, in the crow's feet lines seen at maximum smile, or in the forehead lines seen at maximum eyebrow elevation, see section 4.2. There is a risk of eyelid ptosis following treatment, refer to Section 4.2 for administration instructions on how to minimise this risk.

4.5 Interaction with other medicinal products and other forms of interaction
Theoretically, the effect of botulinum toxin may be potentiated by aminoglycoside antibiotics or spectinomycin, or other medicinal products that interfere with neuromuscular transmission (e.g. neuromuscular blocking agents).

The effect of administering different botulinum neurotoxin serotypes at the same time or within several months of each other is unknown. Excessive neuromuscular weakness may be exacerbated by administration of another botulinum toxin prior to the resolution of the effects of a previously administered botulinum toxin.

No interaction studies have been performed. No interactions of clinical significance have been reported.

There are no data available on the concomitant use of anticholinergics with BOTOX injections in the management of overactive bladder.

4.6 Fertility, pregnancy and lactation
Pregnancy

There are no adequate data from the use of botulinum toxin type A in pregnant women. Studies in animals have shown reproductive toxicity (see Section 5.3). The potential risk for humans is unknown. BOTOX is not recommended during pregnancy and in women of childbearing potential not using contraception.

Breast-feeding

There is no information on whether BOTOX is excreted in human milk. The use of BOTOX during breast-feeding cannot be recommended.

Fertility

There are no adequate data on the effects on fertility from the use of botulinum toxin type A in women of childbearing potential. Studies in male and female rats have shown fertility reductions (see section 5.3).

4.7 Effects on ability to drive and use machines
No studies on the effects on the ability to drive and use machines have been performed. However, BOTOX may cause asthenia, muscle weakness, somnolence, dizziness and visual disturbance, which could affect driving and the operation of machinery.

4.8 Undesirable effects
a) General

In controlled clinical trials adverse events considered by the investigators to be related to BOTOX were reported in 35% of the patients with blepharospasm, 28% with cervical dystonia, 17% with paediatric cerebral palsy, 11% with primary hyperhidrosis of the axillae, 16% with focal spasticity of the upper limb associated with stroke, 15% with focal spasticity of the lower limb associated with stroke, 26% with overactive bladder, and 32% with neurogenic detrusor overactivity. In clinical trials for chronic migraine, the incidence was 26% with the first treatment and declined to 11% with a second treatment.

In controlled clinical trials for glabellar lines seen at maximum frown, adverse events considered by the investigators to be related to BOTOX were reported in 23% (placebo 19%) of patients. In treatment cycle 1 of the pivotal controlled clinical trials for crow's feet lines seen at maximum smile, such events were reported in 8% (24 Units for crow's feet lines alone) and 6% (44 Units: 24 Units for crow's feet lines administered simultaneously with 20 Units for glabellar lines) of patients compared to 5% for placebo.

In treatment cycle 1 of clinical trials for forehead lines seen at maximum eyebrow elevation, adverse events considered by the investigators to be related to BOTOX were reported in 20.6% of patients treated with 40 Units (20 Units to the frontalis with 20 Units to the glabellar complex), and 14.3% of patients treated with 64 Units (20 Units to the frontalis with 20 Units to the glabellar complex and 24 Units to the lateral canthal lines areas), compared to 8.9% of patients that received placebo.

Adverse reactions may be related to treatment, injection technique or both. In general, adverse reactions occur within the first few days following injection and, while generally transient, may have a duration of several months or, in rare cases, longer.

Local muscle weakness represents the expected pharmacological action of botulinum toxin in muscle tissue. However, weakness of adjacent muscles and/or muscles remote from the site of injection has been reported.

As is expected for any injection procedure, localised pain, inflammation, paraesthesia, hypoaesthesia, tenderness, swelling/oedema, erythema, localised infection, bleeding and/or bruising have been associated with the injection. Needle-related pain and/or anxiety have resulted in vasovagal responses, including transient symptomatic hypotension and syncope. Fever and flu syndrome have also been reported after injections of botulinum toxin.

b) Adverse reactions - frequency by indication

The frequency of adverse reactions reported in the clinical trials is defined as follows:

Very Common (≥ 1/10); Common (≥1/100 to <1/10); Uncommon (≥1/1,000 to <1/100); Rare (≥1/10,000 to <1/1,000); Very Rare (<1/10,000).

NEUROLOGIC DISORDERS

Focal spasticity associated with paediatric cerebral palsy

System Organ Class

Preferred Term

Frequency

Infections and infestations

Viral infection, ear infection

Very Common

Nervous system disorders

Somnolence, gait disturbance, paraesthesia

Common

Skin and subcutaneous tissue disorders

Rash

Common

Musculoskeletal and connective tissue disorders

Myalgia, muscular weakness, pain in extremity

Common

Renal and urinary disorders

Urinary incontinence

Common

General disorders and administration site conditions

Malaise, injection site pain, asthenia

Common

Injury, poisoning and procedural complications

Fall

Common

Focal upper limb spasticity associated with stroke

System Organ Class

Preferred Term

Frequency

Psychiatric disorders

Depression, insomnia

Uncommon

Nervous system disorders

Hypertonia

Common

Hypoasthesia, headache, paraesthesia, incoordination, amnesia

Uncommon

Ear and labyrinth disorders

Vertigo

Uncommon

Vascular disorders

Orthostatic hypotension

Uncommon

Gastrointestinal disorders

Nausea, oral paraesthesia

Uncommon

Skin and subcutaneous tissue disorders

Ecchymosis, purpura

Common

Dermatitis, pruritus, rash

Uncommon

Musculoskeletal and connective tissue disorders

Pain in extremity, muscle weakness

Common

Arthralgia, bursitis

Uncommon

General disorders and administration site conditions

Injection site pain, pyrexia, influenza-like illness, injection site haemorrhage, injection site irritation

Common

Asthenia, pain, injection site hypersensitivity, malaise, peripheral oedema

Uncommon

Some of the uncommon events may be disease related.

Focal lower limb spasticity associated with stroke

System Organ Class

Preferred Term

Frequency

Skin and subcutaneous tissue disorders

Rash

Common

Musculoskeletal and connective tissue disorders

Arthralgia, musculoskeletal stiffness, muscular weakness

Common

General disorders and administration site conditions

Peripheral oedema

Common

Injury, poisoning and procedural complications

Fall

Common

Blepharospasm/hemifacial spasm

System Organ Class

Preferred Term

Frequency

Nervous system disorders

Dizziness, facial paresis, facial palsy

Uncommon

Eye disorders

Eyelid ptosis

Very Common

Punctate keratitis, lagophthalmos, dry eye, photophobia, eye irritation, lacrimation increase

Common

Keratitis, ectropion, diplopia, entropion, visual disturbance, blurred vision

Uncommon

Eyelid oedema

Rare

Corneal ulceration, corneal epithelium defect, corneal perforation

Very Rare

Skin and subcutaneous tissue disorders

Ecchymosis

Common

Rash/dermatitis

Uncommon

General disorders and administration site conditions

Irritation, face oedema

Common

Fatigue

Uncommon

Cervical dystonia

System Organ Class

Preferred Term

Frequency

Infections and infestations

Rhinitis, upper respiratory infection

Common

Nervous system disorders

Dizziness, hypertonia, hypoaesthesia, somnolence, headache

Common

Eye disorders

Diplopia, eyelid ptosis

Uncommon

Respiratory, thoracic and mediastinal disorders

Dyspnoea, dysphonia

Uncommon

Gastrointestinal disorders

Dysphagia

Very common

Dry mouth, nausea

Common

Musculoskeletal and connective tissue disorders

Muscular weakness

Very common

Musculoskeletal stiffness and musculoskeletal soreness

Common

General disorders and administration site conditions

Pain

Very common

Asthenia, influenza-like illness, malaise

Common

Pyrexia

Uncommon

Chronic migraine

System Organ Class

Preferred Term

Frequency

Nervous system disorders

Headache*, migraine*, facial paresis

Common

Eye disorders

Eyelid ptosis

Common

Eyelid oedema

Uncommon

Gastrointestinal disorders

Dysphagia

Uncommon

Skin and subcutaneous tissue disorders

Pruritis, rash

Common

Pain of skin

Uncommon

Musculoskeletal and connective tissue disorders

Neck pain, myalgia, musculoskeletal pain, musculoskeletal stiffness, muscle spasms, muscle tightness, muscular weakness

Common

Pain in jaw

Uncommon

General disorders and administration site conditions

Injection site pain

Common

* In placebo-controlled trials, headache and migraine, including serious cases of intractable or worsening of headache/migraine, were reported more frequently with BOTOX (9%) than with placebo (6%). They typically occurred within the first month after the injections and their incidence declined with repeated treatments.

BLADDER DISORDERS

Overactive bladder

System Organ Class

Preferred Term

Frequency

Infections and infestations

Urinary tract infection

Very common

Bacteriuria

Common

Renal and urinary disorders

Dysuria†

Very common

Urinary retention, pollakiuria, leukocyturia

Common

Investigations

Residual urine volume*

Common

*elevated post-void residual urine volume (PVR) not requiring catheterisation

†procedure-related adverse reactions

In the phase 3 clinical trials urinary tract infection was reported in 25.5% of patients treated with BOTOX 100 Units and 9.6% of patients treated with placebo. Urinary retention was reported in 5.8% of patients treated with BOTOX 100 Units and in 0.4% of patients treated with placebo. Clean intermittent catheterisation was initiated in 6.5% of patients following treatment with BOTOX 100 Units versus 0.4% in the placebo group.

Overall, 42.5% of patients (n = 470) were ≥ 65 years of age and 15.1% (n = 167) were ≥ 75 years of age. No overall difference in the safety profile following BOTOX treatment was observed between patients ≥ 65 years compared to patients < 65 years in these studies, with the exception of urinary tract infection where the incidence was higher in elderly patients in both the placebo and BOTOX groups compared to the younger patients.

No change was observed in the overall safety profile with repeat dosing.

Urinary incontinence due to neurogenic detrusor overactivity

System Organ Class

Preferred Term

Frequency

Infections and infestations

Urinary tract infectiona, b, bacteriuriab

Very Common

Investigations

Residual urine volume**b

Very Common

Psychiatric disorders

Insomnia†a

Common

Gastrointestinal disorders

Constipation†a

Common

Musculoskeletal and connective tissue disorders

Muscular weakness†a, muscle spasma

Common

Renal and urinary disorders

Urinary retentiona, b

Very Common

Haematuria*a, b, bladder diverticuluma, dysuria*b

Common

General disorders and administration site conditions

Fatigue†a, gait disturbance†a

Common

Injury, poisoning and procedural complications

Autonomic dysreflexia*a, fall†a

Common

* procedure-related adverse reactions

** elevated PVR not requiring catheterisation

† only in multiple sclerosis

a Adverse reactions occurring in the Phase 2 and pivotal Phase 3 clinical trials

b Adverse reactions occurring in the post-approval study of BOTOX 100U in MS patients not catheterising at baseline

In the phase 3 clinical trials, urinary tract infection was reported in 49% of patients treated with BOTOX 200 Units and in 36% of patients treated with placebo (in multiple sclerosis patients: 53% vs. 29%, respectively; in spinal cord injury patients: 45% vs. 42%, respectively). Urinary retention was reported in 17% of patients treated with BOTOX 200 Units and in 3% of patients treated with placebo (in multiple sclerosis patients: 29% vs. 4%, respectively; in spinal cord injury patients: 5% vs. 1%, respectively). Among patients who were not catheterising at baseline prior to treatment, catheterisation was initiated in 39% following treatment with BOTOX 200 Units versus 17% on placebo. The risk of urinary retention increased in patients older than 65 years.

