"Nov. 2, 2012 -- Safety steps taken in the wake of the fungal meningitis outbreak have worsened drug shortages, raising questions about whether the U.S. must choose between the safety and the availability of crucial medicines.
Spread Of Toxin Effect
Postmarketing safety data from XEOMIN and other approved botulinum toxins suggest that botulinum toxin effects may, in some cases, be observed beyond the site of local injection. The symptoms are consistent with the mechanism of action of botulinum toxin and may include asthenia, generalized muscle weakness, diplopia, blurred vision, ptosis, dysphagia, dysphonia, dysarthria, urinary incontinence, and breathing difficulties. These symptoms have been reported hours to weeks after injection. Swallowing and breathing difficulties can be life threatening and there have been reports of death related to the spread of toxin effects. The risk of symptoms is probably greatest in children treated for spasticity but symptoms can occur in adults treated for spasticity and other conditions, and particularly in those patients who have underlying conditions that would predispose them to these symptoms. In unapproved uses, including spasticity in children and adults, and in approved indications, symptoms consistent with spread of toxin effect have been reported at doses comparable to or lower than doses used to treat cervical dystonia.
Patients or caregivers should be advised to seek immediate medical care if swallowing, speech, or respiratory disorders occur.
Lack Of Interchangeability Between Botulinum Toxin Products
The potency Units of XEOMIN are specific to the preparation and assay method utilized. They are not interchangeable with the other preparations of botulinum toxin products and, therefore, Units of biological activity of XEOMIN cannot be compared to or converted into Units of any other botulinum toxin products assessed with any other specific assay method [see DESCRIPTION].
Hypersensitivity reactions have been reported with botulinum toxin products (anaphylaxis, serum sickness, urticaria, soft tissue edema, and dyspnea). If serious and/or immediate hypersensitivity reactions occur further injection of XEOMIN should be discontinued and appropriate medical therapy immediately instituted.
Dysphagia And Breathing Difficulties
Treatment with XEOMIN and other botulinum toxin products can result in swallowing or breathing difficulties. Patients with pre-existing swallowing or breathing difficulties may be more susceptible to these complications. In most cases, this is a consequence of weakening of muscles in the area of injection that are involved in breathing or swallowing. When distant effects occur, additional respiratory muscles may be involved [See Spread of Toxin Effect].
Deaths as a complication of severe dysphagia have been reported after treatment with botulinum toxin. Dysphagia may persist for several months, and require use of a feeding tube to maintain adequate nutrition and hydration. Aspiration may result from severe dysphagia and is a particular risk when treating patients in whom swallowing or respiratory function is already compromised.
Treatment of cervical dystonia with botulinum toxins may weaken neck muscles that serve as accessory muscles of ventilation. This may result in critical loss of breathing capacity in patients with respiratory disorders who may have become dependent upon these accessory muscles. There have been post-marketing reports of serious breathing difficulties, including respiratory failure, in patients with cervical dystonia treated with botulinum toxin products.
Patients with smaller neck muscle mass and patients who require bilateral injections into the sternocleidomastoid muscles have been reported to be at greater risk of dysphagia. In general, limiting the dose injected into the sternocleidomastoid muscle may decrease the occurrence of dysphagia.
Patients treated with botulinum toxin may require immediate medical attention should they develop problems with swallowing, speech or respiratory disorders. These reactions can occur within hours to weeks after injection with botulinum toxin [See Spread of Toxin Effect above and ADVERSE REACTIONS].
Pre-existing Neuromuscular Disorders
Individuals with peripheral motor neuropathic diseases, amyotrophic lateral sclerosis, or neuromuscular junctional disorders (e.g., myasthenia gravis or Lambert-Eaton syndrome) should be monitored particularly closely when given botulinum toxin. Patients with neuromuscular disorders may be at increased risk of clinically significant effects including severe dysphagia and respiratory compromise from typical doses of XEOMIN [See ADVERSE REACTIONS].
Corneal Exposure, Corneal Ulceration, And Ectropion In Patients Treated For Blepharospasm
Reduced blinking from injection of botulinum toxin products in 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. Because of its anticholinergic effects, XEOMIN should be used with caution in patients at risk of developing narrow angle glaucoma. To prevent ectropion, botulinum toxin products should not be injected into the medial lower eyelid area.
Ecchymosis easily occurs in the soft tissues of the eyelid. Immediate gentle pressure at the injection site can limit that risk.
Risk Of Ptosis In Patients Treated For Glabellar Lines
Do not exceed the recommended dosage and frequency of administration of XEOMIN.
In order to reduce the complication of ptosis the following steps should be taken:
- Avoid injection near the levator palpebrae superioris, particularly in patients with larger brow depressor complexes.
- Corrugator injections should be placed at least 1 cm above the bony supraorbital ridge.
