HIGHLIGHTS OF PRESCRIBING INFORMATION
These highlights do not include all the information needed to use
BOTOX
®
safely and effectively. See full prescribing information for
BOTOX.
BOTOX
(onabotulinumtoxinA) for injection, for intramuscular,
intradetrusor, or intradermal use
Initial U.S. Approval: 1989
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RECENT MAJOR CHANGES
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• Indications and Usage, Detrusor Overactivity associated with a
Neurologic Condition (1.1) 8/2011
• Indications and Usage, Chronic Migraine (1.2) 10/2010
• Dosage and Administration, Detrusor Overactivity associated with a
Neurologic Condition (2.3) 8/2011
• Dosage and Administration, Chronic Migraine (2.4) 10/2010
• Contraindications, Acute Urinary Tract Infection and Acute Urinary
Retention (4.3) 8/2011
• Warnings and Precautions, Autonomic Dysreflexia and Urinary Retention
in Patients Treated for Detrusor Overactivity associated with a Neurologic
Condition (5.10) 8/2011
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INDICATIONS AND USAGE
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BOTOX is an acetylcholine release
inhibitor and a neuromuscular blocking agent
indicated for:
• Treatment of urinary incontinence due to detrusor overactivity associated with a
neurologic condition [e.g., spinal cord injury (SCI), multiple sclerosis (MS)] in
adults who have an inadequate response to or are intolerant of an anticholinergic
medication (1.1)
• Prophylaxis of headaches in adult patients with chronic migraine (≥15 days per
month with headache lasting 4 hours a day or longer) (1.2)
• Treatment of upper limb spasticity in adult patients (1.3)
• Treatment of cervical dystonia in adult patients, to reduce the severity of
abnormal head position and neck pain (1.4)
• Treatment of severe axillary hyperhidrosis that is inadequately managed by
topical agents in adult patients (1.5)
• Treatment of blepharospasm associated with dystonia in patients ≥12 years of
age (1.6)
• Treatment of strabismus in patients ≥12 years of age (1.6)
Important limitations:
• Safety and effectiveness of BOTOX have not been established for the
prophylaxis of episodic migraine (14 headache days or fewer per month).
(1.2)
• Safety and effectiveness of BOTOX have not been established for the
treatment of upper limb spasticity in pediatric patients, and for the
treatment of lower limb spasticity in adult and pediatric patients. (1.3)
• Safety and effectiveness of BOTOX for hyperhidrosis in body areas other
than axillary have not been established. (1.5)
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DOSAGE AND ADMINISTRATION
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• Indication specific dosage and administration recommendations should be
followed; Do not exceed a total dose of 360 Units administered in a 3 month
interval (2)
• See Preparation and Dilution Technique for instructions on BOTOX
reconstitution, storage, and preparation before injection (2.1)
• Detrusor Overactivity associated with a Neurologic Condition:
Recommended total dose 200 Units, as 1 mL (~6.7 Units) injections across
30 sites into the detrusor (2.2)
• Chronic Migraine: Recommended total dose 155 Units, as 0.1 mL (5 Units)
injections per each site divided across 7 head/neck muscles (2.3)
• Upper Limb Spasticity: Select dose based on muscles affected, severity of
muscle activity, prior response to treatment, and adverse event history;
Electromyographic guidance recommended (2.4)
• Cervical Dystonia: Base dosing on the patient’s head and neck position,
localization of pain, muscle hypertrophy, patient response, and adverse event
history; use lower initial dose in botulinum toxin naïve patients (2.5)
• Axillary Hyperhidrosis: 50 Units per axilla (2.6)
• Blepharospasm: 1.25 Units-2.5 Units into each of 3 sites per affected eye
(2.7)
• Strabismus: 1.25 Units-2.5 Units initially in any one muscle (2.8)
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DOSAGE FORMS AND STRENGTHS
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Single-use, sterile 50 Units, 100 Units, or 200 Units vacuum-dried powder for
reconstitution only with sterile, non-preserved 0.9% Sodium Chloride Injection
USP prior to injection (3)
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CONTRAINDICATIONS
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• Hypersensitivity to any botulinum toxin preparation or to any of the
components in the formulation (4.1, 5.3, 6.2)
• Infection at the proposed injection site (4.2)
• Intradetrusor Injections: Acute Urinary Tract Infection and/or Acute
Urinary Retention (4.3)
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WARNINGS AND PRECAUTIONS
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• Potency Units of BOTOX not interchangeable with other preparations of
botulinum toxin products (5.1, 11)
• Spread of toxin effects; swallowing and breathing difficulties can lead to
death. Seek immediate medical attention if respiratory, speech or
swallowing difficulties occur (5.2, 5.4)
• Concomitant neuromuscular disorder may exacerbate clinical effects of
treatment (5.5)
• Use with caution in patients with compromised respiratory function (5.4,
5.6)
• Corneal exposure and ulceration due to reduced blinking may occur with
BOTOX treatment of blepharospasm (5.7)
• Retrobulbar hemorrhages and compromised retinal circulation circulation
may occur with BOTOX treatment of strabismus (5.8)
• Bronchitis and upper respiratory tract infections in patients treated for
upper limb spasticity (5.9)
• Urinary retention: Post-void residual urine volume should be monitored in
patients treated for detrusor overactivity associated with a neurologic
condition who do not catheterize routinely, particularly patients with MS.
(5.10)
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ADVERSE REACTIONS
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The most common adverse reactions (≥5% and >placebo) are (6.1):
• Detrusor Overactivity associated with a neurologic condition: urinary tract
infection, urinary retention
• Chronic Migraine: neck pain, headache
• Spasticity: pain in extremity
• Cervical Dystonia: dysphagia, upper respiratory infection, neck pain, headache,
increased cough, flu syndrome, back pain, rhinitis
• Axillary Hyperhidrosis: injection site pain and hemorrhage, non-axillary
sweating, pharyngitis, flu syndrome
To report SUSPECTED ADVERSE REACTIONS, contact Allergan at 1-
800-433-8871 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.
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DRUG INTERACTIONS
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• Patients receiving concomitant treatment of BOTOX and aminoglycosides
or other agents interfering with neuromuscular transmission (e.g., curare-
like agents), or muscle relaxants, should be observed closely because the
effect of BOTOX may be potentiated (7)
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USE IN SPECIFIC POPULATIONS
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• Pregnancy: Based on animal data, may cause fetal harm (8.1)
• Pediatric Use: Safety and efficacy are not established in patients under
18 years of age for the prophylaxis of headaches in chronic migraine, the
treatment of detrusor overactivity associated with a neurologic condition,
upper limb spasticity, and axillary hyperhidrosis, in patients under
16 years of age for the treatment of cervical dystonia, and in patients
under 12 years of age for the treatment of blepharospasm and strabismus
(8.4)
See 17 for PATIENT COUNSELING INFORMATION and Medication
Guide
Revised: 08/2011
WARNING: DISTANT SPREAD OF TOXIN EFFECT
See full prescribing information for complete boxed warning.
The effects of BOTOX
and all botulinum toxin products may spread
from the area of injection to produce symptoms consistent with
botulinum toxin effects. 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. The risk of
symptoms is probably greatest in children treated for spasticity but
symptoms can also occur in adults, particularly in those patients who
have an underlying condition that would predispose them to these
symptoms. (5.2)