No change in the type and frequency of adverse reactions was observed following 2 treatments.

In the post-approval study of BOTOX 100 Units in MS patients not catheterising at baseline, no difference on the MS exacerbation annualised rate (i.e. number of MS exacerbation events per patient-year) was observed (BOTOX=0, placebo=0.07).

Catheterisation was initiated in 15.2% of patients following treatment with BOTOX 100 Units versus 2.6% on placebo (refer to section 5.1).

SKIN AND SKIN APPENDAGE DISORDERS

Primary hyperhidrosis of the axillae

System Organ Class

Preferred Term

Frequency

Nervous system disorders

Headache, paraesthesia

Common

Vascular disorders

Hot flushes

Common

Gastrointestinal disorders

Nausea

Uncommon

Skin and subcutaneous tissue disorders

Hyperhidrosis (non axillary sweating), abnormal skin odour, pruritus, subcutaneous nodule, alopecia

Common

Musculoskeletal and connective tissue disorders

Pain in extremity

Common

Muscular weakness, myalgia, arthropathy

Uncommon

General disorders and administration site conditions

Injection site pain

Very common

Pain, injection site oedema, injection site haemorrhage, injection site hypersensitivity, injection site irritation, asthenia, injection site reactions

Common

Increase in non axillary sweating was reported in 4.5% of patients within 1 month after injection and showed no pattern with respect to anatomical sites affected. Resolution was seen in approximately 30% of the patients within four months.

Weakness of the arm has been also reported uncommonly (0.7%) and was mild, transient, did not require treatment and recovered without sequelae. This adverse event may be related to treatment, injection technique, or both. In the uncommon event of muscle weakness being reported a neurological examination may be considered. In addition, a re-evaluation of injection technique prior to subsequent injection is advisable to ensure intradermal placement of injections.

In an uncontrolled safety study of BOTOX (50 Units per axilla) in paediatric patients 12 to 17 years of age (n= 144), adverse reactions occurring in more than a single patient (2 patients each) comprised injection site pain and hyperhidrosis (non-axillary sweating).

The following table represent the adverse reactions that have been reported during the double-blind, placebo-controlled clinical studies following injection of BOTOX for Glabellar lines, Crow's Feet Lines with or without Glabellar Lines, Forehead Lines and Glabellar Lines with or without Crow's Feet Lines.

System Organ Class

Preferred Term

Glabellar Line

Crow's Feet Lines with or without Glabellar Lines

Forehead Lines and Glabellar Lines with or without Crow's Feet Lines

Infections and infestations

Infection

Uncommon

n/a

n/a

Psychiatric disorders

Anxiety

Uncommon

n/a

n/a

Nervous system disorders

Headache

Common

n/a

Common

Paraesthesia, dizziness

Uncommon

n/a

n/a

Eye disorders

Eyelid ptosis

Common

n/a

Common1

Blepharitis, eye pain, visual disturbance

Uncommon

n/a

n/a

Eyelid oedema

Uncommon

Uncommon

n/a

Gastrointestinal disorders

Nausea, oral dryness

Uncommon

n/a

n/a

Skin and subcutaneous tissue disorders

Erythema

Common

n/a

n/a

Skin tightness

Uncommon

n/a

Common

oedema (face, periorbital), photosensitivity reaction, pruritus, dry skin

Uncommon

n/a

n/a

Brow Ptosis

n/a

n/a

Common2

Musculoskeletal and connective tissue disorders

Localised muscle weakness

Common

n/a

n/a

Muscle twitching

Uncommon

n/a

n/a

General disorders and administration site conditions

Face pain

Common

n/a

n/a

Injection site bruising*

n/a

n/a

Common

Injection site haematoma*

n/a

Common

Common

Flu syndrome, asthenia, fever

Uncommon

n/a

n/a

Injection site haemorrhage*

n/a

Uncommon

n/a

Injection site pain*

n/a

Uncommon

Uncommon

Injection site paraesthesia

n/a

Uncommon

n/a

n/a – not reported as adverse drug reaction

*procedure-related adverse reactions

1The median time to onset of eyelid ptosis was 9 days following treatment

2The median time to onset of brow ptosis was 5 days following treatment

No change was observed in the overall safety profile following repeat dosing.

c) Additional information

The following list includes adverse drug reactions or other medically relevant adverse events that have been reported since the drug has been marketed, regardless of indication, and may be in addition to those cited in section 4.4 (Special warnings and precautions for use), and section 4.8 (Undesirable effects).

System Organ Class

Preferred Term

Immune system disorders

Anaphylaxis, angioedema, serum sickness, urticaria

Metabolism and nutrition disorders

Anorexia

Nervous system disorders

Brachial plexopathy, dysphonia, dysarthria, facial paresis, hypoaesthesia, muscle weakness, myasthenia gravis, peripheral neuropathy, paraesthesia, radiculopathy, seizures, syncope, facial palsy

Eye disorders

Angle-closure glaucoma (for treatment of blepharospasm), eyelid ptosis, lagophthalmos, strabismus, blurred vision, visual disturbance, dry eye

Ear and labyrinth disorders

Hypoacusis, tinnitus, vertigo

Cardiac disorders

Arrhythmia, myocardial infarction

Respiratory, thoracic and mediastinal disorders

Aspiration pneumonia (some with fatal outcome), dyspnoea, respiratory depression, respiratory failure

Gastrointestinal disorders

Abdominal pain, diarrhoea, constipation, dry mouth, dysphagia, nausea, vomiting

Skin and subcutaneous tissue disorders

Alopecia, brow ptosis, dermatitis psoriasiform, erythema multiforme, hyperhidrosis, madarosis, pruritus, rash

Musculoskeletal and connective tissue disorders

Muscle atrophy, myalgia, localised muscle twitching/ involuntary muscle contractions

General disorders and administration site conditions

Denervation atrophy, malaise, pyrexia

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme, Website: www.mhra.gov.uk/yellowcard.

4.9 Overdose
Overdose of BOTOX is a relative term and depends upon dose, site of injection, and underlying tissue properties. No cases of systemic toxicity resulting from accidental injection of BOTOX have been observed. Excessive doses may produce local, or distant, generalised and profound neuromuscular paralysis. No cases of ingestion of BOTOX have been reported.

Signs and symptoms of overdose are not apparent immediately post-injection. Should accidental injection or ingestion occur or overdose be suspected, the patient should be medically monitored for up to several weeks for progressive signs and symptoms of muscular weakness, which could be local or distant from the site of injection and may include ptosis, diplopia, dysphagia, dysarthria, generalised weakness or respiratory failure. These patients should be considered for further medical evaluation and appropriate medical therapy immediately instituted, which may include hospitalisation.

If the musculature of the oropharynx and oesophagus are affected, aspiration may occur which may lead to development of aspiration pneumonia. If the respiratory muscles become paralysed or sufficiently weakened, intubation and assisted respiration will be required until recovery takes place and may involve the need for a tracheostomy and prolonged mechanical ventilation, in addition to other general supportive care.

5. Pharmacological properties
5.1 Pharmacodynamic properties
ATC class M03A X01 and ATC class D11AX.

The active constituent in BOTOX is a protein complex derived from Clostridium botulinum. The protein consists of type A neurotoxin and several other proteins. Under physiological conditions it is presumed that the complex dissociates and releases the pure neurotoxin.

Clostridium botulinum toxin type A neurotoxin complex blocks peripheral acetyl choline release at presynaptic cholinergic nerve terminals.

Intramuscular injection of the neurotoxin complex blocks cholinergic transport at the neuromuscular junction by preventing the release of acetylcholine. The nerve endings of the neuromuscular junction no longer respond to nerve impulses and secretion of the chemotransmitter is prevented (chemical denervation). Re-establishment of impulse transmission is by newly formed nerve endings and motor end plates. Clinical evidence suggests that BOTOX reduces pain and neurogenic inflammation and elevates cutaneous heat pain thresholds in a capsaicin induced trigeminal sensitization model. Recovery after intramuscular injection takes place normally within 12 weeks of injection as nerve terminals sprout and reconnect with the endplates.

After intradermal injection, where the target is the eccrine sweat glands, the effect lasted for about 4-7 months in patients treated with 50 Units per axilla.

There is limited clinical trial experience of the use of BOTOX in primary axillary hyperhidrosis in adolescents between the ages of 12 and 18. A single, year long, uncontrolled, repeat dose, safety study was conducted in US paediatric patients 12 to 17 years of age (N=144) with severe primary hyperhidrosis of the axillae. Participants were primarily female (86.1%) and Caucasian (82.6%). Participants were treated with a dose of 50 Units per axilla for a total dose of 100 Units per patient per treatment. However, no dose finding studies have been conducted in adolescents so no recommendation on posology can be made. Efficacy and safety of BOTOX in this group have not been established.

BOTOX blocks the release of neurotransmitters associated with the genesis of pain. The presumed mechanism for headache prophylaxis is by blocking peripheral signals to the central nervous system, which inhibits central sensitisation, as suggested by pre-clinical and clinical pharmacodynamic studies.

Following intradetrusor injection, BOTOX affects the efferent pathways of detrusor activity via inhibition of acetylcholine release. In addition BOTOX inhibits afferent neurotransmitters and sensory pathways.

Clinical efficacy and safety

NEUROLOGIC DISORDERS

Focal upper limb spasticity associated with stroke

In controlled and open, non-controlled studies, doses between 200 and 240 Units in wrist and flexor muscles were divided among the selected muscles at a given treatment session. In controlled studies, improvement in muscle tone occurred within two weeks with the peak effect generally seen within four to six weeks. In an open, non-controlled continuation study, most patients were re-injected after an interval of 12 to 16 weeks, when the effect on muscle tone had diminished. These patients received up to four injections with a maximal cumulative dose of 960 Units over 54 weeks.

Focal lower limb spasticity associated with stroke

The efficacy and safety of BOTOX was evaluated in a randomised, multi-centre, double-blind, placebo-controlled study which included 468 post-stroke patients (233 BOTOX and 235 placebo) with ankle spasticity (Modified Ashworth Scale [MAS] ankle score of at least 3) who were at least 3 months post-stroke. BOTOX 300 to 400 Units or placebo were injected intramuscularly into the study mandatory muscles gastrocnemius, soleus, and tibialis posterior and optional muscles including flexor hallucis longus, flexor digitorum longus, flexor digitorum brevis, extensor hallucis, and rectus femoris.

The primary endpoint was the average change from baseline of weeks 4 and 6 MAS ankle score and a key secondary endpoint was the average CGI (Physician Global Assessment of Response) at weeks 4 and 6. Statistically and clinically significant differences were demonstrated between BOTOX and placebo for these measures as shown in the table below.

For the primary endpoint of average MAS ankle score at weeks 4 and 6, no improvement from baseline was observed for patients aged 65 and older in the BOTOX group compared to placebo.

