BOTOX 200 Allergan Units Powder for solution for injection
Summary of Product Characteristics Updated 18-Jun-2024 | AbbVie Ltd
1. Name of the medicinal product
BOTOX
200 Allergan Units
Powder for solution for injection
2. Qualitative and quantitative composition
Botulinum toxin* type A, 200 Allergan Units/vial.
* from Clostridium botulinum
Botulinum toxin units are not interchangeable from one product to another.
For a full list of excipients, see section 6.1.
3. Pharmaceutical form
Powder for solution for injection.
BOTOX product appears as a thin white deposit that may be difficult to see on the base of the vial.
4. Clinical particulars
4.1 Therapeutic indications
BOTOX is indicated for:
Neurologic disorders:
BOTOX is indicated for the symptomatic treatment of:
• treatment of focal spasticity, including:
elbow, wrist and hand in paediatric cerebral palsy patients, two years of age or older as an adjunct to rehabilitative therapy
ankle and foot in ambulant paediatric cerebral palsy patients, two years of age or older as an adjunct to rehabilitative therapy.
upper limb spasticity in adults
ankle and foot disability due to lower limb spasticity in adults
• symptomatic relief of blepharospasm, hemifacial spasm and idiopathic cervical dystonia (spasmodic torticollis)
• prophylaxis of headaches in adults with chronic migraine (headaches on at least 15 days per month of which at least 8 days are with migraine)
Bladder disorders:
• management of bladder dysfunctions in adult patients who are not adequately managed with anticholinergics
overactive bladder with symptoms of urinary incontinence, urgency and frequency
neurogenic detrusor overactivity with urinary incontinence due to subcervical spinal cord injury (traumatic or non-traumatic), or multiple sclerosis
Skin and skin appendage disorders
• management of severe hyperhidrosis of the axillae, which does not respond to topical treatment with antiperspirants or antihidrotics
• temporary improvement in the appearance of:
moderate to severe vertical lines between the eyebrows seen at maximum frown (glabellar lines) and/or,
moderate to severe lateral canthal lines (crow's feet lines) seen at maximum smile and/or,
moderate to severe forehead lines seen at maximum eyebrow elevation when the severity of the facial lines has an important psychological impact in adult patients.
4.2 Posology and method of administration
Posology
Botulinum toxin units are not interchangeable from one product to another. Doses recommended in Allergan Units are different from other botulinum toxin preparations.
Elderly patients
Dosages for elderly patients are the same as for younger adults. Initial dosing should begin at the lowest recommended dose for the specific indication. Elderly patients with significant medical history and concomitant medications should be treated with caution.
There is limited data in patients older than 65 years managed with BOTOX for urinary incontinence with neurogenic detrusor overactivity, ankle and foot disability due to lower limb spasticity, and for facial lines (see section 5.1).
Paediatric population
The safety and efficacy of BOTOX in indications other than those described for the paediatric population in section 4.1 have not been established. No recommendation on posology can be made for indications other than paediatric focal spasticity associated with cerebral palsy. For this indication, BOTOX should only be administered by appropriately qualified healthcare practitioners who are experienced in the assessment and treatment of paediatric focal spasticity and as part of a structured program of rehabilitation.
Currently available data in paediatric populations are described in section 4.2, 4.4, 4.8 and 5.1, as shown in the table below.
| • Focal spasticity in paediatric patients | 2 years (see section 4.2, 4.4 and 4.8) |
| • Blepharospasm/Hemifacial spasm/ Idiopathic Cervical dystonia | 12 years (see section 4.4 and 4.8) |
| • Primary hyperhidrosis of the axillae | 12 years (limited experience in adolescents between 12 and 17 years, see sections 4.4, 4.8 and 5.1) |
| • Paediatric neurogenic detrusor overactivity | 5 - 17 years (see section 4.8 and 5.1) |
| • Paediatric overactive bladder | 12 - 17 years (see section 4.8 and 5.1) |
Method of Administration
BOTOX should only be administered by an appropriately qualified healthcare practitioner with expertise in the treatment of the relevant indication and the use of the required equipment, in accordance with national guidelines.
This product is for single use only and any unused solution should be discarded. The most appropriate vial size should be selected for the indication.
An injection volume of approximately 0.1 ml is recommended. A decrease or increase in the BOTOX dose is possible by administering a smaller or larger injection volume. The smaller the injection volume the less discomfort and less spread of toxin in the injected muscle occurs. This is of benefit in reducing effects on nearby muscles when small muscle groups are being injected.
For instructions on reconstitution of the powder for solution for injection, handling and disposal of vials please refer to section 6.6.
Refer to specific guidance for each indication described below.
Generally valid optimum dose levels and number of injection sites per muscle have not been established for all indications. In these cases, individual treatment regimens should therefore be drawn up by an appropriately qualified healthcare practitioner. Optimum dose levels should be determined by titration but the recommended maximum dose should not be exceeded.
