- Email: [email protected]
Recommendations and current practices for the reconstitution and storage of botulinum toxin type A
Recommendations and current practices for the reconstitution and storage of botulinum toxin type A Austin Liu, MD,a Alastair Carruthers, MD, FRCPC,b Joel L. Cohen, MD,c William P. Coleman III, MD,d Jeffrey S. Dover, MD, FRCPC, FRCP,e C. William Hanke, MD,f Ronald L. Moy, MD,g and David M. Ozog, MDa Detroit, Michigan; Vancouver, British Columbia, Canada; Englewood, Colorado; New Orleans, Louisiana; Chestnut Hill, Massachusetts; Carmel, Indiana; and Los Angeles, California Background: Current guidelines from the Centers for Disease Control and Prevention (CDC) regarding the reconstitution and storage of botulinum toxin type A (BT-A) differ from those of the Centers for Medicare and Medicaid Services and current clinical practice. CDC guidelines require single-patient use of BT-A vials. Strict adherence to these guidelines creates waste and a significant financial impediment, and does not confer increased protection from infection, assuming standard safe injection practices are followed. Objective: This study examines current clinical practices and provides expert consensus recommendations regarding the reconstitution and storage of BT-A. A review of the literature on the sterility and efficacy of BT-A stored beyond the recommended time period of 4 hours is also presented. Methods: An Internet-based survey was used to analyze the current practices of physician members of the American Society for Dermatologic Surgery who administer botulinum type A toxins. Results: After reconstitution, the majority of physicians (68.6%) routinely store BT-A for a period of greater than 1 week and safely use each toxin vial for more than one patient. Not a single case of infection was observed. Limitations: This was a single survey with a 32.2% response rate. Conclusion: A single vial of BT-A can be safely administered to multiple patients, assuming standard safe injection techniques are followed. After reconstitution, Our data suggest that BT-A can be stored beyond the recommended time period of 4 hours. ( J Am Acad Dermatol 2012;67:373-8.) Key words: Botox; Botox reconstitution; Botox storage; botulinum toxin; botulinum toxin consensus recommendations; botulinum toxin reconstitution; botulinum toxin storage.
otulinum toxin type A (BT-A) is widely used today for both cosmetic and noncosmetic purposes. It is the most common nonsurgical intervention for facial rhytids. The current product
B
labeling regarding reconstitution recommends this to be performed using preservative-free saline. However, recent studies have found improved tolerability with less pain upon injection when
From the Department of Dermatology, Division of Mohs Micrographic Surgery, Henry Ford Hospital, Detroita; Department of Dermatology and Skin Science, University of British Columbiab; AboutSkin Dermatology and DermSurgery, Englewoodc; Departments of Dermatology and Plastic Surgery, Tulane Health Sciences Center, New Orleansd; SkinCare Physicians, Chestnut Hille; Laser and Skin Surgery Center of Indianaf; and David Geffen School of Medicine at the University of California at Los Angeles.g Funding sources: None. Conflicts of interest: None declared. Disclosure: Dr Hanke served as an investigator for Allergan, Medicis, Merz, and Galderma, receiving grants. Dr Coleman served as a consultant for Allergan and Merz, receiving grants. Dr Carruthers has been on the advisory board and served as an investigator for Allergan and Merz, receiving honoraria.