BOTOX

300 to 400 Units

(N=233)

Placebo

(N=235)

Mean Change from Baseline in Ankle Plantar Flexors in MAS Score

Week 4 and 6 Average

-0.8*

-0.6

Mean Clinical Global Impression Score by Investigator

Week 4 and 6 Average

0.9*

0.7

Mean Change from Baseline in Toe Flexors in MAS Score

FHaL Week 4 and 6 Average

-1.02*

-0.6

FDL Week 4 and 6 Average

-0.88

- 0.77

Mean Change from Baseline in Ankle Plantar Flexors in MAS Score for Patients ≥ 65 years

N=60

N=64

Week 4 and 6 Average

-0.7

-0.7

*Significantly different from placebo (p<0.05)

Another double-blind, placebo-controlled, randomised, multicentre, phase 3 clinical study was conducted in adult post-stroke patients (average 6.5 years) with lower limb spasticity affecting the ankle. A total of 120 patients were randomised to receive either BOTOX (n=58; total dose of 300 Units) or placebo (n=62).

Significant improvement compared to placebo was observed in the primary endpoint for the overall change from baseline up to week 12 in the MAS ankle score, which was calculated using the area under the curve (AUC) approach. Significant improvements compared to placebo were also observed for the mean change from baseline in MAS ankle score at individual post-treatment visits at weeks 4, 6 and 8. The proportion of responders (patients with at least a 1-grade improvement) was also significantly higher (67%-68%) than in placebo-treated patients (31%-36%) at these visits.

BOTOX treatment was also associated with significant improvement in the investigator's clinical global impression (CGI) of functional disability compared to placebo although the difference was not significant for the patient's CGI.

Cervical dystonia

In initial controlled clinical trials to establish safety and efficacy for cervical dystonia, doses of reconstituted BOTOX ranged from 140 to 280 Units. In more recent studies, doses ranged from 95 to 360 Units (with an approximate mean of 240 Units). Clinical improvement generally occurs within the first two weeks after injection. The maximum clinical benefit generally occurs by six weeks post-injection. The duration of beneficial effect reported in clinical studies showed substantial variation (from 2 to 33 weeks) with a typical duration of approximately 12 weeks.

Chronic migraine

Chronic migraine patients without any concurrent headache prophylaxis who, during a 28-day baseline, had at least 4 episodes and ≥ 15 headache days (with at least 4 hours of continuous headache) with at least 50% being migraine/probable migraine, were studied in two Phase 3 clinical trials. Patients were allowed to use acute headache treatments and 66% overused acute treatments during the baseline period.

During the double-blind phase of the trials, the main results achieved after two BOTOX treatments administered at a 12-week interval are shown in the table below.

Mean change from baseline at Week 24

BOTOX

Placebo

N=688

N=696

P-value

Frequency of headache days

-8.4

-6.6

< 0.001

Frequency of moderate/severe headache days

-7.7

-5.8

< 0.001

Frequency of migraine/probable migraine days

-8.2

-6.2

< 0.001

% patients with 50% reduction in headache days

47%

35%

< 0.001

Total cumulative hours of headache on headache days

120

80

< 0.001

Frequency of headache episodes

-5.2

-4.9

0.009

Total HIT-6* scores

-4.8

-2.4

< 0.001

* Headache Impact Test

The treatment effect appeared smaller in the subgroup of male patients (n=188) than in the whole study population.

BLADDER DISORDERS

Overactive bladder

Two double-blind, placebo-controlled, randomised, 24-week phase 3 clinical studies were conducted in patients with overactive bladder with symptoms of urge urinary incontinence, urgency, and frequency. A total of 1105 patients (mean age of 60 years), whose symptoms had not been adequately managed with at least one anticholinergic therapy (inadequate response or intolerable side effects), were randomised to receive either 100 Units of BOTOX (n=557), or placebo (n=548), after having discontinued anticholinergics for more than one week.

Primary and Secondary Endpoints at Baseline and Change from Baseline in Pooled Pivotal Studies

Botox

100 Units

(N=557)

Placebo

(N=548)

P-value

Daily Frequency of Urinary Incontinence Episodes

Mean Baseline

5.49

5.39

Mean Change† at Week 2

-2.66

-1.05

< 0.001

Mean Change† at Week 6

-2.97

-1.13

< 0.001

Mean Change† at Week 12a

-2.74

-0.95

< 0.001

Proportion with Positive Treatment Response using Treatment Benefit Scale (%)

Week 2

64.4

34.7

< 0.001

Week 6

68.1

32.8

< 0.001

Week 12a

61.8

28.0

< 0.001

Daily Frequency of Micturition Episodes

Mean Baseline

11.99

11.48

Mean Change† at Week 12b

-2.19

-0.82

< 0.001

Daily Frequency of Urgency Episodes

Mean Baseline

8.82

8.31

Mean Change† at Week 12b

-3.08

-1.12

< 0.001

Incontinence Quality of Life Total Score

Mean Baseline

34.1

34.7

Mean Change† at Week 12bc

+21.3

+5.4

< 0.001

King's Health Questionnaire: Role Limitation

Mean Baseline

65.4

61.2

Mean Change† at Week 12bc

-24.3

-3.9

< 0.001

King's Health Questionnaire: Social Limitation

Mean Baseline

44.8

42.4

Mean Change† at Week 12bc

-16.1

-2.5

< 0.001

Percentage of patients achieving full continence at Week 12 (dry patients over a 3-day diary)

27.1%

8.4%

< 0.001

Percentage of patients achieving reduction from baseline in urinary incontinence episodes at Week 12

at least 75%

at least 50%

46.0%

60.5%

17.7%

31.0%

† Least Squares (LS) mean changes are presented

a Co-primary endpoints

b Secondary endpoints

c Pre-defined minimally important change from baseline was +10 points for I-QOL and -5 points for KHQ

The median duration of response following BOTOX treatment, based on patient request for re-treatment, was 166 days (~24 weeks). The median duration of response, based on patient request for re-treatment, in patients who continued into the open label extension study and received treatments with only BOTOX 100 Units (N=438), was 212 days (~30 weeks).

A total of 839 patients were evaluated in a long-term open-label extension study. For all efficacy endpoints, patients experienced consistent response with re-treatments. The mean reductions from baseline in daily frequency of urinary incontinence were -3.07 (n=341), -3.49 (n=292), and -3.49 (n=204) episodes at week 12 after the first, second, and third BOTOX 100 Unit treatments, respectively. The corresponding proportions of patients with a positive treatment response on the Treatment Benefit Scale were 63.6% (n=346), 76.9% (n=295), and 77.3% (n=207), respectively.

In the pivotal studies, none of the 615 patients with analysed serum specimens developed neutralising antibodies after 1 – 3 treatments. In patients with analysed specimens from the pivotal phase 3 and the open-label extension studies, neutralising antibodies developed in 0 of 954 patients (0.0%) while receiving BOTOX 100 Unit doses and 3 of 260 patients (1.2%) after subsequently receiving at least one 150 Unit dose. One of these three patients continued to experience clinical benefit. Compared to the overall BOTOX treated population, patients who developed neutralising antibodies generally had shorter duration of response and consequently received treatments more frequently (see section 4.4).

Urinary incontinence due to neurogenic detrusor overactivity

Pivotal Phase 3 Clinical Trials

Two double-blind, placebo-controlled, randomised phase 3 clinical studies were conducted in a total of 691 patients with spinal cord injury or multiple sclerosis, who were not adequately managed with at least one anticholinergic agent and were either spontaneously voiding or using catheterisation. These patients were randomised to receive either 200 Units of BOTOX (n=227), 300 Units of BOTOX (n=223), or placebo (n=241).

Primary and Secondary Endpoints at Baseline and Change from Baseline in Pooled Pivotal Studies

BOTOX

200 Units

(N=227)

Placebo

(N=241)

P-value

Weekly Frequency of Urinary Incontinence

Mean Baseline

Mean Change† at Week 2

Mean Change† at Week 6a

Mean Change† at Week 12

32.4

-16.8

-20.0

-19.8

31.5

-9.1

-10.5

-9.3

<0.001

<0.001

<0.001

Maximum Cystometric Capacity (ml)

Mean Baseline

Mean Change† at Week 6b

250.2

+140.4

253.5

+6.9

<0.001

Maximum Detrusor Pressure during 1st Involuntary Detrusor Contraction (cmH20)

Mean Baseline

Mean Change† at Week 6b

51.5

-27.1

47.3

-0.4

<0.001

Incontinence Quality of Life Total Scorec,d

Mean Baseline

Mean Change† at Week 6b

Mean Change† at Week 12

35.4

+23.6

+26.9

35.3

+8.9

+7.1

<0.001

<0.001

Percentage of patients achieving full continence at Week 6 (dry patients over a 7 day diary)

37%

9%

Percentage of patients achieving reduction from baseline in urinary incontinence episodes at Week 6

at least 75%

at least 50%

63%

76%

24%

39%

† LS mean changes are presented

a Primary endpoint

b Secondary endpoints

c I-QOL total score scale ranges from 0 (maximum problem) to 100 (no problem at all).

d In the pivotal studies, the pre-specified minimally important difference (MID) for I-QOL total score was 8 points based on MID estimates of 4-11 points reported in neurogenic detrusor overactivity patients.

The median duration of response, based on time to qualification for re-treatment (time to < 50% reduction in incontinence episodes), was 42 weeks in the 200 Unit dose group. The median interval between the first and second administrations was 42 weeks in patients with spinal cord injury and 45 weeks in patients with multiple sclerosis. The median duration of response, based on time to qualification for re-treatment (at least 1 urinary incontinence episode in a 3 day diary), in patients who continued into the open label extension study and received treatments with only BOTOX 200 Units (N=174), was 264 days (~38 weeks).

For all efficacy endpoints in the pivotal phase 3 studies, patients experienced consistent response with re-treatment (n=116).

None of the 475 patients with analysed serum specimens developed neutralising antibodies after 1-2 treatments. In patients with analysed specimens in the drug development program (including the open-label extension study), neutralising antibodies developed in 3 of 300 patients (1.0%) after receiving only BOTOX 200 Unit doses and 5 of 258 patients (1.9%) after receiving at least one 300 Unit dose. Four of these eight patients continued to experience clinical benefit. Compared to the overall BOTOX treated population, patients who developed neutralising antibodies generally had shorter duration of response and consequently received treatments more frequently (see section 4.4).

In the multiple sclerosis (MS) patients enrolled in the pivotal studies, the MS exacerbation annualised rate (i.e. number of MS exacerbation events per patient year) was 0.23 in the 200 Unit dose group and 0.20 in the placebo group. With repeated BOTOX treatments, including data from a long term study, the MS exacerbation annualised rate was 0.19 during each of the first two BOTOX treatment cycles.

Post-approval Study

A placebo controlled, double-blind post-approval study was conducted in multiple sclerosis (MS) patients with urinary incontinence due to neurogenic detrusor overactivity who were not adequately managed with at least one anticholinergic agent and not catheterising at baseline. These patients were randomised to receive either 100 Units of BOTOX (n=66) or placebo (n=78).

Significant improvements compared to placebo in the primary efficacy variable of change from baseline in daily frequency of incontinence episodes were observed for BOTOX (100 Units) at the primary efficacy time point at week 6, including the percentage of dry patients. Significant improvements in urodynamic parameters, and Incontinence Quality of Life questionnaire (I-QOL), including avoidance limiting behaviour, psychosocial impact and social embarrassment were also observed.

