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Dysport 300 units

Last Updated on eMC 10-Mar-2017 View changes  | Ipsen Ltd Contact details

1. Name of the medicinal product

Dysport

300 units

Powder for solution for injection

2. Qualitative and quantitative composition

Clostridium botulinum type A toxin-haemagglutinin complex 300 units*

*One unit (U) is defined as the median lethal intraperitoneal dose in mice.

For a full list of excipients, see section 6.1.

3. Pharmaceutical form

Powder for solution for injection

4. Clinical particulars
4.1 Therapeutic indications

Dysport is indicated for symptomatic treatment of focal spasticity of:

- Upper limbs in adults

- Lower limbs in adults affecting the ankle joint due to stroke or traumatic brain injury (TBI)

- Dynamic equinus foot deformity in ambulant paediatric cerebral palsy patients, two years of age or older.

Dysport is indicated in adults for symptomatic treatment of:

- Spasmodic torticollis

- Blepharospasm

- Hemifacial spasm.

4.2 Posology and method of administration

The units of Dysport are specific to the preparation and are not interchangeable with other preparations of botulinum toxin.

Training: Dysport should only be administered by appropriately trained physicians.

Ipsen can facilitate training in administration of Dysport injections.

For instructions on reconstitution of the powder for solution for injection, handling and disposal of vials please refer to section 6.6.

Focal spasticity in adults

Upper limb:

Posology

Dosing in initial and sequential treatment sessions should be tailored to the individual based on the size, number and location of muscles involved, severity of spasticity, the presence of local muscle weakness, the patient's response to previous treatment, and/or adverse event history with Dysport. In clinical trials, doses of 500 units and 1000 units were divided among selected muscles at a given treatment session as shown below.

No more than 1 ml should generally be administered at any single injection site.

Muscles Injected

Recommended Dose

Dysport (U)

Flexor carpi radialis (FCR)

Flexor carpi ulnaris (FCU)

100-200U

100-200U

Flexor digitorum profundus (FDP)

Flexor digitorum superficialis (FDS)

Flexor pollicis longus

Adductor pollicis

100-200U

100-200U

100-200U

25-50U

Brachialis

Brachioradialis

Biceps brachii (BB)

Pronator teres

200-400U

100-200U

200-400U

100-200U

Triceps brachii (long head)

Pectoralis major

Subscapularis

Latissimus dorsi

150-300U

150-300U

150-300U

150-300U

Although actual location of the injection sites can be determined by palpation, the use of injection guiding technique, e.g. electromyography, electrical stimulation or ultrasound is recommended to target the injection sites.

Clinical improvement may be expected one week after injection and may last up to 20 weeks. Injections may be repeated every 12 - 16 weeks or as required to maintain response, but not more frequently than every 12 weeks. The degree and pattern of muscle spasticity at the time of re-injection may necessitate alterations in the dose of Dysport and muscles to be injected.

Lower limb spasticity affecting the ankle joint:

Posology

In clinical trials, doses of 1000U and 1500U were divided among selected muscles.

The exact dosage in initial and sequential treatment sessions should be tailored to the individual based on the size and number of muscles involved, the severity of the spasticity, also taking into account the presence of local muscle weakness and the patient's response to previous treatment. However the total dose should not exceed 1500U.

No more than 1 ml should generally be administered at any single injection site.

Muscle

Recommended Dose

Dysport (U)

Number of injection sites per muscle

Primary target muscle

Soleus muscle

300 - 550U

2 - 4

Gastrocnemius:

Medial head

Lateral head

 

100 - 450U

1 - 3

100 - 450U

1 - 3

Distal muscles

Tibialis posterior

100 - 250U

1 - 3

Flexor digitorum longus

50 - 200U

1 - 2

Flexor digitorum brevis

50 - 200U

1 - 2

Flexor hallucis longus

50 - 200U

1 - 2

Flexor hallucis brevis

50 - 100U

1 - 2

The degree and pattern of muscle spasticity at the time of re-injection may necessitate alterations in the dose of Dysport and muscles to be injected.

Although actual location of the injection sites can be determined by palpation, the use of injection guiding techniques, e.g. electromyography, electrical stimulation or ultrasound are recommended to help accurately target the injection sites.

Repeat Dysport treatment should be administered every 12 to 16 weeks, or longer as necessary, based on return of clinical symptoms but no sooner than 12 weeks after the previous injection.

Upper and Lower limbs:

If treatment is required in the upper and lower limbs during the same treatment session, the dose of Dysport to be injected in each limb should be tailored to the individual's need, according to the relevant posology and without exceeding a total dose of 1500U.

Children: The safety and effectiveness of Dysport in the treatment of upper limb spasticity in children have not been demonstrated.

Elderly patients (≥ 65 years): Clinical experience has not identified differences in response between the elderly and younger adult patients. In general, elderly patients should be observed to evaluate their tolerability of Dysport, due to the greater frequency of concomitant disease and other drug therapy.

