(in kuh BOT yoo lin num TOKS in aye)
- Botulinum Toxin Type A
- NT 201
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution Reconstituted, Intramuscular [preservative free]:
Xeomin: 50 units (1 ea); 100 units (1 ea); 200 units (1 ea) [latex free; contains albumin human]
Brand Names: U.S.
- Neuromuscular Blocker Agent, Toxin
- Ophthalmic Agent, Toxin
IncobotulinumtoxinA is a neurotoxin produced from Clostridium botulinum that inhibits acetylcholine release from peripheral cholinergic nerve endings. Inhibition occurs sequentially via binding and internalization of the neurotoxin into presynaptic cholinergic nerve terminals, translocation to the nerve terminal cytosol, and enzymatic cleavage of SNAP25, a protein necessary for acetylcholine release. Inhibition of acetylcholine release at the neuromuscular junction produces a state of denervation. Muscle inactivation persists until new fibrils grow from the nerve and form junction plates on new areas of the muscle-cell walls.
Not expected to be present in peripheral blood at recommended doses following IM injection
Onset of Action
Improvement: ~4 to 7 days
Duration of Action
~3 to 4 months
Use: Labeled Indications
Blepharospasm: Treatment of adults with blepharospasm in patients previously treated with onabotulinumtoxinA (Botox).
Cervical dystonia: Treatment of adults with cervical dystonia in both botulinum toxin-naïve and previously treated patients.
Glabellar lines: Temporary improvement in the appearance of moderate to severe glabellar lines associated with corrugator and/or procerus muscle activity in adult patients.
Upper limb spasticity: Treatment of upper limb spasticity in adult patients.
Cervical dystonia: Treatment of cervical dystonia (spasmodic torticollis) in adults.
Hypertonicity disorders: Treatment of hypertonicity disorders of the seventh nerve (eg, blepharospasm, hemifacial spasm) in adults.
Upper limb spasticity: Treatment of poststroke spasticity of upper limb(s) in adults.
Xeomin Cosmetic: Glabellar lines: Temporary improvement in the appearance of moderate to severe glabellar lines in adults.
Off Label Uses
Sialorrhea (drooling) (adults)
The use of botulinum toxin A for decreasing or controlling sialorrhea has demonstrated benefit in randomized controlled trials and meta-analyses in patients with various neurological conditions. EFNS guidelines on the clinical management of ALS recommend botulinum toxin A in patients refractory to first-line therapy. An AAN report classifies botulinum toxin A as probably safe and effective in Parkinson-related sialorrhea. Additional study is needed to determine the expected duration of response, potential candidates, optimal dosing regimens, and standardization of injection procedures.
Hypersensitivity to botulinum toxin or any component of the formulation; infection at the proposed injection site(s)
Canadian labeling: Additional contraindications (not in US labeling): Generalized disorders of muscle activity (eg, myasthenia gravis, Lambert-Eaton syndrome)
US labeling: Initial: Total dose should be the same as previously administered onabotulinumtoxinA dose. If prior onabotulinumtoxinA dose is not known: 1.25 to 2.5 units/injection site (maximum initial dose: 35 units/eye or 70 units/both eyes). Number and location of injection sites based on disease severity and previous dose/response to onabotulinumtoxinA (in clinical trials, a mean number of 6 injections per eye were administered). Cumulative dose should not exceed 35 units/eye or 70 units/both eyes administered no more frequently than every 3 months.
Canadian labeling: Initial: 1.25 to 2.5 units/injection site (maximum initial dose: 25 units/eye for treatment-naïve patients; 35 units/eye for patients previously receiving unknown dose). Titrate dose and interval for maximum patient benefit. Total dose should not exceed 100 units per treatment session. Administer no more frequently than every 3 months.
Cervical dystonia: IM:
US labeling: Initial total dose: 120 units (in clinical trials, similar efficacy was noted with initial total doses of 120 and 240 units and between treatment experienced and treatment naïve patients). Dose and number of injection sites should be individualized based on prior treatment, response, duration of effect, adverse events, number/location of muscle(s) to be treated and disease severity. In clinical trials most patients received a total of 2 to 10 injections into treated muscles. Administer no more frequently than every 3 months. Maximum cumulative dose per treatment session: 400 units.
Canadian labeling: Usual total dose does not exceed 200 units (maximum: 300 units; maximum dose per injection site: 50 units); administer no more frequently than every 3 months
Reduction of glabellar lines: IM: Inject 4 units into each of the 5 sites (2 injections in each corrugator muscle and 1 injection in the procerus muscle) for a total dose of 20 units per treatment session. Administer no more frequently than every 3 months.