Results from the post-approval study are presented below:

Primary and Secondary Endpoints at Baseline and Change from Baseline in Post-Approval Study of BOTOX 100 Units in MS patients not catheterising at baseline

BOTOX

100 Units

(N=66)

Placebo

(N=78)

p-values

Daily Frequency of Urinary Incontinence*

Mean Baseline

Mean Change at Week 2

Mean Change at Week 6a

Mean Change at Week 12

4.2

-2.9

-3.3

-2.8

4.3

-1.2

-1.1

-1.1

p<0.001

p<0.001

p<0.001

Maximum Cystometric Capacity (mL)

Mean Baseline

Mean Change at Week 6b

246.4

+127.2

245.7

-1.8

p<0.001

Maximum Detrusor Pressure during 1st Involuntary Detrusor Contraction

(cmH2O)

Mean Baseline

Mean Change at Week 6b

35.9

-19.6

36.1

+3.7

p=0.007

Incontinence Quality of Life Total Scorec,d

Mean Baseline

Mean Change at Week 6b

Mean Change at Week 12

32.4

+40.4

+38.8

34.2

+9.9

+7.6

p<0.001

p<0.001 * Percentage of dry patients (without incontinence) throughout week 6 was 53.0% (100 Unit BOTOX group) and 10.3% (placebo) a Primary endpoint b Secondary endpoints c I-QOL total score scale ranges from 0 (maximum problem) to 100 (no problem at all). d The pre-specified minimally important difference (MID) for I-QOL total score was 11 points based on MID estimates of 4-11 points reported in neurogenic detrusor overactivity patients. The median duration of response in this study, based on patient request for re-treatment, was 362 days (~52 weeks) for BOTOX 100 Unit dose group compared to 88 days (~13 weeks) with placebo. SKIN AND SKIN APPENDAGE DISORDERS Glabellar lines 537 patients with moderate to severe glabellar lines between the eyebrows seen at maximum frown have been included in clinical studies. BOTOX injections significantly reduced the severity of glabellar lines seen at maximum frown for up to 4 months, as measured by the investigator assessment of glabellar line severity at maximum frown and by subject's global assessment of change in appearance of his/her glabellar lines seen at maximum frown. Improvement generally occurred within one week of treatment. None of the clinical endpoints included an objective evaluation of the psychological impact. Thirty days after injection, 80% (325/405) of BOTOX-treated patients were considered by investigators as treatment responders (none or mild severity at maximum frown), compared to 3% (4/132) of placebo-treated patients. At this same timepoint, 89% (362/405) of BOTOX-treated patients felt they had a moderate or better improvement, compared to 7% (9/132) of placebo-treated patients. BOTOX injections also significantly reduced the severity of glabellar lines at rest. Of the 537 patients enrolled, 39% (210/537) had moderate to severe glabellar lines at rest (15% had no lines at rest). Of these, 74% (119/161) of BOTOX-treated patients were considered treatment responders (none or mild severity) thirty days after injection, compared with 20% (10/49) of placebo-treated patients. There is limited phase 3 clinical data with BOTOX in patients older than 65 years. Only 6.0% (32/537) of subjects were >65 years old and efficacy results obtained were lower in this population.

Crow's feet lines

1362 patients with moderate to severe crow's feet lines seen at maximum smile, either alone (n=445, Study 191622-098) or also with moderate to severe glabellar lines seen at maximum frown (n=917, Study 191622-099), were enrolled.

BOTOX injections significantly reduced the severity of crow's feet lines seen at maximum smile compared to placebo at all timepoints (p <0.001) for up to 5 months (median 4 months). Improvement assessed by the investigator occurred within one week of treatment. This was measured by the proportion of patients achieving a crow's feet lines severity rating of none or mild at maximum smile in both pivotal studies; until day 150 (end of study) in Study 191622-098 and day 120 (end of first treatment cycle) in Study 191622-099. For both investigator and subject assessments, the proportion of subjects achieving none or mild crow's feet lines severity seen at maximum smile was greater in patients with moderate crow's feet lines seen at maximum smile at baseline, compared to patients with severe crow's feet lines seen at maximum smile at baseline. Table 1 summarises results at day 30, the timepoint of the primary efficacy endpoint.

In Study 191622-104 (extension to Study 191622-099), 101 patients previously randomised to placebo were enrolled to receive their first treatment at the 44 Units dose. Patients treated with BOTOX had a statistically significant benefit in the primary efficacy endpoint compared to placebo at day 30 following their first active treatment. The response rate was similar to the 44 Units group at day 30 following first treatment in Study 191622-099. A total of 123 patients received 4 cycles of 44 Units BOTOX for combined crow's feet and glabellar lines treatment.

Day 30: Investigator and Patient Assessment of Crow's Feet Lines Seen at Maximum Smile - Responder Rates (% of Patients Achieving Crow's Feet Lines Severity Rating of None or Mild)

Clinical Study

Dose

BOTOX

Placebo

BOTOX

Placebo

Investigator Assessment

Patient Assessment

191622-098

24 Units

(crow's feet lines)

66.7%*

(148/222)

6.7%

(15/223)

58.1%*

(129/222)

5.4%

(12/223)

191622-099

24 Units

(crow's feet lines)

54.9%*

(168/306)

3.3%

(10/306)

45.8%*

(140/306)

3.3%

(10/306)

44 Units

(24 Units crow's feet lines; 20 Units glabellar lines)

59.0%*

(180/305)

3.3%

(10/306)

48.5%*

(148/305)

3.3%

(10/306)

*p < 0.001 (BOTOX vs placebo)

Improvements from baseline in subject-assessment of the appearance of crow's feet lines seen at maximum smile were seen for BOTOX (24 Units and 44 Units) compared to placebo, at day 30 and at all timepoints following each treatment cycle in both pivotal studies (p<0.001).

Treatment with BOTOX 24 Units also significantly reduced the severity of crow's feet lines at rest. Of the 528 patients treated, 63% (330/528) had moderate to severe crow's feet lines at rest at baseline. Of these, 58% (192/330) of BOTOX-treated patients were considered treatment responders (none or mild severity) thirty days after injection, compared with 11% (39/352) of placebo-treated patients.

Improvements in subject's self-assessment of age and attractiveness were also seen for BOTOX (24 Units and 44 Units) compared to placebo using the Facial Line Outcomes (FLO-11) questionnaire, at the primary timepoint of day 30 (p<0.001) and at all subsequent timepoints in both pivotal studies. In the pivotal studies, 3.9% (53/1362) of patients were older than 65 years of age. Patients in this age group had a treatment response as assessed by the investigator, of 36% (at day 30) for BOTOX (24 Units and 44 Units).When analysed by age groups of ≤50 years and >50 years, both populations demonstrated statistically significant improvements compared to placebo. Treatment response for BOTOX 24 Units, as assessed by the investigator, was lower in the group of subjects >50 years of age than those ≤50 years of age (42.0% and 71.2%, respectively).

Overall BOTOX treatment response for crow's feet lines seen at maximum smile is lower (60%) than that observed with treatment for glabellar lines seen at maximum frown (80%).

916 patients (517 patients at 24 Units and 399 patients at 44 Units) treated with BOTOX had specimens analysed for antibody formation. No patients developed the presence of neutralising antibodies.

Forehead Lines

Forehead lines were treated in conjunction with glabellar lines to minimise the potential of brow ptosis. 822 patients with moderate to severe forehead lines and glabellar lines seen at maximum contraction, either alone (N=254, Study 191622-142) or also with moderate to severe crow's feet lines seen at maximum smile (N=568, Study 191622-143), were enrolled and included for analyses of all primary and secondary efficacy endpoints.

For both investigator and patient assessments, the proportion of patients achieving none or mild forehead lines seen at maximum eyebrow elevation following BOTOX injections was greater than patients treated with placebo at day 30. This primary endpoint along with additional endpoints are provided in the table below.

Day 30 (primary timepoint): Investigator and Patient Assessment of Forehead Lines and Upper Facial Lines at Maximum Contraction and Rest

Clinical Study

Endpoint

BOTOX

Placebo

BOTOX

Placebo

Investigator Assessment

Patient Assessment

Study 191622-142 40 U

(20 U forehead lines + 20 U glabellar lines)

Forehead Lines at Max Contractiona

94.8%

(184/194)

1.7%

(1/60)

87.6%

(170/194)

0.0%

(0/60)

p < 0.0005

p < 0.0005

Forehead Lines at Restb

86.2%

(162/188)

22.4%

(13/58)

89.7%

(174/194)

10.2%

(6/59)

p < 0.0001

p < 0.0001

Study 191622-143 40 U

(20 U forehead lines + 20 U glabellar lines)

Forehead Lines at Max Contractiona

90.5%

(201/222)

2.7%

(3/111)

81.5%

(181/222)

3.6%

(4/111)

p < 0.0005

p < 0.0005

Forehead Lines at Restb

84.1%

(185/220)

15.9%

(17/107)

83.6%

(184/220)

17.4%

(19/109)

p < 0.0001

p < 0.0001

Study 191622-143 64 U

(20 U forehead lines + 20 U glabellar lines + 24 U crow's feet lines)

Forehead Lines at Max Contractiona

93.6%

(220/235)

2.7%

(3/111)

88.9%

(209/235)

3.6%

(4/111)

p < 0.0005

p < 0.0005

Upper Facial Lines at Max Contractionc

56.6%

(133/235)

0.9%

(1/111)

n/a

p < 0.0001

a Proportion of patients achieving none or mild FHL severity at maximum eyebrow elevation

b Proportion of patients with at least a 1-grade improvement from baseline of FHL severity at rest

c Proportion of responders defined as the same patient achieving none or mild in forehead lines, glabellar lines, and crow's feet lines for each facial region at maximum contraction

BOTOX injections significantly reduced the severity of forehead lines seen at maximum eyebrow elevation compared to placebo for up to 6 months (p < 0.05): This was measured by the proportion of patients achieving a forehead lines severity rating of none or mild in both pivotal studies; until day 150 in Study 191622-142 (21.6% with BOTOX treatment compared to 0% with placebo) and day 180 in Study 191622-143 (6.8% with BOTOX treatment compared to 0% with placebo).

When all 3 areas were treated simultaneously in Study 191622-143 (BOTOX 64 U group), BOTOX injections significantly reduced the severity of glabellar lines for up to 6 months (5.5% with BOTOX treatment compared to 0% with placebo), lateral canthal lines for up to 6 months (3.4% with BOTOX treatment compared to 0% with placebo) and forehead lines for up to 6 months (9.4% with BOTOX treatment compared to 0% with placebo).

A total of 116 and 150 patients received 3 cycles over 1 year of BOTOX 40 Units and 64, respectively. The response rate for forehead lines improvement was similar across all treatment cycles.

Using the Facial Lines Satisfaction Questionnaire (FLSQ), 78.1% of patients in Study 191622-142 and 62.7% in Study 191622-143 reported improvements in appearance-related and emotional impacts (as defined by items pertaining to feeling older, negative self-esteem, looking tired, feeling unhappy, looking angry) with BOTOX 40 Units treatment compared to patients treated with placebo 19.0% in Study 191622-142 and 18.9% in Study 191622-143 at day 30 (p < 0.0001 in both studies).

On the same questionnaire, 90.2% of patients in Study 191622-142 and 79.2% (40 Units), or 86.4% (64 Units) in Study 191622-143 reported they were “very satisfied”/ “mostly satisfied” with BOTOX 40 Units or 64 Units compared to patients treated with placebo (1.7%, 3.6% in Study 191622-142 and Study 191622-143, respectively), at the primary timepoint of day 60 using the FLSQ (p < 0.0001 in both studies).

