Document: spc-doc_PL 06958-0028 change

• spc-doc_PL 06958-0028
• spc-doc_PL 34926-0009
• spc-doc_PL 34926-0015

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NAME OF THE MEDICINAL PRODUCT

Botulinum Toxin Type A powder for solution for injection

2 QUALITATIVE AND QUANTITATIVE COMPOSITION

Per Vial.

Active Constituent

Clostridium botulinum type A toxin-

haemagglutinin complex    500U *

Other Constituents

Albumin solution    125 MCG

Lactose    2.5 MG

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

3 PHARMACEUTICAL FORM

Injection.

4    CLINICAL PARTICULARS

4.1    Therapeutic indications

Botulinum Toxin Type A is indicated for focal spasticity, including the treatment of:

- arm symptoms associated with focal spasticity in conjunction with physiotherapy;

and

- dynamic equinus foot deformity due to spasticity in ambulant paediatric cerebral palsy patients, two years of age or older, only in hospital specialist centres with appropriately trained personnel.

Botulinum Toxin Type A is also indicated for the following treatments:

-    Spasmodic torticollis in adults

-    Blepharospasm in adults

-    Hemifacial spasm in adults

-    The temporary improvement in the appearance of moderate to severe glabellar lines (vertical lines between the eyebrows) seen at frown, in adult patients under 65 years, when the severity of these lines has an important psychological impact on the patient.

4.2 Posology and method of administration

The units of Botulinum Toxin Type A are specific to the preparation and are not interchangeable with other preparations of botulinum toxin type A.

Training: Botulinum Toxin Type A should only be administered by appropriately trained physicians.

Ipsen can facilitate training in administration of Botulinum Toxin Type A injections .

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.

Arm spasticity: Posology

The recommended dose is 1000 units in total, distributed amongst the following five muscles:

Biceps brachii (BB)	Flexor digitorum profundus (FDP)	Flexor digitorum superficialis (FDS)	Flexor carpi ulnaris (FCU)	Flexor carpi radialis FCR)	Total Dose
300-400 units (0.6-0.8 mL)	150 units (0.3 mL)	150-250 units (0.3-0.5 mL)	150 units (0.3 mL)	150 units (0.3 mL)	1,000 units (2.0 mL)

The sites of injection should be guided by standard locations used for electromyography, although actual location of the injection site will be determined by palpation. All muscles except the biceps brachii (BB) should be injected at one site, whilst the biceps should be injected at two sites.

The dose should be lowered if there is evidence to suggest that this dose may result in excessive weakness of the target muscles, such as for patients whose target muscles are small, where the BB muscle is not to be injected or patients who are to be

administered multi-level injections. Clinical improvement may be expected within two weeks after injection. Data on repeated and long term treatment are limited.

Children: The safety and effectiveness of Botulinum Toxin Type A in the treatment of arm spasticity in children have not been demonstrated.

Method of administration

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.

When treating arm spasticity, Botulinum Toxin Type A is reconstituted with 1.0 mL of sodium chloride injection B.P. (0.9%) to yield a solution containing 500 units per mL of .

Botulinum Toxin Type A is administered by intramuscular injection into the five muscles detailed above when treating arm spasticity.

Paediatric cerebral palsy spasticity:

Posology

The initial recommended dose is 20 units/kg body weight given as a divided dose between both calf muscles. If only one calf is affected, a dose of 10 units/kg bodyweight should be used. Consideration should be given to lowering this starting dose if there is evidence to suggest that this dose may result in excessive weakness of the target muscles, such as for patients whose target muscles are small or patients who require concomitant injections to other muscle groups. Following evaluation of response to the starting dose subsequent treatment may be titrated within the range 10 units/kg and 30 units/kg divided between both legs. The maximum dose administered must not exceed 1000 units/patient.

Administration should primarily be targeted to the gastrocnemius, although injections of the soleus and injection of the tibialis posterior should also be considered.

The use of electromyography (EMG) is not routine clinical practice but may assist in identifying the most active muscles.

Clinical improvement may be expected within two weeks after injection. Injections may be repeated approximately every 16 weeks or as required to maintain response, but not more frequently than every 12 weeks.