Upper limb spasticity: IM:
US labeling: Initiate dosing at the low end of the dosing range and titrate as clinically indicated. Base dosage, frequency and number of injection sites on size, number and location of muscles to be treated, severity of spasticity, presence of local muscle weakness, patient’s response to previous treatment and adverse event history. Administer no more frequently than every 3 months. Maximum cumulative dose per treatment session: 400 units.
Clenched fist: Flexor digitorum superficialis or flexor digitorum profundus: 25 to 100 units divided into 2 injection sites
Flexor carpi radialis: 25 to 100 units divided into 1 to 2 injection sites
Flexor carpi ulnaris: 20 to 100 units divided into 1 to 2 injection sites
Brachioradialis: 25 to 100 units divided into 1 to 3 injection sites
Biceps: 50 to 200 units divided into 1 to 4 injection sites
Brachialis: 25 to 100 units divided into 1 to 2 injection sites
Pronator quadratus: 10 to 50 units in 1 injection
Pronator teres: 25 to 75 units divided into 1 to 2 injections
Flexor pollicis longus: 10 to 50 units in 1 injection
Adductor pollicis: 5 to 30 units in 1 injection
Flexor pollicis brevis/opponens pollicis: 5 to 30 units in 1 injection
Canadian labeling: Initiate dosing at the low end of the dosing range and titrate as clinically indicated. Administer no more frequently than every 3 months. Total dose should not exceed 400 units in a treatment session.
Flexed wrist: Total initial dose 90 units
Flexor carpi radialis: Initial dose 50 units; subsequent dose range 25 to 100 units divided into 1 to 2 injection sites
Flexor carpi ulnaris: Initial dose 40 units; subsequent dose range 20 to 100 units divided into 1 to 2 injection sites
Clenched fist: Total initial dose 80 units
Flexor digitorum superficialis: Initial dose 40 units; subsequent dose range 40 to 100 units divided into 2 injection sites
Flexor digitorum profundus: Initial dose 40 units; subsequent dose range 40 to 100 units divided into 2 injection sites
Flexed elbow: Total initial dose 130 to 190 units
Brachioradialis: Initial dose 60 units; subsequent dose range 25 to 100 units divided into 1 to 3 injection sites
Biceps: Initial dose 80 units; subsequent dose range 75 to 200 units divided into 1 to 4 injection sites
Brachialis: Initial dose 50 units; subsequent dose range 25 to 100 units divided into 1 to 2 injection sites
Pronated forearm: Total initial dose 25 to 65 units
Pronator quadratus: Initial dose 25 units; subsequent dose range 10 to 50 units in 1 injection
Pronator teres: Initial dose 40 units; subsequent dose range 25 to 75 units divided into 1 to 2 injections
Thumb-in-palm: Total initial dose 10 to 40 units
Flexor pollicis longus: Initial dose 20 units; subsequent dose range 10 to 50 units in 1 injection
Adductor pollicis: Initial dose 10 units; subsequent dose range 5 to 30 units in 1 injection
Flexor pollicis brevis/opponens pollicis: Initial dose 10 units; subsequent dose range 5 to 30 units in 1 injection
Refer to adult dosing. Initiate therapy at lowest recommended dose.
Dosing: Renal Impairment
There are no dosage adjustments provided in manufacturer's labeling.
Dosing: Hepatic Impairment
There are no dosage adjustments provided in manufacturer's labeling.
Using a 20 to 27 gauge short bevel needle, reconstitute with sterile, preservative free 0.9% sodium chloride. Gently inject saline into vial and rotate carefully swirling and inverting/flipping vial to mix. Do not shake vigorously. Do not use if solution is cloudy or contains particulate matter.