The pivotal studies, 3.7% of patients were older than 65 years of age. Responder rates in this BOTOX-treated subgroup were similar to those in the overall population, but statistical significance was not reached due to the small number of patients.

5.2 Pharmacokinetic properties
a) General characteristics of the active substance:

Classical absorption, distribution, biotransformation and elimination studies on the active substance have not been performed due to the extreme toxicity of botulinum toxin type A.

b) Characteristics in patients:

Human ADME studies have not been performed due to the nature of the product. It is believed that little systemic distribution of therapeutic doses of BOTOX occurs. BOTOX is probably metabolised by proteases and the molecular components recycled through normal metabolic pathways.

5.3 Preclinical safety data
Non-clinical data based on conventional studies of safety pharmacology, repeated dose toxicity and genotoxicity reveal no special hazard for humans other than exaggerated pharmacological effects predictable at high doses, given the neurotoxic nature of BOTOX. Carcinogenicity studies have not been conducted.

Acute toxicity

In monkeys receiving a single intramuscular (i.m.) injection of BOTOX, the No Observed Effect Level (NOEL) ranged from 4 to 24 Units/kg. The i.m. LD50 was reported to be 39 Units/kg.

Toxicity on repeated injection

In three different studies (six months in rats; 20 weeks in juvenile monkeys; 1 year in monkeys) where the animals received i.m. injections, the NOEL was at the following respective BOTOX dosage levels: < 4 Units/kg, 8 Units/kg and 4 Units/kg. The main systemic effect was a transient decrease in body weight gain.

There was no indication of a cumulative effect in the animal studies when BOTOX was given at dosage intervals of 1 month or greater.

Decrease in bodyweight was observed following a single intradetrusor injection of <10 Units/kg BOTOX in rats. To simulate inadvertent injection, a single dose of BOTOX (~7 Units/kg) was administered into the prostatic urethra and proximal rectum, the seminal vesicle and urinary bladder wall, or the uterus of monkeys (~3 Units/kg) without adverse clinical effects. However, bladder stones have been observed in monkeys given a single dose of BOTOX to the prostatic urethra and proximal rectum, and in a repeated dose intraprostatic study. Due to anatomical differences the clinical relevance of these findings is unknown. In a 9 month repeat dose intradetrusor study (4 injections), eyelid ptosis was observed at 24 Units/kg, and mortality was observed at doses ≥24 Units/kg. No adverse effects were observed in monkeys at 12 Units/kg, which corresponds to a 3-fold greater exposure than the recommended clinical dose of 200 Units for urinary incontinence due to neurogenic detrusor overactivity (based on a 50 kg person).

Local toxicity

BOTOX was shown not to cause ocular or dermal irritation, or give rise to toxicity when injected into the vitreous body in rabbits.

Allergic or inflammatory reactions in the area of the injection sites are rarely observed after BOTOX administration. However, formation of haematoma may occur.

Reproduction toxicology

Teratogenic effects

When pregnant mice and rats were injected intramuscularly during the period of organogenesis, the developmental NOEL of BOTOX was at 4 Units/kg. Reductions in ossification were observed at 8 and 16 Units/kg (mice) and reduced ossification of the hyoid bone at 16 Units/kg (rats). Reduced foetal body weights were observed at 8 and 16 Units/kg (rats).

In a range-finding study in rabbits, daily injections at dosages of 0.5 Units/kg/day (days 6 to 18 of gestation), and 4 and 6 Units/kg (administered on days 6 and 13 of gestation), caused death and abortions among surviving dams. External malformations were observed in one foetus each in the 0.125 Units/kg/day and the 2 Units/kg dosage groups. The rabbit appears to be a very sensitive species to BOTOX treatment.

Impairment of fertility and reproduction

The reproductive NOEL following i.m. injection of BOTOX was 4 Units/kg in male rats and 8 Units/kg in female rats. Higher dosages were associated with dose-dependent reductions in fertility. Provided impregnation occurred, there were no adverse effects on the numbers or viability of the embryos sired or conceived by treated male or female rats.

Pre- and post-natal developmental effects

In female rats, the reproductive NOEL was 16 Units/kg. The developmental NOEL was 4 Units/kg.

Antigenicity

BOTOX showed antigenicity in mice only in the presence of adjuvant. BOTOX was found to be slightly antigenic in the guinea pig.

Blood compatibility

No haemolysis was detected up to 100 Units/ml of BOTOX in normal human blood.

6. Pharmaceutical particulars
6.1 List of excipients
Human albumin

Sodium chloride

6.2 Incompatibilities
In the absence of compatibility studies, this medicinal product should not be mixed with other medicinal products.

6.3 Shelf life
3 years.

After reconstitution, stability has been demonstrated for 24 hours at 2°C – 8°C.

From a microbiological point of view, the product should be used immediately. If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and would normally not be longer than 24 hours at 2°C to 8°C (see also section 6.6).

6.4 Special precautions for storage
Store in a refrigerator (2°C-8°C), or store in a freezer (-5°C to -20°C).

For storage conditions of the reconstituted medicinal product see section 6.3.

6.5 Nature and contents of container
Clear glass vial, with rubber stopper and tamper-proof aluminium seal, containing white powder for solution for injection.

Pack size:

• Carton comprising one 50 Allergan Unit vial and package leaflet.

• Packs containing one, two, three or six cartons.

Not all pack sizes may be marketed.

6.6 Special precautions for disposal and other handling
Reconstitution

BOTOX is reconstituted prior to use with sterile unpreserved normal saline (0.9% sodium chloride for injection). It is good practice to perform vial reconstitution and syringe preparation over plastic-lined paper towels to catch any spillage. An appropriate amount of diluent (see dilution table below) is drawn up into a syringe. The exposed portion of the rubber septum of the vial is cleaned with alcohol (70%) prior to insertion of the needle. Since BOTOX is denatured by bubbling or similar violent agitation, the diluent should be injected gently into the vial. Discard the vial if a vacuum does not pull the diluent into the vial. Reconstituted BOTOX is a clear colourless to slightly yellow solution free of particulate matter. When reconstituted, BOTOX may be stored in a refrigerator (2-8°C) for up to 24 hours prior to use. After this period used or unused vials should be discarded.

Each vial is for single use only.

Care should be taken to use the correct diluent volume for the presentation chosen to prevent accidental overdose. If different vial sizes of BOTOX are being used as part of one injection procedure, care should be taken to use the correct amount of diluent when reconstituting a particular number of units per 0.1 ml. The amount of diluent varies between BOTOX 50 Allergan Units, BOTOX 100 Allergan Units and BOTOX 200 Allergan Units. Each syringe should be labelled accordingly.

Dilution table for BOTOX 50, 100 and 200 Allergan Units vial size for all indications except bladder disorders:

50 Unit vial

100 Unit vial

200 Unit vial

Resulting dose

(Units per 0.1 ml)

Amount of diluent (sterile unpreserved normal saline (0.9% sodium chloride for injection)) added in a 50 Unit vial

Amount of diluent (sterile unpreserved normal saline (0.9% sodium chloride for injection)) added in a 100 Unit vial

Amount of diluent (sterile unpreserved normal saline (0.9% sodium chloride for injection)) added in a 200 Unit vial

20 Units

0.25 ml

0.5 ml

1 ml

10 Units

0.5 ml

1 ml

2 ml

5 Units

1 ml

2 ml

4 ml

4 Units

1.25 ml

2.5 ml

5 ml

2.5 Units

2 ml

4 ml

8 ml

1.25 Units

4 ml

8 ml

N/A

Overactive bladder:

It is recommended that a 100 Unit or two 50 Unit vials are used for convenience of reconstitution.

Dilution instructions using two 50 Unit vials:

• Reconstitute two 50 Unit vials of BOTOX each with 5 ml of sterile unpreserved normal saline (0.9% sodium chloride for injection) and mix the vials gently.

• Draw the 5 ml from each of the vials into a single 10 ml syringe.

This will result in a 10 ml syringe containing a total of 100 Units of reconstituted BOTOX. Use immediately after reconstitution in the syringe. Dispose of any unused saline.

Dilution instructions using a 100 Unit vial:

• Reconstitute a 100 Unit vial of BOTOX with 10 ml of sterile unpreserved normal saline (0.9% sodium chloride for injection) and mix gently.

• Draw the 10 ml from the vial into a 10 ml syringe.

This will result in a 10 ml syringe containing a total of 100 Units of reconstituted BOTOX. Use immediately after reconstitution in the syringe. Dispose of any unused saline.

Dilution instructions using a 200 Unit vial:

• Reconstitute a 200 Unit vial of BOTOX with 8 ml of sterile unpreserved normal saline (0.9% sodium chloride for injection) and mix gently.

• Draw 4 ml from the vial into a 10 ml syringe.

• Complete the reconstitution by adding 6 ml of sterile unpreserved normal saline (0.9% sodium chloride for injection) into the 10 ml syringe and mix gently.

This will result in a 10 ml syringe containing a total of 100 Units of reconstituted BOTOX. Use immediately after reconstitution in the syringe. Dispose of any unused saline.

This product is for single use only and any unused reconstituted product should be disposed of.

Urinary incontinence due to neurogenic detrusor overactivity:

It is recommended that a 200 Unit vial or two 100 Unit vials are used for convenience of reconstitution.

Dilution instructions using four 50 Unit vials:

• Reconstitute four 50 Unit vials of BOTOX, each with 3 ml of sterile unpreserved normal saline (0.9% sodium chloride for injection) and mix the vials gently.

• Draw 3 ml from the first vial and 1 ml from the second vial into one 10 ml syringe.

• Draw 3 ml from the third vial and 1 ml from the fourth vial into a second 10 ml syringe.

• Draw the remaining 2 ml from the second and fourth vials into a third 10 ml syringe.

• Complete the reconstitution by adding 6 ml of sterile unpreserved normal saline (0.9% sodium chloride for injection) into each of the three 10 ml syringes, and mix gently

This will result in three 10 ml syringes containing a total of 200 Units of reconstituted BOTOX. Use immediately after reconstitution in the syringe. Dispose of any unused saline.

Dilution instructions using two 100 Unit vials:

• Reconstitute two 100 Unit vials of BOTOX, each with 6 ml of sterile unpreserved normal saline (0.9% sodium chloride for injection) and mix the vials gently.

• Draw 4 ml from each vial into each of two 10 ml syringes.

• Draw the remaining 2 ml from each vial into a third 10 ml syringe.

• Complete the reconstitution by adding 6 ml of sterile unpreserved normal saline (0.9% sodium chloride for injection) into each of the 10 ml syringes, and mix gently.

This will result in three 10 ml syringes containing a total of 200 Units of reconstituted BOTOX. Use immediately after reconstitution in the syringe. Dispose of any unused saline.

Dilution instructions using a 200 Unit vial:

• Reconstitute a 200 Unit vial of BOTOX with 6 ml of sterile unpreserved normal saline (0.9% sodium chloride for injection) and mix the vials gently.

• Draw 2 ml from the vial into each of three 10 ml syringes.

• Complete the reconstitution by adding 8 ml of sterile unpreserved normal saline (0.9% sodium chloride for injection) into each of the 10 ml syringes, and mix gently.

This will result in three 10 ml syringes containing a total of 200 Units of reconstituted BOTOX. Use immediately after reconstitution in the syringe. Dispose of any unused saline.

The 'unit' by which the potency of preparations of BOTOX is measured should be used to calculate dosages of BOTOX only and is not transferable to other preparations of botulinum toxin.