NEUROLOGIC DISORDERS
Focal spasticity of the upper limb in paediatric patients
| Recommended needle: | Appropriately sized sterile needle. Needle length should be determined based on muscle location and depth. |
| Administration guidance: | Localisation of the involved muscles with techniques such as needle electromyographic (EMG) guidance, nerve stimulation, or ultrasound is recommended. Prior to injection, local anaesthesia or local anaesthesia in combination with minimal or moderate sedation may be used, per local site practice. The safety and efficacy of BOTOX in the treatment of paediatric spasticity has not been evaluated under general anaesthesia or deep sedation/analgesia.
The following diagram indicates the injection sites for paediatric upper limb spasticity: |
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| Recommended dose: | The recommended dose for treating paediatric upper limb spasticity is 3 Units/kg to 6 Units/kg body weight divided among the affected muscles.
BOTOX Dosing by Muscle for Paediatric Upper Limb Spasticity |
| Muscles Injected | BOTOX 3 Units/kg (maximum Units per muscle) | BOTOX 6 Units/kg (maximum Units per muscle) | Number of Injection Sites |
| Elbow Flexor Muscles | |||
| Biceps | 1.5 Units/kg (50 Units) | 3 Units/kg (100 Units) | 4 |
| Brachialis | 1 Unit/kg (30 Units) | 2 Units/kg (60 Units) | 2 |
| Brachioradialis | 0.5 Units/kg (20 Units) | 1 Unit/kg (40 Units) | 2 |
| Wrist Muscles | |||
| Flexor carpi radialis | 1 Unit/kg (25 Units) | 2 Units/kg (50 Units) | 2 |
| Flexor carpi ulnaris | 1 Unit/kg (25 Units) | 2 Units/kg (50 Units) | 2 |
| Finger Muscles | |||
| Flexor digitorum profundus | 0.5 Units/kg (25 Units) | 1 Unit/kg (50 Units) | 2 |
| Flexor digitorum sublimis | 0.5 Units/kg (25 Units) | 1 Unit/kg (50 Units) | 2 |
| Maximum dose: | The total dose of BOTOX administered per treatment session in the upper limb should not exceed 6 Units/kg body weight or 200 Units, whichever is lower. If it is deemed appropriate by the treating healthcare practitioner, 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. When treating the upper and lower limbs in combination, the total dose should not exceed the lower of 10 Units/kg body weight or 340 Units, in a 12-week interval. |
| Additional information: | Treatment with BOTOX is not intended to substitute for usual standard of care rehabilitation regimens. Clinical improvement generally occurs within the first two weeks after injection. Repeat treatment should be administered when the clinical effect of a previous injection diminishes but not more frequently than every 12 weeks. |
| Focal spasticity of the lower limb in paediatric patients | |
| Recommended needle: | Appropriately sized sterile needle. Needle length should be determined based on muscle location and depth. |
| Administration guidance: | Localisation of the involved muscles with techniques such as needle electromyographic guidance, nerve stimulation, or ultrasound is recommended. Prior to injection, local anaesthesia or local anaesthesia in combination with minimal or moderate sedation may be used, per local site practice. The safety and efficacy of BOTOX in the treatment of paediatric spasticity has not been evaluated under general anaesthesia or deep sedation/analgesia. The following diagram indicates the injection sites for paediatric lower limb spasticity: |
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| Recommended dose: | The recommended dose for paediatric lower limb spasticity is 4 Units/kg to 8 Units/kg body weight divided among the affected muscles. BOTOX Dosing by Muscle for Paediatric Lower Limb Spasticity |
| Muscles Injected | BOTOX 4 Units/kg (maximum Units per muscle) | BOTOX 8 Units/kg (maximum Units per muscle) | Number of Injection Sites |
| Gastrocnemius medial head | 1 Unit/kg (37.5 Units) | 2 Units/kg (75 Units) | 2 |
| Gastrocnemius lateral head | 1 Unit/kg (37.5 Units) | 2 Units/kg (75 Units) | 2 |
| Soleus | 1 Unit/kg (37.5 Units) | 2 Units/kg (75 Units) | 2 |
| Tibialis Posterior | 1 Unit/kg (37.5 Units) | 2 Units/kg (75 Units) | 2 |
| Maximum dose: | The total dose of BOTOX administered per treatment session in the lower limb should not exceed 8 Units/kg body weight or 300 Units, whichever is lower. If it is deemed appropriate by the treating healthcare practitioner, 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. When treating both lower limbs or the upper and lower limbs in combination, the total dose should not exceed the lower of 10 Units/kg body weight or 340 Units, in a 12-week interval. |
| Additional information: | Treatment with BOTOX is not intended to substitute for usual standard of care rehabilitation regimens. Clinical improvement generally occurs within the first two weeks after injection. Repeat treatment should be administered when the clinical effect of a previous injection diminishes but not more frequently than every 12 weeks. |
| Focal upper limb spasticity in adults | |
| 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. The following diagram indicates the injection sites for adult upper limb spasticity: |
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| Recommended dose: | The recommended dose for treating adult upper limb spasticity is up to 400 Units divided among the affected muscles as listed in the following table. 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. |
| Muscle | Recommended Dose; Number of Sites |
| Shoulder* Pectoralis major Teres major Latissimus dorsi | 75 – 125 Units; 3 sites 30 – 50 Units; 2 sites 45 – 75 Units; 3 sites |
| Elbow Biceps brachii Brachioradialis Brachialis | 70 Units; 2 sites 45 Units; 1 site 45 Units; 1 site |
| Forearm Pronator quadratus Pronator teres | 10 – 50 Units; 1 site 15 – 25 Units; 1 site |
| Wrist Flexor carpi radialis Flexor carpi ulnaris | 15 – 60 Units; 1-2 sites 10 – 50 Units; 1-2 sites |
| Fingers/Hand Flexor digitorum profundus Flexor digitorum sublimis/superficialis Lumbricals** Interossei** | 15 – 50 Units; 1-2 sites 15 – 50 Units; 1-2 sites 5 – 10 Units;1 site 5 – 10 Units;1 site |
| Thumb Adductor pollicis Flexor pollicis longus Flexor pollicis brevis Opponens pollicis | 20 Units; 1-2 sites 20 Units; 1-2 sites 5 – 25 Units; 1 site 5 – 25 Units; 1 site |
*When injecting the shoulder muscles in combination, the recommended maximum dose is 250 U.