50 unit vials: May be reconstituted with 0.25 mL of diluent to obtain concentration of 20 units per 0.1 mL; 0.5 mL of diluent to obtain concentration of 10 units per 0.1 mL; 1 mL of diluent to obtain concentration of 5 units per 0.1 mL; 1.25 mL of diluent to obtain concentration of 4 units per 0.1 mL; 2 mL of diluent to obtain concentration of 2.5 units per 0.1 mL; 2.5 mL of diluent to obtain concentration of 2 units per 0.1 mL; 4 mL of diluent to obtain concentration of 1.25 units per 0.1 mL; 5 mL of diluent to obtain concentration of 1 unit per 0.1 mL
100 unit vials: May be reconstituted with 0.5 mL of diluent to obtain concentration of 20 units per 0.1 mL; 1 mL of diluent to obtain concentration of 10 units per 0.1 mL; 1.25 mL of diluent to obtain concentration of 8 units per 0.1 mL; 2 mL of diluent to obtain concentration of 5 units per 0.1 mL; 2.5 mL of diluent to obtain concentration of 4 units per 0.1 mL; 4 mL of diluent to obtain concentration of 2.5 units per 0.1 mL; 5 mL of diluent to obtain concentration of 2 units per 0.1 mL
200 unit vials: May be reconstituted with 0.5 mL of diluent to obtain concentration of 40 units per 0.1 mL; 1 mL of diluent to obtain concentration of 20 units per 0.1 mL; 1.25 mL of diluent to obtain concentration of 16 units per 0.1 mL; 2 mL of diluent to obtain concentration of 10 units per 0.1 mL; 2.5 mL of diluent to obtain concentration of 8 units per 0.1 mL; 4 mL of diluent to obtain concentration of 5 units per 0.1 mL; 5 mL of diluent to obtain concentration of 4 units per 0.1 mL
For IM injection only. Note: Do not inject through pen marks (if proposed injection sites are marked with a pen); permanent tattooing effect may occur.
Blepharospasm: Use a 30-gauge (12.5 mm length) needle. Electromyography guidance is unnecessary. Avoid injecting near the levator palpebrae superioris (may decrease ptosis). Avoid medial lower lid injections (may decrease ectropion). Apply pressure at the injection site to prevent ecchymosis in the soft eyelid tissues.
Cervical dystonia and upper limb spasticity: Use a 26-gauge (37 mm length) needle for superficial muscles and a 22-gauge (75 mm length) needle for deeper musculature; electromyography or nerve stimulation may help localize the involved muscles. The Canadian labeling recommends avoiding administering bilateral injections or doses >100 units to the sternocleidomastoid muscle (increased risk of adverse events, particularly dysphagia).
Reduction of glabellar lines: Use a 30- to 33-gauge (13 mm length) needle. To reduce ptosis, corrugator injections should be ≥1 cm above the bony supraorbital ridge and injections near the levator palpebrae superioris should be avoided.
Undiluted vials may be stored at room temperature 20°C to 25°C (68°F to 77°F), under refrigeration 2°C to 8°C (36°F to 46°F), or frozen -20°C to -10°C (-4°F to 14°F). After reconstitution, store in refrigerator at 2°C to 8°C (36°F to 46°F) and administer within 24 hours. Vial should only be used for one injection session and one patient.
Upper limb spasticity and cervical dystonia:
Central nervous system: Myasthenia (cervical dystonia: 7% to 11%)
Gastrointestinal: Dysphagia (cervical dystonia: 13% to 18%)
Neuromuscular & skeletal: Neck pain (cervical dystonia: 7% to 15%)
1% to 10%:
Central nervous system: Seizure (upper limb spasticity: 3%)
Gastrointestinal: Xerostomia (upper limb spasticity: 2%)
Local: Pain at injection site (cervical dystonia: 9%)
Neuromuscular & skeletal: Musculoskeletal pain (cervical dystonia: 4% to 7%)
Respiratory: Nasopharyngitis (upper limb spasticity: 2%), upper respiratory tract infection (upper limb spasticity: 2%)
Blepharospasm and glabellar lines:
Gastrointestinal: Xerostomia (blepharospasm: 16%)
Ophthalmic: Blepharoptosis (blepharospasm: 19%; reduction of glabellar lines: <1%), dry eye syndrome (blepharospasm: 16%), visual disturbance (blepharospasm: 12%)
1% to 10%:
Central nervous system: Headache (blepharospasm: 7%; reduction of glabellar lines: 5%)
Gastrointestinal: Diarrhea (blepharospasm: 8%)
Respiratory: Dyspnea (blepharospasm: 5%), nasopharyngitis (blepharospasm: 5%), respiratory tract infection (blepharospasm: 5%)
<1%, postmarketing and/or case reports: Any indication: Abdominal distention, abnormal dreams, allergic dermatitis, alopecia, anaphylaxis, antibody development, asthma, blepharospasm, blurred vision, cardiac insufficiency, circulatory shock, corneal perforation, cough, diplopia, dysarthria, edema, erythema, eye disease, eyelid edema, facial pain, facial paresis, fatigue, fixed drug eruption, flu-like symptoms, hematoma at injection site, herpes zoster, hypersensitivity reaction, inflammation at injection site, injection site reaction, lymphadenopathy, madarosis, muscle spasm, myalgia, nausea, pruritus, reduced blinking (leading to corneal ulceration), serum sickness, skin rash, swelling of eye, trismus, urinary incontinence, urticaria, vascular insufficiency, voice disorder, weakness
Concerns related to adverse effects:
• Anaphylaxis/hypersensitivity reactions: Hypersensitivity and anaphylactic reactions may occur; discontinue therapy immediately with signs/symptoms of hypersensitivity. Immediate medical treatment should be available.