Disposal

For safe disposal, unused vials should be reconstituted with a small amount of water then autoclaved. Any used vials, syringes, and spillages etc. should be autoclaved, or the residual BOTOX inactivated using dilute hypochlorite solution (0.5%).

Any unused product or waste material should be disposed of in accordance with local requirements.

7. Marketing authorisation holder
Allergan Limited

Marlow International

The Parkway, Marlow,

Bucks SL7 1YL, UK

8. Marketing authorisation number(s)
PL 00426/0118

9. Date of first authorisation/renewal of the authorisation
21/09/2007

10. Date of revision of the text
22/11/2019

Version 16

Allergan Ltd

Address
Marlow International, The Parkway, Marlow, Bucks, SL7 1YL, UK

Telephone
+44 (0)1628 494444

Medical Information Direct Line
+44 (0)1628 494026

Out of Hours contact
+44 (0)1628 494026

Fax
+44 (0)1628 494449

Medical Information e-mail:
UK_MedInfo@Allergan.com

Below is a representation of the Patient Information Leaflet for BOTOX 

BOTOX 50, 100 and 200 Allergan Units

Package leaflet: Information for the user

BOTOX, 50 Allergan Units, Powder for Solution for Injection

BOTOX, 100 Allergan Units, Powder for Solution for Injection

BOTOX, 200 Allergan Units, Powder for Solution for Injection

Botulinum toxin type A

Read all of this leaflet carefully before you start using this medicine because it contains important information for you.

Keep this leaflet. You may need to read it again.
If you have any further questions, ask your doctor or pharmacist.
This medicine has been prescribed for you only. Do not pass it on to others. It may harm them, even if their signs of illness are the same as yours.
If you get any side effects, talk to your doctor or pharmacist. This includes any possible side effects not listed in this leaflet. See section 4.
What is in this leaflet:

1. What BOTOX is and what it is used for
2. What you need to know before you use BOTOX
3. How to use BOTOX
4. Possible side effects
5. How to store BOTOX
6. Contents of the pack and other information

1. What BOTOX is and what it is used for

BOTOX is a muscle relaxant used to treat a number of conditions within the body. It contains the active substance Botulinum toxin type A and is injected into either the muscles, the bladder wall or deep into the skin. It works by partially blocking the nerve impulses to any muscles that have been injected and reduces excessive contractions of these muscles. In the case of chronic migraine, it is thought that BOTOX blocks pain signals, which indirectly block the development of a migraine.

When injected into the skin, BOTOX works on sweat glands to reduce the amount of sweat produced.

When injected into the bladder wall, BOTOX works on the bladder muscle to prevent leakage of urine (urinary incontinence) due to uncontrolled contractions of the bladder muscle.

1) BOTOX can be injected directly into the muscles, and can be used to control the following conditions:

Persistent muscle spasms in the leg in children aged two years or older with cerebral palsy, who can walk; BOTOX is used to control foot deformity caused by the persistent muscle spasms in the legs.
persistent muscle spasms in the wrist, hand, ankle or foot of adult patients who have suffered a stroke;
persistent muscle spasms in the eyelid and face of adult patients;
persistent muscle spasms in the neck and shoulders of adult patients
2) BOTOX is used to prevent headaches in adult patients with chronic migraine.

Chronic migraine is a disease affecting the nervous system. To be diagnosed with chronic migraine, you must have headaches 15 days or more a month. In addition, on 8 or more days a month, your headaches must have at least two of the following characteristics:

affect only one side of the head
cause a pulsating pain
cause moderate to severe pain
are aggravated by routine physical activity
and they must cause at least one of the following:

nausea, vomiting, or both
sensitivity to light and sound.
BOTOX has been shown to significantly reduce the frequency of days with headache and to improve the quality of life of patients suffering from chronic migraine. After two treatment sessions, approximately 47% of patients had a 50% or greater reduction from baseline in the number of days with headache they experienced.

3) When injected into the bladder wall, BOTOX works on the bladder muscle to reduce leakage of urine (urinary incontinence) and control the following conditions in adults:

overactive bladder with leakage of urine, the sudden urge to empty your bladder and needing to go to the toilet more than usual;
leakage of urine due to bladder problems associated with spinal cord injury or multiple sclerosis.
In patients who have not managed to control overactive bladder with leakage of urine with medicines called anticholinergics, BOTOX has been shown to reduce leakage of urine from an average of about 5 episodes per day down to 2 after 12 weeks. 27% of patients had no leakage of urine at all.

In patients with bladder problems associated with spinal cord injury or multiple sclerosis who have not managed to control leakage of urine with medicines called anticholinergics, BOTOX has been shown to reduce leakage of urine, from an average of about 30 episodes per week down to 10 after 6 weeks. 37% of patients had no leakage of urine at all.

4) In adults, BOTOX can be injected deep into the skin and can work on sweat glands to reduce excessive sweating of the armpits, which affects the activities of daily living when other local treatments do not help.

5) BOTOX is used for the temporary improvement in the appearance of:

Vertical lines between the eyebrows seen at maximum frown and/or
Fan-shaped lines from the corner of the eyes seen at maximum smile and/or,
Forehead lines seen at maximum raised eyebrows,
When the severity of the facial lines has an important psychological impact in adult patients.

2. What you need to know before you use BOTOX

Do not use BOTOX

if you are allergic (hypersensitive) to botulinum toxin type A or any of the other ingredients of this medicine (listed in section 6);
if you have an infection at the proposed site of injection;
when you are being treated for leakage of urine and have either a urinary tract infection or a sudden inability to empty your bladder (and are not regularly using a catheter), or if you have bladder stones;
if you are being treated for leakage of urine and are not willing to begin using a catheter if required.
Warnings and precautions

Talk to your doctor or pharmacist before using BOTOX:

if you have ever had problems with swallowing or food or liquid accidentally going into your lungs, especially if you will be treated for persistent muscle spasms in the neck and shoulders;
if you are over 65 years of age and have other serious illnesses;
if you suffer from any other muscle problems or chronic diseases affecting your muscles (such as myasthenia gravis or Eaton Lambert Syndrome);
suffer from certain diseases affecting your nervous system (such as amyotrophic lateral sclerosis or motor neuropathy);
if you have significant weakness or wasting of the muscles which your doctor plans to inject;
if you have had any surgery that may have in some way changed the muscle to be injected;
if you have had any problems with injections (such as fainting) in the past;
if you have inflammation in the muscles or skin area where your doctor plans to inject;
if you have had problems in the past with previous botulinum toxin injections;
if you suffer from cardiovascular disease (disease of the heart or blood vessels);
if you suffer of have suffered from seizures;
if you have an eye disease called closed-angle glaucoma (high pressure in the eye) or were told you are at risk for developing this type of glaucoma;
if you will have an operation soon;
if you are taking any blood thinning medicine.
After you have been given BOTOX

You or your caregiver should contact your doctor and seek medical attention immediately if you experience any of the following:

difficulty in breathing, swallowing, or speaking;
hives, swelling including swelling of the face or throat, wheezing, feeling faint and shortness of breath (possible symptoms of severe allergic reaction).
If you have been treated for vertical and/or fan-shaped and/or forehead lines, please inform your doctor if you see no significant improvement of your lines one month after your first course of treatment.

General precautions

As with any injection, it is possible for the procedure to result in infection, pain, swelling, burning and stinging, increased sensitivity, tenderness, redness, and/or bleeding/bruising at the site of injection.

Side effects possibly related to the spread of toxin distant from the site of administration have been reported with botulinum toxin (e.g. muscle weakness, difficulty swallowing or unwanted food or liquid in the airways). This is a particular risk for patients with an underlying illness that makes them susceptible to these symptoms.

If you are given BOTOX too often or the dose is too high, you may experience muscle weakness and side effects related to the spread of toxin, or your body may start producing some antibodies, which can reduce the effect of BOTOX. To limit this risk, the interval between two treatments must not be less than two or three months depending on the indication.

When BOTOX is used in the treatment of a condition that it is not listed in this leaflet, it could result in serious reactions, particularly in patients who already experience difficulty in swallowing or have significant debility.

If you have not done much exercise for a long time before receiving BOTOX treatment, then after your injections you should start any activity gradually.

It is unlikely that this medicine will improve the range of motion of joints where the surrounding muscle has lost its ability to stretch.

When treating adults with post-stroke ankle muscle spasms, BOTOX should only be used if it is expected to result in improvement in function (e.g. walking) or symptoms (e.g. spasms or pain) or to help with patient care. Furthermore, for patients who may be more likely to fall, your doctor will judge if this treatment is suitable.

When BOTOX is used in the treatment of persistent muscle spasms in the eyelid, it could make your eyes blink less often, which may harm the surface of your eyes. In order to prevent this, you may need treatment with eye drops, ointments, soft contact lenses or even protective covering which closes the eye. Your doctor will tell you if this is required.

BOTOX does not prevent headaches in patients with episodic migraine, which occur less than 15 days a month.

When BOTOX is used in the treatment of vertical and/or fan-shaped and/or forehead lines drooping of eyelid may occur after treatment.

Other medicines with BOTOX

Tell your doctor or pharmacist if:

you are using any antibiotics (used to treat infections), or any medicines that affect the nerves that control muscles (for example anticholinesterase medicines or muscle relaxants). Some of these medicines may increase the effect of BOTOX.
you have recently been injected with a medicine containing a botulinum toxin (the active substance of BOTOX), as this may increase the effect of BOTOX too much.
you are using any anti-platelet (aspirin-like) products and/or anticoagulants (blood thinners).
Tell your doctor or pharmacist if you are taking or have recently taken or might take any other medicine.

Pregnancy and breast-feeding

The use of BOTOX is not recommended during pregnancy and in women of childbearing potential not using contraception. BOTOX is not recommended in breast-feeding women.

If you are pregnant or breast-feeding, think you may be pregnant or are planning to have a baby, ask your doctor or pharmacist for advice before using this medicine.

Driving and using machines

BOTOX may cause dizziness, sleepiness, tiredness or problems with your vision. If you experience any of these effects, do not drive or use any machines. If you are not sure, ask your doctor for advice.

3. How to use BOTOX

BOTOX must only be injected by doctors with specific skills and experience on how to use the medicine.

Method and route of administration

BOTOX is injected into your muscles (intramuscularly), into the bladder wall via a specific instrument (cystoscope) to inject into the bladder or into the skin (intradermally). It is injected directly into the affected area of your body; your doctor will usually inject BOTOX into several sites within each affected area.

General information about dosage

The number of injections per muscle and the dose vary depending on the indications. Therefore, your doctor will decide how much, how often, and in which muscle(s) BOTOX will be given to you. It is recommended that your doctor uses the lowest effective dose;
Dosages for older people are the same as for other adults.
The dosage of BOTOX and the duration of its effect will vary depending on the condition for which you are treated. Below are details corresponding to each condition.

The safety and effectiveness of BOTOX has been established in children/adolescents over the age of two years for the treatment of foot deformity caused by muscle spasms in the legs, associated with Cerebral Palsy.

The safety and effectiveness of BOTOX in the treatment of foot deformity caused by muscle spasms in the legs of children who have Cerebral palsy has been established in children/adolescents over the age of 2 years.

Limited information is available on the use of BOTOX in the following conditions in children/adolescents over the age of 12 years. No recommendation on dosage can be made for these indications.