Dr Cohen served as a consultant and investigator for Allergan, Medicis, and Merz, receiving grants and honoraria. Dr Moy served as an investigator for Inamed, receiving grants and is a stockholder of Claro. Dr Dover served as an investigator for Allergan, receiving grants. Drs Liu and Ozog have no conflicts of interest to declare. Accepted for publication October 6, 2011. Reprint requests: David M. Ozog, MD, Department of Dermatology, Division of Mohs Micrographic Surgery, Henry Ford Hospital, 3031 W Grand Blvd, Suite 800, Detroit, MI 48202. E-mail: [email protected]. Published online November 7, 2011. 0190-9622/$36.00 Ó 2011 by the American Academy of Dermatology, Inc. doi:10.1016/j.jaad.2011.10.008
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reconstitution is performed with bacteriostatic (prepractices including: method of BT-A reconstitution, servative-containing) saline.1,2 Furthermore, the prolength of storage after reconstitution, single- versus duct labeling states that the reconstituted toxin multiple-patient use, current viewpoints on product should be refrigerated (28C-88C) and used within 4 safety when stored beyond the manufacturers’ rechours, on a single patient. These guidelines are based ommendations, instances of local infection, and total on concerns regarding reduced potency, contaminumber of years in clinical practice. nation, and consequent infections. In the clinical setting, such guidelines are often RESULTS difficult to follow without Of the 1000 physicians inCAPSULE SUMMARY wasting a substantial quantity vited to participate in the surof the product and creating a vey, 322 (32.2%) responded The Centers for Disease Control and significant financial burden to the questionnaire. A total Prevention recommends strict to the patient. Oftentimes, of 312 participants were inadherence to single-patient use for each clinicians use a single vial cluded in the study after 10 botulinum toxin A vial to prevent for more than one patient responders who indicated infectious complications. but comply with the guidethat they did not perform line of use within 4 hours of Currently, physicians safely administer BT-A injections in their pracreconstitution by scheduling toxin from a single vial to multiple tices were excluded. The mapatients receiving BT-A injecpatients, and most physicians routinely jority of physicians surveyed tions on specific days, in an store botulinum toxin for greater than (146; 46.8%) had been in effort to minimize the waste 1 week. practice for greater than 15 of this expensive product. years (Fig 2). Assuming standard safe injection However, current guidelines With regard to methods of practices are followed, a single vial of from the Centers for Disease reconstitution, the majority botulinum toxin can be safely Control and Prevention of participants (243; 77.9%) administered to multiple patients, (CDC) advocate strict adheruse bacteriostatic saline (Fig 3). thereby reducing waste and increasing ence to the Food and Drug Most physicians (214; 68.6%) the financial feasibility of its use. Administrationeapproved routinely keep reconstituted single-use labeling for each vials of toxin for 1 week or vial of toxin.3 Furthermore, compliance with the greater (Fig 4). A total of 209 (67.0%) respondents CDC guidelines is required for Joint Commission believed the reconstituted toxin vials could be safely accreditation.4 kept for treating patients for a duration between 1 to The main concern of the CDC regarding single4 weeks (Fig 5). No instances of local infections patient use stems from the possible spread of infecwere ever documented by any of the 312 responders tious diseases when unsafe injection practices are (Fig 6). performed. However, even with other medications labeled as ‘‘multiple-patient use,’’ unsafe injection DISCUSSION practices can cause contamination and spread of Our consensus recommendations are as follows: infectious agents. We surveyed the current practices d Once reconstituted, BT-A vials that are labeled for of experienced physicians and provide expert consingle-patient use may be administered to multisensus recommendations on the reconstitution and ple patients provided that safe injection techstorage of BT-A. We also provide a review of the niques are practiced. literature on the sterility and efficacy of BT-A when d BT-A reconstitution may be performed using bacreconstituted and stored beyond the manufacturers’ teriostatic saline as this has been found to deguidelines. crease pain and improve tolerability upon injection. METHODS d Reconstituted BT-A may be stored for a period of A total of 1000 randomly selected physician at least 2 weeks without detrimental effect to its members of the American Society for Dermatologic safety/sterility or efficacy. Surgery were invited to participate in an Internetbased survey on the use of BT-A (Fig 1). No monThe two primary concerns regarding the use of etary incentives were provided. Participants who BT-A outside of the manufacturers’ guidelines are indicated that they did not use BT-A in their practices safety (sterility) and efficacy. CDC guidelines insist were excluded from the study. The questionnaire on adherence to single-patient use for each vial of assessed multiple aspects of current physician toxin. This stems from concerns regarding the spread d
d
d