Method of administration

When treating focal spasticity affecting the upper and lower limbs in adults, Dysport is reconstituted with sodium chloride injection B.P. (0.9 % w/v) to yield a solution containing either 100 units per ml, 200 units per ml or 500 units per ml of Dysport (see section 6.6).

Dysport is administered by intramuscular injection into the muscles as described above.

Dynamic equinus foot deformity due to focal spasticity in ambulant paediatric cerebral palsy patients, two years of age or older

Posology

Dosing in initial and sequential treatment sessions should be tailored to the individual based on the size, number and location of muscles involved, severity of spasticity, the presence of local muscle weakness, the patient's response to previous treatment, and/or adverse event history with botulinum toxins. For treatment initiation, consideration should be given to start with a lower dose.

The maximum total dose of Dysport administered per treatment session must not exceed 15 units/kg for unilateral lower limb injections or 30 units/kg for bilateral injections. In addition the total Dysport dose per treatment session must not exceed 1000 units or 30 units/kg, whichever is lower. The total dose administered should be divided between the affected spastic muscles of the lower limb(s). When possible the dose should be distributed across more than 1 injection site in any single muscle.

No more than 0.5 ml of Dysport should be administered in any single injection site. See below table for recommended dosing:

Muscle

Recommended Dose Range per muscle per leg (U/kg Body Weight)

Number of injection sites per muscle

Gastrocnemius

5 to 15 U/kg

Up to 4

Soleus

4 to 6 U/kg

Up to 2

Tibialis posterior

3 to 5 U/kg

Up to 2

Total dose

Up to 15 U/kg/leg

Although actual location of the injection sites can be determined by palpation, the use of injection guiding technique, e.g. electromyography, electrical stimulation or ultrasound is recommended to target the injection sites.

Repeat Dysport treatment should be administered when the effect of a previous injection has diminished, but no sooner than 12 weeks after the previous injection. A majority of patients in clinical studies were retreated between 16 - 22 weeks; however some patients had a longer duration of response, i.e. 28 weeks. The degree and pattern of muscle spasticity at the time of re-injection may necessitate alterations in the dose of Dysport and muscles to be injected.

Clinical improvement may be expected within two weeks after injection.

Method of administration

When treating spasticity associated with cerebral palsy in children, Dysport is reconstituted with sodium chloride injection B.P. (0.9 % w/v) and is administered by intramuscular injection as detailed above (see also section 6.6).

Spasmodic torticollis

Posology

The doses recommended for torticollis are applicable to adults of all ages, provided the adults are of normal weight with no evidence of reduced neck muscle mass. A lower dose may be appropriate if the patient is markedly underweight or in the elderly, where reduced muscle mass may exist.

The initial recommended dose for the treatment of spasmodic torticollis is 500 units per patient given as a divided dose and administered into the two or three most active neck muscles.

• For rotational torticollis distribute the 500 units by administering 350 units into the splenius capitis muscle, ipsilateral to the direction of the chin/head rotation and 150 units into the sternomastoid muscle, contralateral to the rotation.

• For laterocollis, distribute the 500 units by administering 350 units into the ipsilateral splenius capitis muscle and 150 units into the ipsilateral sternomastoid muscle. In cases associated with shoulder elevation the ipsilateral trapezoid or levator scapulae muscles may also require treatment, according to visible hypertrophy of the muscle or electromyographic (EMG) findings. Where injections of three muscles are required, distribute the 500 units as follows, 300 units splenius capitis, 100 units sternomastoid and 100 units to the third muscle.

• For retrocollis distribute the 500 units by administering 250 units into each of the splenius capitis muscles. Bilateral splenii injections may increase the risk of neck muscle weakness.

• All other forms of torticollis are highly dependent on specialist knowledge and EMG to identify and treat the most active muscles. EMG should be used diagnostically for all complex forms of torticollis, for reassessment after unsuccessful injections in non-complex cases, and for guiding injections into deep muscles or in overweight patients with poorly palpable neck muscles.

On subsequent administration, the doses may be adjusted according to the clinical response and side effects observed. Doses within the range of 250 - 1000 units are recommended, although the higher doses may be accompanied by an increase in side effects, particularly dysphagia. The maximum dose administered must not exceed 1000 units.

The relief of symptoms of torticollis may be expected within a week after the injection.

Injections may be repeated approximately every 16 weeks or as required to maintain a response, but not more frequently than every 12 weeks.

Children: The safety and effectiveness of Dysport in the treatment of spasmodic torticollis in children have not been demonstrated.

Method of administration

When treating spasmodic torticollis, Dysport is reconstituted with sodium chloride injection B.P. (0.9 % w/v) to yield a solution containing 500 units per ml of Dysport (see section 6.6).

Dysport is administered by intramuscular injection as described above.

Blepharospasm and hemifacial spasm

Posology

In a dose ranging clinical trial on the use of Dysport for the treatment of benign essential blepharospasm, a dose of 40 units per eye was significantly effective. Doses of 80 units and 120 units per eye resulted in a longer duration of effect. However, the incidence of local adverse events, specifically ptosis, was dose related. In the treatment of blepharospasm and hemifacial spasm, the maximum dose used must not exceed a total dose of 120 units per eye.