Method of administration

When treating paediatric cerebral palsy spasticity, Botulinum Toxin Type A is reconstituted with 1.0 mL of sodium chloride injection B.P. (0.9%) to yield a solution containing 500 units per mL of Botulinum Toxin Type A. Botulinum Toxin Type A is administered by intramuscular injection into the calf muscles when treating spasticity.

Spasmodic torticollis:

Posology

Adults and elderly: The doses recommended for torticollis are applicable to adults of all ages providing the adults are of normal weight with no evidence of low neck muscle mass. A reduced 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 to 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. This may be followed by bilateral trapezius injections (up to 250 units per muscle) after 6 weeks, if there is insufficient response. 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. Doses above 1000 units are not recommended.

The relief of symptoms of torticollis may be expected within a week after the injection. Injections should be repeated approximately every 12 weeks or as required to prevent recurrence of symptoms.

Children: The safety and effectiveness of Botulinum Toxin Type A in the treatment of spasmodic torticollis in children have not been demonstrated.

Method of administration

When treating spasmodic torticollis Botulinum Toxin Type A is reconstituted with 1.0 mL of sodium chloride injection B.P. (0.9%) to yield a solution containing 500 units per mL of Botulinum Toxin Type A. Botulinum Toxin Type A is administered by intramuscular injection as above when treating spasmodic torticollis.

Blepharospasm and hemifacial spasm

Posology

Adults and elderly: In the treatment of bilateral blepharospasm the recommended initial dose is 120 units per eye.

Injection of 0.1 mL (20 units) should be made medially and of 0.2.mL (40 units) should be made laterally into the junction between the preseptal and orbital parts of both the upper and lower orbicularis oculi muscles of each eye.

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. 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 12 weeks or as required to prevent recurrence of symptoms. On such subsequent administrations the dose may need to be reduced to 80 units per eye - viz -: 0.1 mL (20 units) medially and 0.1 mL (20 units) laterally above and below each eye in the manner previously described. The dose may be further reduced to 60 units per eye by omitting the medial lower lid injection.

0.1 mL 0.2 mL

0.1 mL    0.2 mL

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 Botulinum Toxin Type A in the treatment of blepharospasm and hemifacial spasm in children have not been demonstrated.

Method of administration

When treating blepharospasm and hemifacial spasm Botulinum Toxin Type A is reconstituted with 2.5 mL of sodium chloride injection BP (0.9%) to yield a solution containing 200 units per mL of Botulinum Toxin Type A. Botulinum Toxin Type A 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.

Glabellar Lines:

Posology and method of administration

Once reconstituted, Botulinum Toxin Type A should only be used to treat a single patient, during a single session.

Prior to injection, the product should be reconstituted, instructions for which are given in Section 6.6.

Remove any make-up and disinfect the skin with a local antiseptic.

Intramuscular injections should be performed at right angles to the skin using a sterile 29-30 gauge needle.

The recommended dose is 50 Speywood units (0.25 ml of reconstituted solution) of Botulinum Toxin Type A to be divided into 5 injection sites, 10 Speywood units (0.05 ml of reconstituted solution) are to be administered intramuscularly into each of the 5 sites: 2 injections into each corrugator muscle and one into the procerus muscle near the nasofrontal angle as shown below:

The anatomical landmarks can be more readily identified if observed and palpated at maximal frown. Before injection, place the thumb or index finger firmly below the orbital rim in order to prevent extravasation below the orbital rim. The needle should be pointed upward and medially during the injection. In order to reduce the risk of ptosis, avoid injections near the levator palpebrae superioris muscle, particularly in patients with larger brow-depressor complexes (depressor supercilii). Injections in the corrugator muscle must be made into the central part of that muscle, at least 1 cm above the orbital rim.

The treatment interval depends on the individual patient’s response after assessment. In clinical studies, an optimal effect was demonstrated for up to 4 months after injection. Some patients were still responders at 5 months. Treatment interval 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 treatment failure after the first treatment session, the following approaches may be considered:

• Analysis of the causes of failure, e.g. incorrect muscles injected, injection technique, and formation of toxin-neutralising antibodies;

•    Re-evaluation of the relevance of treatment with botulinum toxin A

Use in children

The safety and effectiveness of Botulinum Toxin Type A in treating glabellar lines in individuals under 18 years of age have not been demonstrated.