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Abbreviations used: BT-A: CDC: CMS:
botulinum toxin type A Centers for Disease Control and Prevention Centers for Medicare and Medicaid Services
of infection, including hepatitis B and C. However, the instances of contamination documented by the CDC were related to unsafe injection practices including the reinsertion of used needles into multiple-dose vials (a form of ‘‘double-dipping’’) and the use of a single needle/syringe to dispense intravenous medications to multiple patients. These injection practices can potentially cause contamination regardless of whether the vials were designed for single- or multiple-patient use. Proper technique involves the use of new/unused needles to extract the toxin from the vial. Indeed, our study found that most physicians routinely use a single vial of BT-A on multiple patients and commonly store the reconstituted product for greater than 1 week. Not a single instance of local infection was reported. In contrast to CDC guidelines, the Centers for Medicare and Medicaid Services (CMS) encourages the use of single-use BT-A vials for multiple patients, to efficiently use this costly product.5 The CMS will reimburse for the exact amount of BT-A administered to each patient. However, if any remaining toxin in a vial must be discarded, the CMS will cover the cost of the entire vial as well. BT-A is packaged in single-use vials because the crystalline complex form does not contain any preservatives. We found that for reconstitution, most clinicians prefer using preservative-containing or bacteriostatic saline. This preference for preserved saline is a result of clinical studies documenting decreased pain upon injection when compared with BT-A reconstituted with nonpreserved saline. Randomized controlled trials have found BT-A reconstituted with preserved saline to cause significantly less pain than toxin reconstituted with unpreserved saline when used for both cosmetic1 and noncosmetic2 purposes. In addition, the investigators found no difference in clinical outcomes during a 3- to 6-month follow-up period. The reason for this difference is the presence of benzyl alcohol in preserved saline, which acts as both a preservative and an anesthetic. Furthermore, a consensus panel on the use of BT-A agreed that preserved saline can be used for dilution, given its improved clinical tolerability.6 Regarding efficacy, numerous studies have examined the effectiveness of BT-A after reconstitution
Liu et al 375
and storage beyond the suggested 4 hours. Under those conditions, animal7 and in vitro8 studies have shown decreases in duration of action and potency, respectively. However, clinical evaluations with human beings have not shown similar reductions in efficacy or duration of action. Jabor et al7 used a rabbit model to compare BT-A reconstituted and refrigerated for up to 12 weeks with freshly reconstituted BT-A. They found no differences in initial potency but a decrease in duration of action after storage periods of greater than 2 weeks. The inherent difficulty regarding in vitro and animal studies is determining its significance in human beings. Clinical studies have not shown reduced efficacy after the use of BT-A reconstituted and stored for various time intervals including 1 week,9 2 weeks,10-13 6 weeks,14 or 6 months.15 Lizarralde et al9 compared BT-A reconstituted and refrigerated for 1 week with freshly reconstituted BT-A in treating external canthus dynamic lines (crow’s feet). Assessments included a facial nerve conduction study and photographic evaluation, with a follow-up period of 18 weeks. No significant differences were seen between the two groups in initial potency or duration of action. Sloop et al10 compared freshly reconstituted BT-A with toxin that was reconstituted and either frozen or refrigerated for 2 weeks. No difference in potency between the groups was noted upon evaluation of the degree of extensor digitorum brevis muscle paralysis. The treatment of different facial locations has also been examined in studies of BT-A reconstitution and storage. After cold storage of reconstituted BT-A for 2 weeks, the toxin has been shown to retain its efficacy and time of onset in the treatment of lateral periorbital rhytids11 (crow’s feet), horizontal forehead rhytids,13 and glabellar rhytids.12 The follow-up periods in these studies ranged from 3 to 4 months. Clinical studies of reconstituted BT-A using longer storage periods provide stronger evidence of the stability of the toxin. Hexsel et al14 did not reveal any diminution of the efficacy on glabellar rhytids of BT-A after refrigerator storage of reconstituted vials for 6 weeks. In fact, with a follow-up period of more than 4 months, no detrimental effect on toxin efficacy was seen in this study of 6-week-old reconstituted BT-A. Parsa et al15 compared reconstituted BT-A frozen for 6 months with freshly reconstituted BT-A for treating glabellar, forehead transverse, and lateral canthal rhytids. Again, no loss in potency was noted after prolonged cold storage in this study as well. In addition to efficacy, the extended lengths of storage also theoretically raise concerns for possible contamination. However, none of the clinical studies cited in this article reported any instances of
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Fig 1. Questionnaire completed by study participants.