An injection of 10 units (0.05 ml) medially and 10 units (0.05 ml) laterally should be made into the junction between the preseptal and orbital parts of both the upper (3 and 4) and lower orbicularis oculi muscles (5 and 6) of each eye. In order to reduce the risk of ptosis, injections near the levator palpebrae superioris should be avoided.

For injections into the upper lid the needle should be directed away from its centre to avoid the levator muscle. A diagram to aid placement of these injections is provided above. The relief of symptoms may be expected to begin within two to four days with maximal effect within two weeks.

Injections should be repeated approximately every twelve weeks or as required to prevent recurrence of symptoms but not more frequently than every twelve weeks.

On such subsequent administrations, if the response from the initial treatment is considered insufficient, the dose per eye may need to be increased to:

- 60 units: 10 units (0.05 ml) medially and 20 units (0.1 ml) laterally;

- 80 units: 20 units (0.1 ml) medially and 20 units (0.1 ml) laterally; or

- up to 120 units: 20 units (0.1 ml) medially and 40 units (0.2 ml) laterally,

above and below each eye in the manner previously described. Additional sites in the frontalis muscle above the brow (1 and 2) may also be injected if spasms here interfere with vision.

In cases of unilateral blepharospasm the injections should be confined to the affected eye. Patients with hemifacial spasm should be treated as for unilateral blepharospasm. The doses recommended are applicable to adults of all ages including the elderly.

Children: The safety and effectiveness of Dysport in the treatment of blepharospasm and hemifacial spasm in children have not been demonstrated.

Method of administration

When treating blepharospasm and hemifacial spasm, Dysport is reconstituted with sodium chloride injection B.P. (0.9 % w/v) to yield a solution containing 200 units per ml of Dysport (see section 6.6).

Dysport is administered by subcutaneous injection medially and laterally into the junction between the preseptal and orbital parts of both the upper and lower orbicularis oculi muscles of the eyes as described above.

4.3 Contraindications

Known hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

4.4 Special warnings and precautions for use

Side effects related to spread of toxin distant from the site of administration have been reported (see section 4.8) which, in some cases, was associated with dysphagia, pneumonia and/or significant debility resulting, very rarely, in death. Patients treated with therapeutic doses may present with excessive muscle weakness. The risk of occurrence of such undesirable effects may be reduced by using the lowest effective possible dose and by not exceeding the maximum recommended dose.

Dysport should only be used with caution and under close medical supervision in patients with subclinical or clinical evidence of marked defective neuromuscular transmission (e.g. myasthenia gravis). Such patients may have an increased sensitivity to agents such as Dysport, which may result in excessive muscle weakness with therapeutic doses. Patients with underlying neurological disorders are at increased risk of this side effect.

Caution should be exercised when treating adult patients especially the elderly, with focal spasticity affecting the lower limbs, who may be at increased risk of fall. In placebo-controlled clinical studies, where patients were treated for lower limb spasticity, 6.3% and 3.7% of patients experienced a fall in the Dysport and placebo groups, respectively.

Very rare cases of death, occasionally in the context of dysphagia, pneumopathy (including but not limited to dyspnoea, respiratory failure, respiratory arrest) and/or in patients with significant asthenia have been reported following treatment with botulinum toxin A or B. Patients with disorders resulting in defective neuromuscular transmission, difficulty in swallowing or breathing are more at risk of experiencing these effects. In these patients, treatment must be administered under the control of a specialist and only if the benefit of treatment outweighs the risk.

Dysport should be administered with caution to patients with pre-existing swallowing or breathing problems as these can worsen following the distribution of the effect of toxin into the relevant muscles. Aspiration has occurred in rare cases and is a risk when treating patients who have a chronic respiratory disorder.

The recommended posology and frequency of administration for Dysport must not be exceeded (see section 4.2).

Patients and their care-givers must be warned of the necessity to seek immediate medical treatment in case of swallowing, speech or respiratory problems.

For the treatment of spasticity associated with cerebral palsy in children, Dysport should only be used in children of 2 years of age or over.

Dysport should not be used to treat spasticity in patients who have developed a fixed contracture.

As with any intramuscular injection, Dysport should only be used where strictly necessary in patients with prolonged bleeding times, infection or inflammation at the proposed site(s) of injection.

Dysport should only be used to treat a single patient, during a single session. Specific precautions must be taken during the preparation and administration of the product (see section 4.2) and for the inactivation and disposal of any unused reconstituted solution (see section 6.6).

Antibody formation to botulinum toxin has been noted rarely in patients receiving Dysport. Clinically, neutralising antibodies might be suspected by a substantial deterioration in response to therapy and/or the need for consistent use of increased doses.

Careful consideration should be given before the injection of patients who have experienced a previous allergic reaction to a product containing botulinum toxin type A. The risk of a further allergic reaction must be considered in relation to the benefit of treatment.