Human Albumin And Transmission Of Viral Diseases
This product contains albumin, a derivative of human blood. Based on effective donor screening and product manufacturing processes, it carries an extremely remote risk for transmission of viral diseases. A theoretical risk for transmission of Creutzfeldt-Jakob disease (CJD) is also considered extremely remote. No cases of transmission of viral diseases or CJD have ever been reported for albumin.
Patient Counseling Information
See FDA-approved patient labeling (Medication Guide)
Provide a copy of the Medication Guide and review the contents with the patient.
Patients or caregivers should be advised to seek immediate medical care if swallowing, speech or respiratory disorders arise.
Previously immobile or sedentary patients should be reminded to gradually resume activities following the injection of XEOMIN for the treatment of cervical dystonia and blepharospasm.
Patients should be informed that injections of XEOMIN may cause dyspnea, or mild to severe dysphagia, with the risk of aspiration [see BOXED WARNING and WARNINGS AND PRECAUTIONS].
Patients should be counseled that if loss of strength, muscle weakness, blurred vision, or drooping eyelids occur, they should avoid driving a car or engaging in other potentially hazardous activities.
Patients should be informed that injections of XEOMIN may cause reduced blinking or effectiveness of blinking, and that they should seek immediate medical attention if eye pain or irritation occurs following treatment.
Carcinogenesis, Mutagenesis, Impairment Of Fertility
Studies to evaluate the carcinogenic potential of XEOMIN have not been conducted.
Genotoxicity studies have not been conducted for XEOMIN.
Impairment of Fertility
In a fertility and early embryonic development study in rabbits, males and females were dosed with XEOMIN (1.25 Units/kg, 2.5 Units/kg, or 3.5 Units/kg) intramuscularly every two weeks for 5 and 3 doses, respectively, beginning 2 weeks prior to mating. No effects on mating or fertility were observed. The highest dose tested is approximately twice the maximum recommended human dose for cervical dystonia (120 Units) on a body weight basis.
Use In Specific Populations
Pregnancy Category C
There are no adequate and well-controlled studies in pregnant women. XEOMIN should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. XEOMIN was embryotoxic in rats and increased abortions in rabbits when given at doses higher than the maximum recommended human dose (MRHD) for cervical dystonia (120 Units) on a body weight basis.
When XEOMIN was administered intramuscularly to pregnant rats during organogenesis (3 Units/kg, 10 Units/kg, or 30 Units/kg on gestational days [GDs] 6, 12, and 19; or 7 Units/kg on GDs 6 to 19; or 2, 6, or 18 Units/kg on GDs 6, 9, 12, 16, and 19), decreases in fetal body weight and skeletal ossification were observed at doses that were also maternally toxic. The no-effect level for embryotoxicity in rats was 6 Units/kg (3 times the MRHD for cervical dystonia on a body weight basis). Intramuscular administration to pregnant rabbits during organogenesis (1.25 Units/kg, 2.5 Units/kg, or 5.0 Units/kg on GDs 6, 18, and 28) resulted in an increased rate of abortion at the highest dose, which was also maternally toxic. In rabbits, the no-effect level for increased abortion was 2.5 Units/kg (similar to the MRHD for cervical dystonia on a body weight basis).
It is not known whether botulinum toxin type A is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when XEOMIN is administered to a nursing woman.
Safety and effectiveness of XEOMIN in patients less than 18 years of age have not been established [see WARNINGS AND PRECAUTIONS].
In the Phase 3 study in cervical dystonia [see Clinical Studies], 29 patients were older than 65 years of age, including 19 patients who received XEOMIN and 10 patients who received placebo. Of these, ten (53%) XEOMIN-treated patients and four (40%) placebo-treated patients experienced an adverse event. For patients over 65 years of age treated with XEOMIN, the most common adverse events were dysphagia (4 patients, 21%) and asthenia (2 patients, 11%). One XEOMIN-treated patient (5%) experienced severe dizziness.
In the Phase 3 study in blepharospasm [see Clinical Studies], 41 patients were older than 65 years of age, including 29 of 75 patients (39%) who received XEOMIN and 12 of 34 patients (35%) who received placebo. Of these patients, 22 of 29 (76%) XEOMIN-treated patients, compared with 7 of 12 (58%) placebo-treated patients, experienced an adverse event. One XEOMIN-treated patient experienced severe dysphagia.
There are limited clinical data with XEOMIN in subjects over 65 years of age and over in clinical studies with glabellar lines. Of the total number of subjects in the placebo-controlled clinical studies GL1 and GL2, 21 (4%) subjects were 65 and over. Efficacy was observed in 20% (3/15) of XEOMIN subjects 65 years and over. For the entire safety database of geriatric subjects, there was no increase in the incidence of adverse events related to treatment with XEOMIN.This monograph has been modified to include the generic and brand name in many instances.
Last reviewed on RxList: 12/14/2015
Additional Xeomin Information
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