Limited information is available on the use of BOTOX in persistent muscle spasms in the eyelid and face in children/adolescents over the age of 12 years. No recommendation on dosage can be made for this indication.

Limited information is available on the use of BOTOX in persistent muscle spasms in the neck and shoulder in children/adolescents over the age of 12 years. No recommendation on dosage can be made for this indication.

Limited information is available on the use of BOTOX in the excessive sweating of the armpits in children/adolescents over the age of 12 years. There is limited experience in adolescents between age of 12 and 17 years. Speak to your doctor for further information. No recommendation on dosage can be made for this indication.

In addition, there is limited experience of using BOTOX in the treatment of vertical and/or fan-shaped and/or forehead lines in patients older than 65 years.

The total dose for treatment of forehead lines (20 Units) in conjunction with glabellar lines (20 Units) is 40 Units.

Dosage

For persistent muscle spasms in the legs of children who have cerebral palsy the maximum dose (Units per affected area) in the first treatment is 4 Units/kg (hemiplegia)/6 Units/kg (diplegia) and also 4 Units/kg (hemiplegia)/6 Units/kg (diplegia) for the following treatments. The minimal time between treatments is 3 months*.

For persistent muscle spasms in the wrist and hand of patients who have had a stroke the maximum dose (Units per affected area) in the first treatment the exact dosage and number of injection sites per hand/wrist is tailored to individual needs, up to a maximum of 240 Units. In the following treatments the exact dosage and number of injection sites is tailored to individual needs, up to a maximum of 240 Units. The minimal time between treatments is 12 weeks.

For persistent muscle spasms in the ankle and foot of patients who have had a stroke the maximum dose in the first treatment your doctor may give multiple injections in the affected muscles. The total dose is 300 Units to 400 Units divided among up to 6 muscles. The total dose is 300 Units to 400 Units divided among up to 6 muscles in the following treatments. The minimal time between treatments is 12 weeks.

For persistent muscle spasms of the eyelid and face the maximum dose in the first treatment is 25 Units per eye. It is up to 100 Units in the following treatments. The minimal time between treatments is 3 months.

For persistent muscle spasms of the neck and shoulders the maximum dose in the first treatment is 200 Units. It is up to 300 Units for the following treatments. The minimal time between treatments is 10 weeks.

For headache in adults who have chronic migraine the maximum dose in the first treatment is 155 to 195 Units. It is also 155 to 195 Units in the following treatments. The minimal time between treatments is 12 weeks.

For overactive bladder with leakage of urine the maximum dose in the first treatment is 100 Units. It is also 100 Units in the following treatments. The minimal time between treatments is 3 months.

For leakage of urine due to bladder problems associated with spinal cord injury or multiple sclerosis the maximum dose in the first treatment is 200 Units. It is also 200 Units for the following treatments. The minimal time between treatments is 3 months. The effects of more than two treatment sessions have not been evaluated.

For excessive sweating of the armpits the maximum dose in the first treatment is 50 Units per armpit. It is also 50 units per armpit for the following treatments. The minimal time between treatments is 16 weeks.

For Vertical lines between the eyebrows seen at maximum frown the maximum dose in the first treatment is 20 Units**. It is up to 50 Units for the following treatments. The minimal time between treatments is 3 months. The effects of more than four treatment sessions have not been evaluated.

For Fan-shaped lines from the corner of the eyes seen at maximum smile the maximum dose in the first treatment is 24 Units**. It is also 24 Units for the following treatments. The minimal time between treatments is 3 months.

For Forehead lines seen at maximum raised eyebrows the maximum dose in the first treatment is 20 Units***. The minimal time between treatments is 3 months.

* The doctor may select a dose that would mean the treatment may be up to 6 months apart.

** If you are treated for fan-shaped lines from the corner of the eyes seen at maximum smile at the same time as vertical lines between the eyebrows seen at maximum frown, you will receive a total dose of 44 Units.

*** If you are treated for all 3 facial lines at the same time (fan-shaped lines from the corner of the eyes seen at maximum smile, vertical lines between the eyebrows seen at maximum frown, and forehead lines seen at maximum raised eyebrows) you will receive a total dose of 64 Units

Information for patients treated for leakage of urine

Your doctor will give you antibiotics around the time of the injection to help prevent urinary tract infection. The injection will be administered by a procedure called cystoscopy. An instrument with a light source at the end will be introduced into your bladder through the opening by which you let out the urine (called urethra). This enables the doctor to see the inside of the bladder and place the injections into the bladder wall. Please ask your doctor to explain further details of the procedure to you.

If you were not using a catheter (a soft, hollow tube that is inserted into your urethra to help empty urine from the bladder) before treatment with BOTOX, you should be seen by your doctor approximately 2 weeks after the injection. You will be asked to pass urine and will then have the volume of urine left in your bladder measured. If your doctor assesses you have too much urine left in your bladder you will be instructed to use a catheter to empty your bladder. Your doctor will decide if and when you need to return for the same test.

For overactive bladder with leakage of urine

You may be given a local anaesthetic before the injections (your bladder would be filled with anaesthetic solution for a while and then drained). You may also be given a sedative.

You will be observed for at least 30 minutes after the injection before you can leave to see if you can pass urine spontaneously.

You must contact your doctor if at any time you are unable to pass urine because it is possible that you may need to start using a catheter. In clinical trials, approximately 6 out of 100 patients not using a catheter before treatment may need to use a catheter after treatment.

For leakage of urine due to bladder problems associated with spinal cord injury or multiple sclerosis

You may be given a local or general anaesthetic before the procedure.

You will be observed for at least 30 minutes after the injection before you can leave. At the time of the injection, due to the procedure by which the injection is delivered into your bladder, you may experience possible uncontrolled reflex reaction of your body (e.g. profuse sweating, throbbing headache or increase in pulse rate).

You must contact your doctor if at any time you are unable to pass urine because it is possible that you may need to start using a catheter. In clinical trials, approximately one fifth of patients reported an inability to completely empty their bladder after BOTOX treatment. At least one third of patients not using a catheter before treatment may need to use a catheter after treatment.

Time to Improvement and Duration of Effect

For persistent muscle spasms in the legs of children who have cerebral palsy, the improvement usually appears within the first 2 weeks after the injection.

For persistent muscle spasms in the wrist and hand of patients who have had a stroke, you will usually see an improvement within the first 2 weeks after the injection. The maximum effect is usually seen about 4 to 6 weeks after treatment.

For persistent muscle spasms of the eyelid and face, you will usually see an improvement within 3 days after the injection and the maximum effect is usually seen after 1 to 2 weeks.

For persistent muscle spasms of the neck and shoulders, you will usually see an improvement within 2 weeks after the injection. The maximum effect is usually seen about 6 weeks after treatment.

For leakage of urine due to overactive bladder, you will usually see an improvement within 2 weeks after the injection. Typically patients find the effect lasts approximately 6-7 months after the injection.

For leakage of urine due to bladder problems associated with spinal cord injury or multiple sclerosis, you will usually see an improvement within 2 weeks after the injection. Typically patients find the effect lasts approximately 9-10 months after the injection.

For excessive sweating of the armpits, you will usually see an improvement within the first week after injection. On average the effect usually lasts 4-7 months after the first injection.

For vertical lines between the eyebrows seen at maximum frown, you will usually see an improvement within 1 week after treatment, the maximum effect being observed 5 to 6 weeks after injection. The treatment effect has been demonstrated for up to 4 months after injection.

For fan-shaped lines from the corner of the eyes seen at maximum smile you will usually see an improvement within 1 week after treatment. The treatment effect has been demonstrated for an average of 4 months after injection.

For forehead lines seen at maximum eyebrow elevation you will usually see an improvement within 1 week after treatment. The treatment effect has been demonstrated for an average of 4 months after injection.

If you have received more BOTOX than you should

The signs of too much BOTOX may not appear for several days after the injection. Should you swallow BOTOX or have it accidentally injected, you should see your doctor who might keep you under observation for several weeks.

If you have received too much BOTOX, you may have any of the following symptoms and you must contact your doctor immediately. He/she will decide if you have to go to hospital:

muscle weakness which could be local or distant from the site of injection;
difficulty in breathing, swallowing or speaking due to muscle paralysis;
food or liquid accidentally going into your lungs which might cause pneumonia (infection of the lungs) due to muscle paralysis;
drooping of the eyelids, double vision;
generalised weakness.
If you have any further questions on the use of this product, ask your doctor or pharmacist.

4. Possible side effects

If you have any difficulty in breathing, swallowing or speaking after receiving BOTOX, contact your doctor immediately.

If you experience hives, swelling including swelling of the face or throat, wheezing, feeling faint and shortness of breath, contact your doctor immediately.

Like all medicines, this medicine can cause side effects, although not everybody gets them. In general, side effects occur within the first few days following injection. They usually last only for a short time, but they may last for several months and in rare cases, longer.

As expected for any injection procedure, pain/burning/stinging, swelling and/or bruising may be associated with the injection.

The side effects are classified into the following categories, depending on how often they occur:

Very common may affect more than 1 in 10 people

Common may affect up to 1 in 10 people

Uncommon may affect up to 1 in 100 people

Rare may affect up to 1 in 1,000 people

Very rare may affect up to 1 in 10,000 people

Below are lists of side effects which vary depending on the part of the body where BOTOX is injected. If any of the side effects gets serious, or if you notice any side effects not listed in this leaflet, please tell your doctor or pharmacist.

Injections in the legs of children with cerebral palsy

Very Common

Viral infection, ear infection
Common

Sleepiness, problems with walking, numbness
Muscle pain, muscle weakness, pain of the extremities
Urinary incontinence (leakage of urine)
Feeling generally unwell or weak
Pain where the injection was given
Fall
Rash
There have been rare spontaneous reports of death sometimes associated with aspiration pneumonia in children with severe cerebral palsy after treatment with BOTOX.

Injections in the wrist and hand of patients who have had a stroke

Common

Muscle weakness, increased muscle tension
Pain in the hand and fingers
Bruising and bleeding under the skin causing red patches (ecchymosis or purpura)
Bleeding, burning, pain where the injection was given
Fever, flu manifestations
Uncommon

Depression, difficulty in sleeping (insomnia)
A fall in blood pressure on standing up which causes dizziness, light headedness or fainting
Feeling of dizziness or “spinning” (vertigo)
Lack of coordination of movements, loss of memory, decreased skin sensation, numbness, headache
General weakness, feeling generally unwell
Feeling sick, numbness around the mouth
Pain, swelling of the extremities such as the hands and feet
Joint pain or inflammation
Inflammation of the skin (dermatitis), rash, itching, increased sensitivity where the injection was given
Some of these uncommon side effects may also be related to your disease.