cutaneous infection after the application of reconstituted BT-A stored for longer than the recommended 4 hours. No evidence of bacterial contamination has been reported after cold storage of reconstituted BT-A for periods of 5 to 7 days,16 7 weeks,17 12 weeks,7 and 10 months.12 Menon and Murray16 did not find any microbial growth in vials of reconstituted BT-A after 4 hours of exposure to room temperature followed by refrigerator storage for 5 to 7 days. Alam et al17 found no contamination in vials of reconstituted BT-A after
refrigerator storage and serial re-extractions over 7 weeks. In a study with one of the longest periods of refrigerator storage, no bacterial contamination was identified after 10 months.12 Together, these studies provide solid evidence that BT-A reconstitution and storage for periods significantly longer than suggested by the manufacturers is both safe and clinically effective, and commonplace in clinical practice. Our recommendation for the storage and use of BT-A for 2 weeks after reconstitution is based on the numerous studies
J AM ACAD DERMATOL VOLUME 67, NUMBER 3
Fig 2. Number of years in practice by participating physicians.
Fig 3. Method of reconstitution of botulinum toxin type A.
Liu et al 377
Fig 5. Physician viewpoints regarding time period during which reconstituted botulinum toxin type A can be safely used for treating patients.
Fig 6. Instances of local infection after botulinum toxin type A injection.
beyond 2 weeks would need to be performed to provide sufficient evidence for a longer storage period. The safety of using single-patient vials for multiple patients rests upon the practice of safe injection techniques by the physician and support staff. Overall, this has important practical implications for both clinicians and patients in the office setting. Specifically, patients will have much greater flexibility with regard to scheduling for treatments, and physicians will not have to needlessly discard large amounts of reconstituted BT-A, which would otherwise ultimately result in a greater financial burden to the patient. Fig 4. Duration of use of reconstituted botulinum toxin type A vials.
demonstrating preserved toxin efficacy after a 2-week storage period.10-13 Additional studies demonstrating the safety and efficacy of BT-A storage
REFERENCES 1. Alam M, Dover JS, Arndt KA. Pain associated with injection of botulinum A exotoxin reconstituted using isotonic sodium chloride with and without preservative: a double blind, randomized controlled trial. Arch Dermatol 2002;138:510-4. 2. Kwiat DM, Bersani TA, Bersani A. Increased patient comfort utilizing botulinum toxin type A reconstituted with preserved
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3.
4.
5.
6.
7.
8.
9.