4.5 Interaction with other medicinal products and other forms of interaction

The effects of botulinum toxin may be potentiated by drugs interfering either directly or indirectly with neuromuscular function (e.g. aminoglycosides, curare-like non-depolarising blockers, muscle relaxants) and such drugs should be used with caution in patients treated with botulinum toxin due to the potential for undesirable effects.

4.6 Fertility, pregnancy and lactation

Pregnancy:

There are limited data from the use of Clostridium botulinum type A toxin-haemagglutinin complex in pregnant women. Studies in animals have shown reproductive toxicity at high doses causing maternal toxicity (see section 5.3).

Dysport should be used during pregnancy only if the benefit justifies any potential risk to the foetus. Caution should be exercised when prescribing to pregnant women.

Breast-feeding:

It is not known whether Clostridium botulinum type A toxin-haemagglutinin complex is excreted in human milk. The excretion of Clostridium botulinum type A toxin-haemagglutinin complex in milk has not been studied in animals. The use of Clostridium botulinum type A toxin-haemagglutinin complex during lactation cannot be recommended.

Fertility:

Studies in male and female rats have shown effects on fertility (see section 5.3).

4.7 Effects on ability to drive and use machines

There is a potential risk of muscle weakness or visual disturbances which, if experienced, may temporarily impair the ability to drive or operate machinery.

4.8 Undesirable effects

General

Side effects related to spread of toxin distant from the site of administration have been reported, such as dry mouth, exaggerated muscle weakness, dysphagia, aspiration/aspiration pneumonia, with fatal outcome in some very rare cases (see section 4.4). Hypersensitivity reactions have also been reported post-marketing.

The frequency of adverse reactions reported in placebo-controlled trials after a single administration is defined as follows:

Very common >1/10; Common >1/100, <1/10; Uncommon >1/1000, <1/100; Rare >1/10 000, < 1/1000.

The following adverse reactions were seen in patients treated across a variety of indications including blepharospasm, hemifacial spasm, torticollis and spasticity associated with either cerebral palsy or stroke/TBI:

System Organ Class

Frequency

Adverse Drug Reaction

Nervous system disorders

Rare

Neuralgic amyotrophy

Skin and subcutaneous tissue disorders

Uncommon

Pruritus

Rare

Rash

General disorders and administration site conditions

Common

Asthenia, fatigue, influenza like illness, injection site pain/bruising

Frequency of specific adverse reactions by indication

In addition, the following adverse reactions specific to individual indications were reported:

Focal spasticity affecting the upper limbs

System Organ Class

Frequency

Adverse Drug Reaction

Gastrointestinal disorders

Uncommon

Dysphagia*

Musculoskeletal and connective tissue disorders

Common

Muscular weakness, musculoskeletal pain

Uncommon

Pain in the extremity

* The frequency for Dysphagia was derived from pooled data from open-label studies. Dysphagia was not observed in the double-blind studies in the Adult Upper Limb (AUL) indication.

Focal spasticity affecting the lower limbs

System Organ Class

Frequency

Adverse Drug Reaction

Gastrointestinal disorders

Common

Dysphagia

Musculoskeletal and connective tissue disorders

Common

Muscular weakness, myalgia

General disorders and administration site conditions

Common

Asthenia, fatigue, influenza-like illness, injection site reactions (pain, bruising, rash, pruritus)

Injury, poisoning and procedural complications

Common

Fall

Dynamic equinus foot deformity due to focal spasticity in ambulant paediatric cerebral palsy patients, two years of age or older

System Organ Class

Frequency

Adverse Drug Reaction

Musculoskeletal and connective tissue disorders

Common

Myalgia, muscular weakness

Renal and urinary disorders

Common

Urinary incontinence

General disorders and administration site conditions

Common

Influenza-like illness, injection site reaction (e.g. pain, erythema, bruising etc.), gait disturbance, fatigue

Uncommon

Asthenia

Injury, poisoning and procedural complications

Common

Fall

Spasmodic torticollis

System Organ Class

Frequency

Adverse Drug Reaction

Nervous system disorders

Common

Headache, dizziness, facial paresis

Eye disorders

Common

Vision blurred, visual acuity reduced

Uncommon

Diplopia, ptosis

Respiratory, thoracic and mediastinal disorders

Common

Dysphonia, dyspnoea

Rare

Aspiration

Gastrointestinal disorders

Very common

Dysphagia, dry mouth

Uncommon

Nausea

Musculoskeletal and connective tissue disorders

Very common

Muscle weakness

Common

Neck pain, musculoskeletal pain, myalgia, pain in extremity, musculoskeletal stiffness

Uncommon

Muscle atrophy, jaw disorder

Dysphagia appeared to be dose related and occurred most frequently following injection into the sternomastoid muscle. A soft diet may be required until symptoms resolve.

These side effects may be expected to resolve within two to four weeks.