Injections in the ankle and foot of patients who have had a stroke

Common

Rash
Joint pain or inflammation, stiff or sore muscles, muscular weakness
Swelling of the extremities such as the hands and feet
Fall
Injections in the eyelid and face for muscle spasms

Very Common

Drooping of the eyelid
Common

Swelling of the face
Pinpoint damage of the cornea (transparent surface covering the front of the eye), difficulty in completely closing the eye, overflow of tears, dry eyes, eye irritation and sensitivity to light
Bruising under the skin
Irritation
Uncommon

Dizziness, weakness of the face muscles, drooping of the muscles on one side of the face
Visual disturbance, blurred vision, double vision, inflammation of the cornea (transparent surface covering the front of the eye), abnormal turning of the eyelids outwards or inwards
Rash
Tiredness
Rare

Swelling of the eyelid
Very rare

Damage to the cornea (transparent surface covering the front of the eye) including ulcer and perforation
Injections in the neck and shoulder

Very Common

Difficulty in swallowing
Pain
Muscle weakness
Common

Dizziness, sleepiness, headache
Feeling of weakness or generally unwell, flu manifestations
Feeling sick, dry mouth
Muscle cramps, stiff or sore muscles, increased muscle tension
Decreased skin sensation
Swelling and irritation inside the nose (rhinitis), signs of infection of the nose or throat (blocked or runny nose, cough, sore throat)
Uncommon

Shortness of breath, changes in your voice
Double vision, drooping of the eyelid
Fever
Injections in the head and neck to prevent headache in patients who suffer from chronic migraine

Common

Increase in headache or migraine
Weakness of the face muscles
Drooping of the eyelid
Rash, itching
Pain where the injection was given
Muscle weakness, neck pain, muscle pain or cramp, muscle stiffness or tightness
Uncommon

Difficulty in swallowing
Swollen eyelid
Skin pain
Jaw pain
Injections in the bladder wall for overactive bladder with leakage of urine

Very common

Urinary tract infection, painful urination after the injection*
Common

Inability to empty the bladder (urinary retention), incomplete emptying of the bladder, frequent daytime urination
Bacteria or white blood cells in the urine
*This side effect is related to the injection procedure.

Injections in the bladder wall for leakage of urine due to bladder problems associated with spinal cord injury or multiple sclerosis

Very common

Urinary tract infection (in about half the patients)
Inability to empty your bladder (urinary retention; see section 3)
Common

Muscle spasm
Bulge in the bladder wall (bladder diverticulum)
The following side effects have only been reported in multiple sclerosis:

Difficulty in sleeping (insomnia)
Tiredness, problems with walking (gait disturbance)
Constipation
Muscle weakness, fall
The following side effects are related to the injection procedure:

Blood in the urine after the injection
Uncontrolled reflex reaction of the body (profuse sweating, throbbing headache or increase in pulse rate) around the time of the injection (autonomic dysreflexia; see section 3)
Injections for excessive sweating of the armpits

Very common

Pain where the injection was given
Common

Headache, numbness
Hot flushes
Increased sweating at sites other than the armpit, abnormal skin odour, itching, lump under the skin
Hair loss
Pain in the extremities, such as the hands and fingers
Pain, reaction where the injection was given such as swelling, bleeding, burning or increased sensitivity
Uncommon

Muscle weakness, muscle pain, problem with the joints
Feeling weak
Feeling sick
Injections in the legs of children with cerebral palsy

Very Common

Viral infection, ear infection
Common

Sleepiness, problems with walking, numbness
Muscle pain, muscle weakness, pain of the extremities
Urinary incontinence (leakage of urine)
Feeling generally unwell or weak
Pain where the injection was given
Fall
Rash
Injections in the wrist and hand of patients who have had a stroke

Common

Muscle weakness, increased muscle tension
Pain in the hand and fingers
Bruising and bleeding under the skin causing red patches (ecchymosis or purpura)
Bleeding, burning, pain where the injection was given
Fever, flu manifestations
Uncommon

Depression, difficulty in sleeping (insomnia)
A fall in blood pressure on standing up which causes dizziness, light headedness or fainting
Feeling of dizziness or “spinning” (vertigo)
Lack of coordination of movements, loss of memory, decreased skin sensation, numbness, headache
General weakness, feeling generally unwell
Feeling sick, numbness around the mouth
Pain, swelling of the extremities such as the hands and feet
Joint pain or inflammation
Inflammation of the skin (dermatitis), rash, itching, increased sensitivity where the injection was given
Injections in the ankle and foot of patients who have had a stroke

Common

Rash
Joint pain or inflammation, stiff or sore muscles, muscular weakness
Swelling of the extremities such as the hands and feet
Fall
Injections in the eyelid and face for muscle spasms

Very Common

Drooping of the eyelid
Common

Swelling of the face
Pinpoint damage of the cornea (transparent surface covering the front of the eye), difficulty in completely closing the eye, overflow of tears, dry eyes, eye irritation and sensitivity to light
Bruising under the skin
Irritation
Uncommon

Dizziness, weakness of the face muscles, drooping of the muscles on one side of the face
Visual disturbance, blurred vision, double vision, inflammation of the cornea (transparent surface covering the front of the eye), abnormal turning of the eyelids outwards or inwards
Rash
Tiredness
Rare

Swelling of the eyelid
Very rare

Damage to the cornea (transparent surface covering the front of the eye) including ulcer and perforation
Injections in the neck and shoulder

Very Common

Difficulty in swallowing
Pain
Muscle weakness
Common

Dizziness, sleepiness, headache
Feeling of weakness or generally unwell, flu manifestations
Feeling sick, dry mouth
Muscle cramps, stiff or sore muscles, increased muscle tension
Decreased skin sensation
Swelling and irritation inside the nose (rhinitis), signs of infection of the nose or throat (blocked or runny nose, cough, sore throat)
Uncommon

Shortness of breath, changes in your voice
Double vision, drooping of the eyelid
Fever
Injections in the head and neck to prevent headache in patients who suffer from chronic migraine

Common

Increase in headache or migraine
Weakness of the face muscles
Drooping of the eyelid
Rash, itching
Pain where the injection was given
Muscle weakness, neck pain, muscle pain or cramp, muscle stiffness or tightness
Uncommon

Difficulty in swallowing
Swollen eyelid
Skin pain
Jaw pain
Injections in the bladder wall for overactive bladder with leakage of urine

Very common

Urinary tract infection, painful urination after the injection*
Common

Inability to empty the bladder (urinary retention), incomplete emptying of the bladder, frequent daytime urination
Bacteria or white blood cells in the urine
Injections in the bladder wall for leakage of urine due to bladder problems associated with spinal cord injury or multiple sclerosis

Very common

Urinary tract infection (in about half the patients)
Inability to empty your bladder (urinary retention; see section 3)
Common

Muscle spasm
Bulge in the bladder wall (bladder diverticulum)
The following side effects have only been reported in multiple sclerosis:

Difficulty in sleeping (insomnia)
Tiredness, problems with walking (gait disturbance)
Constipation
Muscle weakness, fall
The following side effects are related to the injection procedure:

Blood in the urine after the injection
Uncontrolled reflex reaction of the body (profuse sweating, throbbing headache or increase in pulse rate) around the time of the injection (autonomic dysreflexia; see section 3)
Injections for excessive sweating of the armpits

Very common

Pain where the injection was given
Common

Headache, numbness
Hot flushes
Increased sweating at sites other than the armpit, abnormal skin odour, itching, lump under the skin
Hair loss
Pain in the extremities, such as the hands and fingers
Pain, reaction where the injection was given such as swelling, bleeding, burning or increased sensitivity
Uncommon

Muscle weakness, muscle pain, problem with the joints
Feeling weak
Feeling sick
Injection in the forehead for vertical lines

Common

Headache
Drooping of the eyelid
Localised muscle weakness
Face pain
Skin redness
Uncommon

Skin tightness
Infection
Anxiety
Numbness, dizziness
Inflammation of the eyelid, eye pain, visual disturbance
Swelling (face around the eyes), skin sensitivity to light, dry skin, itching
Eyelid swelling
Feeling sick, dry mouth
Muscle twitching
Fever, flu manifestations, feeling weak
Injections in the fan-shaped lines from the corner of the eyes, when treated with or without vertical lines between the eyebrows seen at frown

Common

Injection site haematoma*
Uncommon

Eyelid swelling
Injection site bleeding*
Injection site pain*
Injection site tingling or numbness
Injections in the forehead lines and vertical lines between the eyebrows seen at frown when treated with or without the fan-shaped lines from the corner of the eyes

Common

Headache
Drooping of the eyelid
Injection site haematoma*
Injection site bruising*
Skin tightness
Drooping eyebrow2
Uncommon

Injection site pain*
*Some of these side effects may also be related to the injection procedure.

1.The median time to onset of drooping eyelid was 9 days following treatment

2. The median time to onset of drooping eyebrow was 5 days following treatment

General information about other side effects

The following list describes additional side effects reported for BOTOX, in any disease, since it has been marketed:

Affecting the immune system

sudden allergic reactions, which can be serious (swelling of the face or throat, difficulty in breathing, feeling faint)
delayed reaction which may include fever, skin reaction, joint pain (serum sickness)
hives
Affecting metabolism

loss of appetite
Affecting the nervous system

nerve damage (brachial plexopathy)
slurred speech, speech problems
weakness or drooping of the muscles on one side of the face
decreased skin sensation
muscle weakness
chronic disease affecting the muscles (myasthenia gravis)
difficulty moving the arm and shoulder
numbness, tingling and pain in hands and feet
pain/numbness/or weakness starting from the spine
seizures, fainting
Affecting the eyes

increase in eye pressure
drooping eyelid
difficulty in completely closing the eye
strabismus (squint)
blurred vision
visual disturbance
dry eye
Affecting the ears

decreased hearing
noises in the ear
feeling of dizziness or “spinning” (vertigo)
Affecting the cardiovascular system

heart problems including heart attack
Affecting the respiratory system

aspiration pneumonia (lung inflammation caused by accidentally breathing in food, drink, saliva or vomit)
breathing problems, respiratory depression and/or respiratory failure
Affecting the gastrointestinal system

abdominal pain
diarrhoea, constipation
dry mouth
difficulty swallowing
feeling sick, vomiting
Affecting the skin

hair loss, loss of eyebrows
drooping eyebrow
different types of red blotchy skin rashes
excessive sweating
itching
rash
Affecting muscles

muscles pain, loss of nerve supply to/shrinkage of injected muscle
localised muscle twitching/involuntary muscle contractions
Affecting the body

feeling generally unwell
fever
Reporting of side effects

If you get any side effects, talk to your doctor. This includes any possible side effects not listed in this leaflet. You can also report side effects directly via Yellow Card Scheme, Website: www.mhra.gov.uk/yellowcard. By reporting side effects you can help provide more information on the safety of this medicine.

5. How to store BOTOX

Keep out of the sight and reach of children.

Store in a refrigerator (2°C – 8°C), or store in a freezer (-5°C to -20°C).

After the solution is made up, immediate use of the solution is recommended; however it can be stored for up to 24 hours in a refrigerator (2°C – 8°C).

Your doctor should not use BOTOX after the expiry date which is stated on the label after ‘EXP’. The expiry date refers to the last day of that month.

6. Contents of the pack and other information

What BOTOX contains

The active substance is: Botulinum toxin type A from Clostridium botulinum.
The other ingredients are human albumin and sodium chloride.
What BOTOX looks like and content of the pack

BOTOX is presented as a thin white powder that may be difficult to see on the bottom of a transparent glass vial. Prior to injection, the product must be dissolved in sterile unpreserved normal saline (0.9% sodium chloride for injection).

Each vial contains either 50, 100 or 200 Allergan Units of botulinum toxin type A.

Each pack contains 1, 2, 3 or 6 vials. Not all pack sizes may be marketed.

Marketing Authorisation Holder and Manufacturer

Marketing Authorisation Holder:

Allergan Ltd.
Marlow International
The Parkway
Marlow
Bucks
SL7 1YL
UK
Manufacturer:

Allergan Pharmaceuticals Ireland
Castlebar Road
Westport
County Mayo
Ireland

This leaflet was last revised in August 2019.