versus nonpreserved saline. Ophthal Plast Reconstr Surg 2004; 20:186-9. Siegel JD, Rhinehart E, Jackson M, Chiarello L, Health Care Infection Control Practices Advisory Committee. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in health care settings. Am J Infect Control 2007;35(Suppl):S65-164. Joint Commission. Accreditation program: hospital infection prevention and control. Available from: URL:http://www. premierinc.com/quality-safety/tools-services/safety/topics/in fluenza/downloads/HAP_IC-09-incl-influenza.pdf. Accessed March 1, 2011. WPS Medicare. Coding and billing: botulinum toxin type A and type B. Available from: URL:http://wpsmedicare.com/ j5macpartb/policy/active/local/_files/l28555_inj018_cbg.pdf. Accessed March 1, 2011. Carruthers J, Fagien S, Matarasso SL, Botox Consensus Group. Consensus recommendations on the use of botulinum toxin type A in facial aesthetics [review]. Plast Reconstr Surg 2004; 114(Suppl):1-22S. Jabor MA, Kaushik R, Shayani P, Ruiz-Razura A, Smith BK, Morimoto KW, et al. Efficacy of reconstituted and stored botulinum toxin type A: an electrophysiologic and visual study in the auricular muscle of the rabbit. Plast Reconstr Surg 2003; 111:2419-31. Gartlan MG, Hoffman HT. Crystalline preparation of botulinum toxin type A (Botox): degradation in potency with storage. Otolaryngol Head Neck Surg 1993;108:135-40. Lizarralde M, Gutierrez SH, Venegas A. Clinical efficacy of botulinum toxin type A reconstituted and refrigerated 1 week
SEPTEMBER 2012
10.
11.
12.
13.
14.
15.
16. 17.
before its application in external canthus dynamic lines. Dermatol Surg 2007;33:1328-33. Sloop RR, Cole BA, Escutin RO. Reconstituted botulinum toxin type A does not lose potency in humans if it is refrozen or refrigerated for 2 weeks before use. Neurology 1997;48: 249-53. Hui JI, Lee WW. Efficacy of fresh versus refrigerated botulinum toxin in the treatment of lateral periorbital rhytids. Ophthal Plast Reconstr Surg 2007;23:433-8. Hexsel D, Rutowitsch MS, de Castro LC, do Prado DZ, Lima MM. Blind multicenter study of the efficacy and safety of injections of a commercial preparation of botulinum toxin type A reconstituted up to 15 days before injection. Dermatol Surg 2009;35:933-40. Yang GC, Chiu RJ, Gillman GS. Questioning the need to use Botox within 4 hours of reconstitution: a study of fresh vs 2-week-old Botox. Arch Facial Plast Surg 2008;10:273-9. Hexsel DM, De Almeida AT, Rutowitsch M, De Castro IA, Silveira VL, Gobatto DO, et al. Multicenter, double-blind study of the efficacy of injections with botulinum toxin type A reconstituted up to six consecutive weeks before application. Dermatol Surg 2003;29:523-9. Parsa AA, Lye KD, Parsa FD. Reconstituted botulinum type A neurotoxin: clinical efficacy after long-term freezing before use. Aesthetic Plast Surg 2007;31:188-93. Menon J, Murray A. Microbial growth in vials of botulinum toxin following use in clinic. Eye (Lond) 2007;21:995-7. Alam M, Yoo SS, Wrone DA, White LE, Kim JY. Sterility assessment of multiple use botulinum A exotoxin vials: a prospective simulation. J Am Acad Dermatol 2006;55:272-5.
otulinum toxin type A (BT-A) is widely used today for both cosmetic and noncosmetic purposes. It is the most common nonsurgical intervention for facial rhytids. The current product
B
labeling regarding reconstitution recommends this to be performed using preservative-free saline. However, recent studies have found improved tolerability with less pain upon injection when
From the Department of Dermatology, Division of Mohs Micrographic Surgery, Henry Ford Hospital, Detroita; Department of Dermatology and Skin Science, University of British Columbiab; AboutSkin Dermatology and DermSurgery, Englewoodc; Departments of Dermatology and Plastic Surgery, Tulane Health Sciences Center, New Orleansd; SkinCare Physicians, Chestnut Hille; Laser and Skin Surgery Center of Indianaf; and David Geffen School of Medicine at the University of California at Los Angeles.g Funding sources: None. Conflicts of interest: None declared. Disclosure: Dr Hanke served as an investigator for Allergan, Medicis, Merz, and Galderma, receiving grants. Dr Coleman served as a consultant for Allergan and Merz, receiving grants. Dr Carruthers has been on the advisory board and served as an investigator for Allergan and Merz, receiving honoraria.