Blepharospasm and hemifacial spasm

System Organ Class

Frequency

Adverse Drug Reaction

Nervous system disorders

Common

Facial paresis

Uncommon

VIIth nerve paralysis

Eye disorders

Very common

Ptosis

Common

Diplopia, dry eye, lacrimation increased

Rare

Ophthalmoplegia

Skin and subcutaneous tissue disorders

Common

Eyelid oedema

Rare

Entropion

Side effects may occur due to deep or misplaced injections of Dysport temporarily paralysing other nearby muscle groups.

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 at: www.mhra.gov.uk/yellowcard

4.9 Overdose

Excessive doses may produce distant and profound neuromuscular paralysis. Overdose could lead to an increased risk of the neurotoxin entering the bloodstream and may cause complications associated with the effects of oral botulinum poisoning (e.g. dysphagia and dysphonia). Respiratory support may be required where excessive doses cause paralysis of respiratory muscles. There is no specific antidote; antitoxin should not be expected to be beneficial and general supportive care is advised. In the event of overdose, the patient should be medically monitored for signs and/or symptoms of excessive muscle weakness or muscle paralysis. Symptomatic treatment should be instigated if necessary.

Symptoms of overdose may not present immediately following injection. Should accidental injection or oral ingestion occur, the patient should be medically supervised for several weeks for signs and/or symptoms of excessive muscle weakness or muscle paralysis.

5. Pharmacological properties
5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Other muscle relaxants, peripherally acting agents.

ATC code: M03AX01

Clostridium botulinum type A toxin-haemagglutinin complex blocks peripheral cholinergic transmission at the neuromuscular junction by a presynaptic action at a site proximal to the release of acetylcholine. The toxin acts within the nerve ending to antagonise those events that are triggered by Ca2+ which culminate in transmitter release. It does not affect postganglionic cholinergic transmission or postganglionic sympathetic transmission.

The action of toxin involves an initial binding step whereby the toxin attaches rapidly and avidly to the presynaptic nerve membrane. Secondly, there is an internalisation step in which toxin crosses the presynaptic membrane, without causing onset of paralysis. Finally the toxin inhibits the release of acetylcholine by disrupting the Ca2+ mediated acetylcholine release mechanism, thereby diminishing the endplate potential and causing paralysis.

Recovery of impulse transmission occurs gradually as new nerve terminals sprout and contact is made with the postsynaptic motor endplate, a process which takes 6-8 weeks in the experimental animal.

Focal spasticity in adults

Upper limb:

The efficacy and safety of Dysport for the treatment of upper limb spasticity was evaluated in a randomised, multi-centre, double-blind, placebo-controlled study that included 238 patients (159 Dysport and 79 placebo) with upper limb spasticity who were at least 6 months post-stroke (90%) or post-traumatic brain injury (10%). The primary targeted muscle group (PTMG) was the extrinsic finger flexors (56%), followed by the elbow (28%) and wrist flexors (16%).

The primary efficacy variable was the PTMG muscle tone at week 4, as measured by the Modified Ashworth Scale (MAS), a 5 point scale ranging from 0 (no increase in muscle tone) to 4 (affected in part[s] rigid in flexion or extension) and the first secondary endpoint was the Physician Global Assessment (PGA) of response to treatment (a 9 point scale ranging from -4 [markedly worse], through 0 [no change], to +4 [markedly improved]). The main results achieved at Week 4 and Week 12 are shown below:

Week 4

Week 12

Placebo

 

(N=79)

Dysport

(500U)

(N=80)

Dysport

(1000U)

(N=79)

Placebo

 

(N=79)

Dysport

(500U)

(N=80)

Dysport

(1000U)

(N=79)

LS Mean Change from Baseline in PTMG Muscle Tone on the MAS

-0.3

-1.2**

-1.4**

-0.1

n=75

-0.7**

n=76

-0.8**

n=76

LS Mean PGA of Response to Treatment

0.7

1.4*

1.8**

0.4

n=75

0.5

n=76

1.0*

n=76

LS Mean Change from Baseline in Wrist Flexor Muscle Tone on the MAS

-0.3

n=54

-1.4**

n=57

-1.6**

n=58

-0.3

n=52

-0.7*

n=54

-0.9*

n=56

LS Mean Change from Baseline in Finger Flexor Muscle Tone on the MAS

-0.3

n=70

-0.9*

n=66

-1.2**

n=73

-0.1

n=67

-0.4*

n=62

-0.6*

n=70

LS Mean Change from Baseline in Elbow Flexor Muscle Tone on the MAS

-0.3

n=56

-1.0*

n=61

-1.2**

n=48

-0.3

n=53

-0.7*

n=58

-0.8*

n=46

Mean Change from Baseline in Shoulder Extensors Muscle Tone on the MAS (1)

-0.4

n=12

-0.6

n=7

-0.7

n=6

0.0

n=12

-0.9

n=7

0.0

n=6

*p < 0.05; **p < 0.0001;

LS = Least Square

(1) No statistical tests performed due to low frequency by treatment and placebo groups. There are limited data in patients treated in the shoulder muscles.