• Antibody formation: Higher doses, more frequent administration and/or onset of disease at a younger age may result in neutralizing antibody formation and loss of efficacy.
• Cardiovascular events: Rarely, arrhythmia and myocardial infarction have been reported with use of another botulinum toxin product, sometimes in patients with preexisting cardiovascular disease.
• CNS depression: May impair ability to drive and/or operate machinery due to the intended effects of treatment; if loss of strength, muscle weakness, or impaired vision occur, patients should avoid driving or engaging in other hazardous activities.
• Dysphagia: Common when used for cervical dystonia; may occur within hours to weeks and persist for several months after administration. In severe cases, patients may require alternative feeding methods. Risk factors include smaller neck muscle mass and bilateral injections into the sternocleidomastoid muscle. Incidence of dysphagia may be reduced by limiting dose administered into sternocleidomastoid muscle.
• Hematologic: Use with caution in patients with bleeding disorders and/or receiving anticoagulation therapy.
• Systemic toxicity: [US Boxed Warning]: Distant spread of botulinum toxin beyond the site of injection has been reported; dysphagia and breathing difficulties have occurred and may be life threatening; other symptoms reported include blurred vision, diplopia, dysarthria, dysphonia, generalized muscle weakness, ptosis, and urinary incontinence which may develop within hours or weeks following injection. The risk is likely greatest in children treated for the unapproved use of spasticity. Systemic effects have occurred following use in approved and unapproved uses, including low doses. Use caution in patients with underlying conditions which may predispose them to these symptoms. Immediate medical attention required if respiratory, speech, or swallowing difficulties appear.
• Neuromuscular disease: Use with caution in patients with neuromuscular diseases such as myasthenia gravis or Lambert- Eaton syndrome (contraindicated in Canadian labeling) and neuropathic disorders (such as amyotrophic lateral sclerosis). Risk of adverse events including severe dysphagia and respiratory compromise may be increased.
• Ocular diseases: Reduced blinking from injection of the orbicularis muscle can lead to corneal exposure and ulceration when treating blepharospasm. Careful testing of corneal sensation, avoidance of lower lid injections to prevent ectropion, and treatment of epithelial defects are necessary. Therapeutic soft contact lenses, application of protective drops or ointment, or covering the affected eye may help. Gentle pressure at injection site may limit bruising of eyelid. Use caution in patients with angle-closure glaucoma.
• Respiratory disease: Use extreme caution in patients with pre-existing respiratory disease; treatment of cervical dystonia using botulinum toxin may weaken accessory muscles that are necessary for these patients to maintain adequate ventilation. Risk of aspiration resulting from severe dysphagia is increased in patients with decreased respiratory function.
Concurrent drug therapy issues:
• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.
Dosage form specific issues:
• Albumin: Product contains albumin and may carry a remote risk of virus transmission.
• Product interchangeability: Botulinum products (incobotulinumtoxinA, abobotulinumtoxinA, onabotulinumtoxinA, rimabotulinumtoxinB) are not interchangeable; potency units are specific to each preparation and cannot be compared or converted to any other botulinum product.
• Chronic therapy: Long-term effects of chronic therapy unknown.
• Injection site: Use with caution if there is excessive weakness or atrophy at the proposed injection site(s); use is contraindicated if infection is present.
Pregnancy Risk Factor
Adverse events were observed in some animal reproduction studies. Canadian labeling does not recommend use for temporary improvement in appearance of moderate to severe glabellar lines during pregnancy.
• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)
• Patient may experience injection site irritation, headache, neck pain, dry mouth, reduced blinking, dry eyes, nausea, or diarrhea. Have patient report immediately to prescriber blurred vision, seeing double, change in voice, drooping eyelids, loss of strength and energy, loss of bladder control, difficulty breathing, dysphagia, difficulty speaking, signs of infection, severe muscle pain, sudden vision changes, eye pain, or eye irritation (HCAHPS).
• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.
Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for healthcare professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience and judgment in diagnosing, treating and advising patients.
More about incobotulinumtoxinA
- Side Effects
- During Pregnancy
- Dosage Information
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- En Español
- 1 Review – Add your own review/rating
- Drug class: skeletal muscle relaxants
Other brands: Xeomin