4.3 Contraindications

Botulinum Toxin Type A is contraindicated:

In individuals with known hypersensitivity to any components of Botulinum Toxin Type A or to any of the excipients of the formulation.

In the presence of infection at the proposed injection sites;

In the presence of myasthenia gravis, Eaton Lambert syndrome or Amyotrophic lateral sclerosis.

4.4 Special warnings and precautions for use

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

Patients with a history of dysphagia and aspiration should be treated with extreme caution. Swallowing or breathing disorders can worsen due to the spread of toxin distant from the site of administration. Aspiration has occurred in rare cases and this is a risk when treating patients who have a chronic respiratory disorder. Botulinum Toxin Type A should be used under specialist supervision in all such patients and should only be used if the benefit of treatment is considered to outweigh the risk.

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 in death very rarely.

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

Antibody formation to botulinum toxin has been noted rarely in patients receiving Botulinum Toxin Type A. Clinically, neutralising antibodies have been detected by a substantial deterioration in response to therapy and /or a need for consistently increasing doses.

For the treatment of cerebral palsy in children, Botulinum Toxin Type A should only be used in children over 2 years of age.

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

Botulinum Toxin Type A should only be used to treat a single patient, during a single session. Specific precautions must be taken for 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).

When treating glabellar lines, it is essential to study the patient’s facial anatomy prior to administering. Facial asymmetry, ptosis, excessive dermatochalasis, scarring and any alterations to this anatomy, as a result of previous surgical interventions should be taken into consideration. Caution should be taken when the targeted muscle shows excessive weakness or atrophy.

The effect of administering different botulinum neurotoxins during the course of treatment with Botulinum Toxin Type A is unknown and must be avoided.

As with any intramuscular injection, Botulinum Toxin Type A should be used only where strictly necessary in patients with prolonged bleeding times.

This product contains a small amount of human albumin. The risk of transmission of viral infection cannot be excluded with absolute certainty following the use of human blood or blood products.

4.5 Interaction with other medicinal products and other forms of interaction

The effects of botulinum toxin may be enhanced by drugs interfering directly or indirectly with the neuromuscular function ( e.g. aminoglycosides, curare-like nondepolarising blockers) and such drugs should be used with caution in patients treated with botulinum toxin.

4.6 Pregnancy and lactation

Teratological and other reproductive studies have not been performed with Botulinum Toxin Type A. The safety of its use in pregnant or lactating women has not been demonstrated.

Botulinum Toxin Type A should not be used in pregnant or lactating women, unless clearly necessary.

4.7 Effects on ability to drive and use machines

Botulinum Toxin Type A may impair the ability to drive or operate machinery in case of adverse reactions such as muscle weakness and eye disorders (diplopia, blurred vision, eyelid ptosis).

4.8 Undesirable effects

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

Side effects related to spread of toxin distant from the site of administration have been reported ( exaggerated muscle weakness, dysphagia, aspiration/aspiration pneumonia, with fatal outcome in some very rare cases). ( See section 4.4).

General

In the clinical trial programme, approximately 28% of the patients treated with Dysport experienced an adverse event.

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

Nervous system disorders

Rare: Neuralgic amyotrophy

Skin and subcutaneous tissue disorders Uncommon: Itching

Rare: Skin rashes

General disorders and administration site conditions

Common: Generalised weakness, fatigue, flu-like syndrome, pain / bruising at injection site.

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

Arm spasticity

Gastrointestinal disorders Common: Dysphagia

Musculoskeletal and connective tissue disorders Common: Arm muscle weakness

Injury, poisoning and procedural complications Common: Accidental injury/falls

Paediatric cerebral palsy spasticity

Gastrointestinal disorders

Common: Diarrhoea, vomiting

Musculoskeletal and connective tissue disorders Common: Leg muscle weakness

Renal and urinary disorders

Common: Urinary incontinence

General disorders and administration site conditions Common: Abnormal gait

Injury, poisoning and procedural complications Common: Accidental injury due to falling

Accidental injury due to falling and abnormal gait may have been due to the overweakening of the target muscle and / or the local spread of Botulinum Toxin Type A to other muscles involved in ambulation and balance.