The Principal Target of Treatment (PTT) of the Disability Assessment Scale (DAS) was used to investigate the effect of treatment on functional impairment (passive function). Although some improvements in the mean change from baseline at Week 4 in the Dysport groups was observed, it did not reach statistical significance compared to placebo, the proportion of DAS score responders (subjects achieving at least a one grade improvement) for the PTT was significantly higher at the 1000U dose as shown below:

Treatment Group

Week 4

% Responders

Week 12

% Responders

Dysport 500U

50.0

n=80

p = 0.13

41.3

n=76

p = 0.11

Dysport 1000U

62.0

n=78

p = 0.0018

55.7

n=76

p = 0.0004

Placebo

39.2

n=79

32.9

n=75

Domains included in DAS are hygiene, limb position, dressing and pain.

In addition, statistically significant improvements in spasticity (grade and angle) assessed by the Tardieu scale, in the active range of motion of the fingers, wrist or elbow, and in ease of applying a splint by the subject were observed, especially at the 1000U dose. However, there was no effect of treatment shown on the active function, as assessed by the Modified Frenchay Score, and on quality of life EQ5D or SF-36 questionnaires.

Lower limb affecting the ankle joint:

The efficacy and safety of Dysport for the treatment of lower limb spasticity was evaluated in a pivotal randomised, multi-centre, double-blind, placebo-controlled study that included 385 post-stroke and brain injury patients (255 Dysport and 130 placebo-treated subjects) with lower limb spasticity primarily affecting the ankle joint. Two doses of Dysport were evaluated for efficacy; Dysport 1000U (N = 125), Dysport 1500U (N = 128) against Placebo (N =128). The primary target muscle group was the gastrocnemius - soleus complex (GSC). The primary end point was Modified Ashworth Scale (MAS) score assessed at the ankle joint (with the knee extended) at week 4.

Dysport was divided between the GSC and at least one other distal or proximal lower limb muscle according to clinical presentation.

When assessing the primary endpoint, MAS at the ankle with the knee extended (involving all plantar flexors), statistically significant improvement was observed for 1500U. When assessing MAS at the ankle with the knee flexed (involving all plantar flexors except the gastrocnemius), statistically significant improvement was observed for both 1000U and 1500U.

Week 4

Week 12

Placebo

 

(N= 128)

Dysport

(1000U)

(N=125)

Dysport

(1500U)

(N=128)

Placebo

 

(N=128)

Dysport

(1000U)

(N=125)

Dysport

(1500U)

(N=128)

LS Mean Change from Baseline on the MAS (knee extended)

-0.5

-0.6

-0.8*

-0.4

-0.4

-0.6*

LS Mean Change from Baseline on the MAS (knee flexed)

-0.4

-0.7*

-0.8**

-0.3

-0.5*

-0.6*

*p < 0.05; **p < 0.001; LS = Least Square

Spasticity assessment using the Tardieu Scale (TS) showed that there were statistically significant improvements in spasticity grade at Weeks 4 to 20 in the Dysport 1500U group and at Weeks 4 to 12 in the Dysport 1000U group. In addition it showed statistically significant differences in Angle of Catch at Week 1 and 16, favouring the higher dose of Dysport. Based on post hoc analysis due to non-normality of PGA data, Dysport treatment was also associated with statistically significant clinical improvement at both doses as measured by the Physician Global Assessment (PGA) Score.

Numerical improvement in ankle dorsiflexion for the higher Dysport dose was seen with the change peaking at 4 weeks post administration. Additional endpoints such as reduction in pain, using walking aids and quality of life measures did not show statistically significant improvement.

On completion of this study, 345 patients entered an open-label extension study in which re-treatment with Dysport 1000U or 1500U was determined by clinical need. This long term follow up study confirmed a prolonged treatment effect on spasticity related outcome measures following repeated injections. Improvements in efficacy parameters (MAS, PGA and TS) seen after 4 weeks of double blind treatment with Dysport in the lower limb were maintained over repeated treatment.

Improvements in 10-m walking speed (comfortable and maximal, with or without shoes) were observed, which increased with successive treatment cycles. No significant improvements in lower limb pain using the SPIN scale, use of walking aids or quality of life measures were observed.

Blepharospasm

Three Dysport doses were investigated over 1 treatment cycle in a clinical study.

Efficacy was measured by the medians of differences in the Percentage of Normal Activity (PNA) values (derived from the Blepharospasm Disability Scale) between each treatment group and placebo. A dose-dependent improvement in blepharospasm was evident with increasing Dysport dose, with all treatment groups being superior to placebo.

Difference between the median of the changes in PNA values from baseline in the active group and the median of the changes in PNA values from baseline in the placebo group

Visit

Dysport 40U

(N=30)

Dysport 80U

(N=31)

Dysport 120U

(N=31)

Week 4:

31.2 %

41.3 %

48.5 %

Week 8:

36.0 %

48.3 %

55.0 %

Week 12:

36.0 %

36.3 %

50.0 %

Week 16:

10.5 %[a]

24.2 %

31.3 %

[a] p value > 0.001

For the 40 units, 80 units and 120 units Dysport treatment groups, the medians of the changes from baseline in PNA values were statistically significantly higher compared to those in placebo group at weeks 4, 8, and 12.