Dr Cohen served as a consultant and investigator for Allergan, Medicis, and Merz, receiving grants and honoraria. Dr Moy served as an investigator for Inamed, receiving grants and is a stockholder of Claro. Dr Dover served as an investigator for Allergan, receiving grants. Drs Liu and Ozog have no conflicts of interest to declare. Accepted for publication October 6, 2011. Reprint requests: David M. Ozog, MD, Department of Dermatology, Division of Mohs Micrographic Surgery, Henry Ford Hospital, 3031 W Grand Blvd, Suite 800, Detroit, MI 48202. E-mail: [email protected]. Published online November 7, 2011. 0190-9622/$36.00 Ó 2011 by the American Academy of Dermatology, Inc. doi:10.1016/j.jaad.2011.10.008
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reconstitution is performed with bacteriostatic (prepractices including: method of BT-A reconstitution, servative-containing) saline.1,2 Furthermore, the prolength of storage after reconstitution, single- versus duct labeling states that the reconstituted toxin multiple-patient use, current viewpoints on product should be refrigerated (28C-88C) and used within 4 safety when stored beyond the manufacturers’ rechours, on a single patient. These guidelines are based ommendations, instances of local infection, and total on concerns regarding reduced potency, contaminumber of years in clinical practice. nation, and consequent infections. In the clinical setting, such guidelines are often RESULTS difficult to follow without Of the 1000 physicians inCAPSULE SUMMARY wasting a substantial quantity vited to participate in the surof the product and creating a vey, 322 (32.2%) responded The Centers for Disease Control and significant financial burden to the questionnaire. A total Prevention recommends strict to the patient. Oftentimes, of 312 participants were inadherence to single-patient use for each clinicians use a single vial cluded in the study after 10 botulinum toxin A vial to prevent for more than one patient responders who indicated infectious complications. but comply with the guidethat they did not perform line of use within 4 hours of Currently, physicians safely administer BT-A injections in their pracreconstitution by scheduling toxin from a single vial to multiple tices were excluded. The mapatients receiving BT-A injecpatients, and most physicians routinely jority of physicians surveyed tions on specific days, in an store botulinum toxin for greater than (146; 46.8%) had been in effort to minimize the waste 1 week. practice for greater than 15 of this expensive product. years (Fig 2). Assuming standard safe injection However, current guidelines With regard to methods of practices are followed, a single vial of from the Centers for Disease reconstitution, the majority botulinum toxin can be safely Control and Prevention of participants (243; 77.9%) administered to multiple patients, (CDC) advocate strict adheruse bacteriostatic saline (Fig 3). thereby reducing waste and increasing ence to the Food and Drug Most physicians (214; 68.6%) the financial feasibility of its use. Administrationeapproved routinely keep reconstituted single-use labeling for each vials of toxin for 1 week or vial of toxin.3 Furthermore, compliance with the greater (Fig 4). A total of 209 (67.0%) respondents CDC guidelines is required for Joint Commission believed the reconstituted toxin vials could be safely accreditation.4 kept for treating patients for a duration between 1 to The main concern of the CDC regarding single4 weeks (Fig 5). No instances of local infections patient use stems from the possible spread of infecwere ever documented by any of the 312 responders tious diseases when unsafe injection practices are (Fig 6). performed. However, even with other medications labeled as ‘‘multiple-patient use,’’ unsafe injection DISCUSSION practices can cause contamination and spread of Our consensus recommendations are as follows: infectious agents. We surveyed the current practices d Once reconstituted, BT-A vials that are labeled for of experienced physicians and provide expert consingle-patient use may be administered to multisensus recommendations on the reconstitution and ple patients provided that safe injection techstorage of BT-A. We also provide a review of the niques are practiced. literature on the sterility and efficacy of BT-A when d BT-A reconstitution may be performed using bacreconstituted and stored beyond the manufacturers’ teriostatic saline as this has been found to deguidelines. crease pain