Spasmodic torticollis

Nervous system disorders Common: Dysphonia Uncommon: Headache

Eye disorders

Uncommon: Diplopia, blurred vision

Respiratory, thoracic and mediastinal disorders Rare: Respiratory disorders

Gastrointestinal disorders

Very common: Dysphagia Uncommon: Dry mouth

Musculoskeletal and connective tissue disorders Common: Neck muscle weakness

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

Nervous system disorders

Common: Facial muscle weakness Uncommon: Facial nerve paresis

Eye disorders

Very common: Ptosis

Common: Diplopia, dry eyes, tearing

Rare: Ophthalmoplegia

Skin and subcutaneous tissue disorders Common: Eyelid oedema

Rare: Entropion

Side effects may occur due to deep or misplaced injections of Botulinum Toxin Type A temporarily paralysing other nearby muscle groups.

Glabellar Lines

Nervous system disorders	Very Common Headache Common Facial paresis (predominantly describes brow paresis) Uncommon Dizziness
Eye disorders	Common Asthenopia, Ptosis, Eyelid oedema, Lacrimation increase, Dry eye, Muscle twitching (twitching of muscles around the eyes) Uncommon Visual disturbances, Vision blurred, Diplopia Rare Eye movement disorder
Skin and subcutaneous tissue disorders	Uncommon Pruritus, Rash Rare Urticaria
General disorders and administration site conditions	Very Common Injection site reactions (e.g. erythema, oedema, irritation, rash, pruritus, paraesthesia, pain, discomfort, stinging and bruising)
Immune system disorders	Uncommon Hypersensitivity

Post-marketing experience

The profile of adverse reactions reported to the Company during postmarketing use reflects the pharmacology of the product and those seen during clinical trials. In addition, hypersensitivity reactions have been reported.

4.9 Overdose

Excessive doses may produce distant and profound neuromuscular paralysis. 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. 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. deglutition and dysphonia).

Symptomatic treatment should be instituted if necessary. In the event of an overdose the patient should be medically monitored for several weeks for symptoms of systemic weakness or muscle paralysis.

5.1 Pharmacodynamic properties

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 post synaptic motor endplate, a process which takes 6 - 8 weeks in the experimental animal.

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

There is no further pre-clinical information relevant to the prescribing physician that has not been included in other sections of the Summary of Product Characteristics.

6    PHARMACEUTICAL PARTICULARS

6.1    List of excipients

Albumin and Lactose.

6.2 Incompatibilities

None known.

6.3 Shelf life

The shelf life of the packaged product is 24 months at 2-8°C.

The product may be stored for up to 8 hours at 2-8°C following reconstitution.

Since the product does not contain an antimicrobial agent, from a microbiological point of view, it is recommended that the product should be used immediately following reconstitution.

6.4 Special precautions for storage

Unopened vials must be maintained at temperatures between 2°C and 8°C. Botulinum Toxin Type A must be stored in a refrigerator at the hospital where the injections are to be carried out and should not be given to the patient to store.

Reconstituted Botulinum Toxin Type A may be stored in a refrigerator (2-8°C) for up to 8 hours prior to use. Botulinum Toxin Type A should not be frozen.

6.5 Nature and contents of container

Nature of container/closure:

Type 1 glass vials 3 mL capacity. 13 mm chlorbutyl freeze-drying closures oversealed by 13 mm aluminium overseals with centre hole, crimped over.

Contents of container:

A white lyophilised powder for reconstitution.

6.6 Special precautions for disposal

Immediately after treatment of the patient, any residual Botulinum Toxin Type A which may be present in either vial or syringe should be inactivated with dilute hypochlorite solution (1% available chlorine). Thereafter, all items should be disposed of in accordance with standard hospital practice.

Spillage of Botulinum Toxin Type A should be wiped up with an absorbent cloth soaked in dilute hypochlorite solution.