A statistically significant difference compared to placebo group was also observed for the 80 units and 120 units Dysport treatment groups at week 16, indicating a greater duration of response at the 80 units and 120 units doses.

The incidence of related Treatment Emergent Adverse Events (TEAEs), specifically ptosis, was higher in the Dysport treatment groups than in the placebo treatment group and was dose-dependent with greater incidence seen at higher Dysport doses. See table below:

Statistic

Placebo

(N=26)

Dysport 40U

(N=31)

Dysport 80U

(N=31)

Dysport 120U

(N=31)

Patients with related TEAEs

n (%)

3 (12)

19 (61)

23 (74)

26 (84)

Patients with related eye TEAEs

n (%)

3 (12)

16 (52)

23 (74)

26 (84)

Dynamic equinus foot deformity due to focal spasticity in ambulant paediatric cerebral palsy patients, two years of age or older

A double-blind, placebo-controlled multicentre study (Study Y-55-52120-141) was conducted in children with dynamic equinus foot deformity due to spasticity in children with cerebral palsy. A total of 235 botulinum toxin naïve or non-naïve patients with a Modified Ashworth Score (MAS) of grade 2 or greater were enrolled to receive Dysport 10 units/kg/leg, Dysport 15 units/kg/leg or placebo. Forty one percent of patients were treated bilaterally resulting in a total Dysport dose of either 20 units/kg or 30 units/kg. The primary efficacy variable was the mean change from baseline in MAS in ankle plantar flexors at Week 4. Secondary efficacy variables were the mean Physicians Global Assessment (PGA) score and Mean Goal Attainment Scaling (GAS) score at Week 4. Patients were followed up for at least 12 weeks post-treatment and up to a maximum of 28 weeks. On completion of this study, patients were offered entry into an open-label extension study (Study Y-55-52120-147).

MAS Change from Baseline at Week 4 and week 12, PGA and GAS at Week 4 and Week 12 (ITT Population)

Parameter

Placebo

(N=77)

Dysport

10 U/kg/leg

(N=79)

15 U/kg/leg

(N=79)

LS mean change from baseline in ankle plantar MAS score

Week 4

Week 12

-0.5

-0.5

-0.9 **

-0.8*

-1.0 ***

-1.0 ***

LS mean score for PGA response to treatment [b]

Week 4

Week 12

0.7

0.4

1.5 ***

0.8 *

1.5 ***

1.0 **

LS mean GAS score [a]

Week 4

Week 12

46.2

45.9

51.5 ***

52.5 ***

50.9 **

50.5 *

*p ≤ 0.05; **p ≤ 0.003; ***p ≤ 0.0006 compared to placebo; LS = least square

[a] GAS score measures progress towards goals that were selected at baseline from a list of twelve categories. The five most commonly selected goals were improved walking pattern (70.2%), improved balance (32.3%), decreased frequency of falling (31.1%), decreased frequency of tripping (19.6%) and improved endurance (17.0%)

Improvement in the spasticity of the ankle plantar flexors was observed, as assessed by the Tardieu scale. The spasticity grade (Y) was statistically significantly improved compared to placebo for both the 10 units/kg/leg and 15 units/kg/leg Dysport treatment groups at Week 4 and Week 12, and the angle of catch (Xv3) was significant for the 10 units/kg/leg Dysport group at Week 12 and at both Week 4 and Week 12 for the 15 units/kg/leg Dysport group.

Both Dysport treatment groups, 10 units/kg/leg and 15 units/kg/leg, demonstrated a significant improvement from baseline in the Observational Gait Scale (OGS) overall score at Week 4 when compared to placebo and a statistically significantly higher proportion of patients were treatment responders for initial foot contact on the OGS at Week 4 and Week 12.

Parents completed the condition-specific Module for cerebral palsy for the Paediatric Quality of Life Inventory. There was a statistically significant improvement from baseline in fatigue at Week 12 in the Dysport 10 units/kg/leg and 15 units/kg/leg Dysport treatment groups compared to placebo. No other statistically significant improvements were observed in the other subscales.

On completion of this study, 216 patients entered an open-label extension study (Y-55-52120-147) where they could receive re-treatment based on clinical need. Both distal (gastrocnemius, soleus and tibialis posterior) and proximal (hamstrings and hip adductors) muscles were permitted to be injected, including multilevel injections. Efficacy was observed over repeated treatment sessions for up to 1 year as assessed by MAS, PGA and GAS.

5.2 Pharmacokinetic properties

Pharmacokinetic studies with botulinum toxin pose problems in animals because of the high potency, the minute doses involved, the large molecular weight of the compound and the difficulty of labelling toxin to produce sufficiently high specific activity. Studies using I125 labelled toxin have shown that the receptor binding is specific and saturable, and the high density of toxin receptors is a contributory factor to the high potency. Dose and time responses in monkeys showed that at low doses there was a delay of 2 - 3 days with peak effect seen 5 - 6 days after injection. The duration of action, measured by changes of ocular alignment and muscle paralysis varied between 2 weeks and 8 months. This pattern is also seen in man, and is attributed to the process of binding, internalisation and changes at the neuromuscular junction.