and improve tolerability upon injection. METHODS d Reconstituted BT-A may be stored for a period of A total of 1000 randomly selected physician at least 2 weeks without detrimental effect to its members of the American Society for Dermatologic safety/sterility or efficacy. Surgery were invited to participate in an Internetbased survey on the use of BT-A (Fig 1). No monThe two primary concerns regarding the use of etary incentives were provided. Participants who BT-A outside of the manufacturers’ guidelines are indicated that they did not use BT-A in their practices safety (sterility) and efficacy. CDC guidelines insist were excluded from the study. The questionnaire on adherence to single-patient use for each vial of assessed multiple aspects of current physician toxin. This stems from concerns regarding the spread d
d
d
J AM ACAD DERMATOL VOLUME 67, NUMBER 3
Abbreviations used: BT-A: CDC: CMS:
botulinum toxin type A Centers for Disease Control and Prevention Centers for Medicare and Medicaid Services
of infection, including hepatitis B and C. However, the instances of contamination documented by the CDC were related to unsafe injection practices including the reinsertion of used needles into multiple-dose vials (a form of ‘‘double-dipping’’) and the use of a single needle/syringe to dispense intravenous medications to multiple patients. These injection practices can potentially cause contamination regardless of whether the vials were designed for single- or multiple-patient use. Proper technique involves the use of new/unused needles to extract the toxin from the vial. Indeed, our study found that most physicians routinely use a single vial of BT-A on multiple patients and commonly store the reconstituted product for greater than 1 week. Not a single instance of local infection was reported. In contrast to CDC guidelines, the Centers for Medicare and Medicaid Services (CMS) encourages the use of single-use BT-A vials for multiple patients, to efficiently use this costly product.5 The CMS will reimburse for the exact amount of BT-A administered to each patient. However, if any remaining toxin in a vial must be discarded, the CMS will cover the cost of the entire vial as well. BT-A is packaged in single-use vials because the crystalline complex form does not contain any preservatives. We found that for reconstitution, most clinicians prefer using preservative-containing or bacteriostatic saline. This preference for preserved saline is a result of clinical studies documenting decreased pain upon injection when compared with BT-A reconstituted with nonpreserved saline. Randomized controlled trials have found BT-A reconstituted with preserved saline to cause significantly less pain than toxin reconstituted with unpreserved saline when used for both cosmetic1 and noncosmetic2 purposes. In addition, the investigators found no difference in clinical outcomes during a 3- to 6-month follow-up period. The reason for this difference is the presence of benzyl alcohol in preserved saline, which acts as both a preservative and an anesthetic. Furthermore, a consensus panel on the use of BT-A agreed that preserved saline can be used for dilution, given its improved clinical tolerability.6 Regarding efficacy, numerous studies have examined the effectiveness of BT-A after reconstitution
Liu et al 375
and storage beyond the suggested 4 hours. Under those conditions, animal7 and in vitro8 studies have shown decreases in duration of action and potency, respectively. However, clinical evaluations with human beings have not shown similar reductions in efficacy or duration of action. Jabor et al7 used a rabbit model to compare BT-A reconstituted and refrigerated for up to 12 weeks with freshly reconstituted BT-A. They found no differences in initial potency but a decrease in duration of action after storage periods of greater than 2 weeks. The inherent difficulty regarding in vitro and animal studies is determining its significance in human beings. Clinical studies have not shown reduced efficacy after the use of BT-A reconstituted and stored for various time intervals including 1 week,9 2 weeks,10-13 6 weeks,14 or 6 months.15 Lizarralde et al9 compared BT-A reconstituted and refrigerated for 1 week with freshly reconstituted BT-A in treating external canthus dynamic lines (crow’s feet). Assessments included a facial nerve conduction study and photographic evaluation, with a follow-up period of 18 weeks. No significant differences were seen between the two groups