**When injecting both lumbricals and/or interossei, the recommended maximum dose is 50 U per hand.
| Maximum dose: | 400 Units in total |
| Additional information: | If it is deemed appropriate by the treating healthcare practitioner, 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 in adults | |
| 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. The following diagrams indicate the injection sites for adult lower limb spasticity: |
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| 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 healthcare practitioner, 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: |
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| 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 naï ve 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. The following diagrams indicate the injection sites: |
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| 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. The following diagrams indicate recommended muscle groups for optional additional injections: | |
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| 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 sites*) |
| Corrugator** | 10 Units (2 sites) |
| Procerus | 5 Units (1 site) |
| Frontalis** | 20 Units (4 sites) |
| Temporalis** | 40 Units (8 sites) up to 50 Units (up to 10 sites) |
| Occipitalis** | 30 Units (6 sites) up to 40 Units (up to 8 sites) |
| Cervical Paraspinal Muscle Group** | 20 Units (4 sites) |
| Trapezius** | 30 Units (6 sites) up to 50 Units (up to 10 sites) |
| Total Dose Range: | 155 Units to 195 Units 31 to 39 sites |
*1 IM injection site = 0.1 ml = 5 Units BOTOX
**Dose 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. |
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| 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 healthcare practitioner 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. |
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| 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. |
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| 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. |
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| 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.
In treating paediatric patients, including when treating for multiple indications, the maximum cumulative dose should not exceed the lower of 10 Units/kg body weight or 340 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 naï ve patients should begin with the lowest recommended dose for the specific indication.
This medicinal product contains less than 1 mmol sodium (23 mg) per vial, i.e. essentially “ sodium free” .
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 exercised 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.
Traceability
In order to improve the traceability of biological medicinal products, the name and the batch number of the administered product should be clearly recorded.
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 in adult and paediatric 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 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 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% patients with blepharospasm, 28% with cervical dystonia, 8% with paediatric spasticity, 11% with primary hyperhidrosis of the axillae, 9% in adults with focal spasticity of the upper limb, 11% in adults with focal spasticity of the lower limb, 26% with overactive bladder, 32% in adults with neurogenic detrusor overactivity and 6.2% in paediatric patients 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); Not known (cannot be estimated from the available data).
NEUROLOGIC DISORDERS
Focal spasticity of the upper limb in paediatric patients
| System Organ Class | Preferred Term | Frequency |
| Infections and infestations | Upper respiratory tract infection | Common |
| Gastrointestinal disorders | Nausea | Common |
| Musculoskeletal and connective tissue disorders | Muscular weakness | Common |
| General disorders and administration site conditions | Injection site pain | Common |
Focal spasticity of the lower limb in paediatric patients
| System Organ Class | Preferred Term | Frequency |
| Skin and subcutaneous tissue disorders | Rash | Common |
| Musculoskeletal and connective tissue disorders | Muscular weakness | Uncommon |
| General disorders and administration site conditions | Gait disturbance, injection site pain, | Common |
| Injury, poisoning and procedural complications | Ligament sprain, skin abrasion | Common |
Focal upper limb spasticity in adult patients
| System Organ Class | Preferred Term | Frequency |
| Gastrointestinal disorders | Nausea | Common |
| Musculoskeletal and connective tissue disorders | Pain in extremity, muscular weakness | Common |
| General disorders and administration site conditions | Fatigue, peripheral oedema | Common |
No change was observed in the overall safety profile with repeat dosing.
Injection of BOTOX for spasticity of the upper limb in patients with decreased pulmonary function has been associated with small but statistically significant decreases in forced vital capacity (FVC) and/or forced expiratory volume 1 second (FEV1) that were subclinical and were not correlated with any adverse clinical pulmonary reactions.
Focal lower limb spasticity in adult patients
| 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 |