5.3 Preclinical safety data

In a chronic toxicity study performed in rats, up to 12 units/animal, there was no indication of systemic toxicity. Reproductive toxicity studies in pregnant rats and rabbits given Clostridium botulinum type A toxin-haemagglutinin complex by daily intramuscular injection, at doses of 6.6 units/kg (79 units/kg total cumulative dose) and 3.0 units/kg (42 units/kg total cumulative dose) in rats and rabbits respectively, did not result in embryo/fetal toxicity. Implantation losses at maternally toxic doses were observed at higher doses in both species. Clostridium botulinum type A toxin-haemagglutinin complex demonstrated no teratogenic activity in either rats or rabbits and no effects were observed in the pre- and postnatal study on the F1 generation in rats. Fertility of male and female rats was decreased due to reduced mating, secondary to muscle paralysis, at doses of 29.4 units/kg weekly in males and increased implantation loss at 20 units/kg weekly in females (see section 4.6).

In a pivotal single dose study, juveniles showed a slight delay in sexual maturation (not observed in the repeat dose study), an effect associated with decreased body weight, but subsequent mating performance and fertility were unaffected. In a pivotal repeated dose juvenile study, rats treated weekly from the age of weaning on Postnatal Day 21 up to 13 weeks of age comparable to children of 2 years old, to young adulthood (11 administrations over 10 weeks, up to total dose of approximately 33 units/kg) do not show adverse effects on postnatal growth (including skeletal evaluation), reproductive, neurological and neurobehavioral development.

The effects in reproduction, juvenile and chronic toxicity non-clinical studies were limited to changes in injected muscles related to the mechanism of action of Clostridium botulinum type A toxin-haemagglutinin complex.

There was no ocular irritation following administration of Clostridium botulinum type A toxin-haemagglutinin complex into the eyes of rabbits.

6. Pharmaceutical particulars
6.1 List of excipients

Human albumin

Lactose.

6.2 Incompatibilities

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

6.3 Shelf life

Unopened vial:

2 years

Reconstituted solution:

Chemical and physical in-use stability has been demonstrated for 24 hours at 2°C - 8°C.

From a microbiological point of view, unless the method of reconstitution precludes the risk of microbial contamination, 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.

6.4 Special precautions for storage

Unopened vial:

Store in a refrigerator (2°C - 8°C).

Do not freeze.

Reconstituted solution:

For storage conditions after reconstitution of the medicinal product, see section 6.3.

6.5 Nature and contents of container

3 ml vial (type 1 glass) with a stopper (bromobutyl rubber), with an overseal (aluminium), containing 300 units of botulinum toxin type A powder for solution for injection.

Pack sizes of 1 or 2 vials.

Not all pack sizes may be marketed.

6.6 Special precautions for disposal and other handling

When preparing and handling Dysport solutions, the use of gloves is recommended. If Dysport dry powder or reconstituted solution should come into contact with the skin or mucous membranes, they should be washed thoroughly with water.

Instructions for reconstitution

The exposed central portion of the rubber stopper should be cleaned with alcohol immediately prior to piercing the septum. A sterile 23 or 25 gauge needle should be used.

Each vial is for single use only.

Reconstitution instructions are specific for each of the 300 unit vial and the 500 unit vial. These volumes yield concentrations specific for the use for each indication.

Resulting Dose

Unit per ml

Diluent* per

500U vial

Diluent* per

300U vial

500U

200U

100U

1 ml

2.5 ml

5 ml

0.6 ml

1.5 ml

3 ml

*Preservative-free 0.9 % sodium chloride injection

For paediatric cerebral palsy spasticity, which is dosed using unit per body weight, further dilution may be required to achieve the final volume for injection.

Appearance of product after reconstitution:
A clear, colourless solution, free from particulate matter.

Disposal

Immediately after treatment of the patient, any residual Dysport which may be present in either vial or syringe should be inactivated with dilute hypochlorite solution (1 % available chlorine).

Spillage of Dysport should be wiped up with an absorbent cloth soaked in dilute hypochlorite solution.

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

7. Marketing authorisation holder

Ipsen Limited

190 Bath Road

Slough

Berkshire

SL1 3XE

United Kingdom

8. Marketing authorisation number(s)

PL 34926/0014

9. Date of first authorisation/renewal of the authorisation

Date of first authorisation: 05 January 2011

10. Date of revision of the text

27 February 2017

Company contact details

Ipsen Ltd

Company image
Address

190 Bath Road, Slough, Berkshire, SL1 3XE

Fax

+44 (0)1753 627 778

Medical Information e-mail
Telephone

+44 (0)1753 627 777

Medical Information Direct Line

+44 (0)1753 627 777

Customer Care direct line

+44 (0)1753 627 627

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Active ingredients

clostridium botulinum type a toxin-haemagglutinin complex

Legal categories

POM - Prescription Only Medicine

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