in initial potency or duration of action. Sloop et al10 compared freshly reconstituted BT-A with toxin that was reconstituted and either frozen or refrigerated for 2 weeks. No difference in potency between the groups was noted upon evaluation of the degree of extensor digitorum brevis muscle paralysis. The treatment of different facial locations has also been examined in studies of BT-A reconstitution and storage. After cold storage of reconstituted BT-A for 2 weeks, the toxin has been shown to retain its efficacy and time of onset in the treatment of lateral periorbital rhytids11 (crow’s feet), horizontal forehead rhytids,13 and glabellar rhytids.12 The follow-up periods in these studies ranged from 3 to 4 months. Clinical studies of reconstituted BT-A using longer storage periods provide stronger evidence of the stability of the toxin. Hexsel et al14 did not reveal any diminution of the efficacy on glabellar rhytids of BT-A after refrigerator storage of reconstituted vials for 6 weeks. In fact, with a follow-up period of more than 4 months, no detrimental effect on toxin efficacy was seen in this study of 6-week-old reconstituted BT-A. Parsa et al15 compared reconstituted BT-A frozen for 6 months with freshly reconstituted BT-A for treating glabellar, forehead transverse, and lateral canthal rhytids. Again, no loss in potency was noted after prolonged cold storage in this study as well. In addition to efficacy, the extended lengths of storage also theoretically raise concerns for possible contamination. However, none of the clinical studies cited in this article reported any instances of
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Fig 1. Questionnaire completed by study participants.
cutaneous infection after the application of reconstituted BT-A stored for longer than the recommended 4 hours. No evidence of bacterial contamination has been reported after cold storage of reconstituted BT-A for periods of 5 to 7 days,16 7 weeks,17 12 weeks,7 and 10 months.12 Menon and Murray16 did not find any microbial growth in vials of reconstituted BT-A after 4 hours of exposure to room temperature followed by refrigerator storage for 5 to 7 days. Alam et al17 found no contamination in vials of reconstituted BT-A after
refrigerator storage and serial re-extractions over 7 weeks. In a study with one of the longest periods of refrigerator storage, no bacterial contamination was identified after 10 months.12 Together, these studies provide solid evidence that BT-A reconstitution and storage for periods significantly longer than suggested by the manufacturers is both safe and clinically effective, and commonplace in clinical practice. Our recommendation for the storage and use of BT-A for 2 weeks after reconstitution is based on the numerous studies
J AM ACAD DERMATOL VOLUME 67, NUMBER 3
Fig 2. Number of years in practice by participating physicians.
Fig 3. Method of reconstitution of botulinum toxin type A.
Liu et al 377
Fig 5. Physician viewpoints regarding time period during which reconstituted botulinum toxin type A can be safely used for treating patients.
Fig 6. Instances of local infection after botulinum toxin type A injection.
beyond 2 weeks would need to be performed to provide sufficient evidence for a longer storage period. The safety of using single-patient vials for multiple patients rests upon the practice of safe injection techniques by the physician and support staff. Overall, this has important practical implications for both clinicians and patients in the office setting. Specifically, patients will have much greater flexibility with regard to scheduling for treatments, and physicians will not have to needlessly discard large amounts of reconstituted BT-A, which would otherwise ultimately result in a greater financial burden to the patient. Fig 4. Duration of use of reconstituted botulinum toxin type A vials.
demonstrating preserved toxin efficacy after a 2-week storage period.10-13 Additional studies demonstrating the safety and efficacy of BT-A storage
REFERENCES 1. Alam M, Dover JS, Arndt KA. Pain associated with injection of botulinum A exotoxin reconstituted using isotonic sodium chloride with and without preservative: a double blind, randomized controlled trial. Arch Dermatol 2002;138:510-4. 2. Kwiat DM, Bersani TA, Bersani A. Increased patient comfort utilizing botulinum toxin type A reconstituted with preserved
J AM ACAD DERMATOL
378 Liu et al
3.
4.
5.
6.
7.
8.
9.
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