Pharmacotherapeutic group: other peripherally acting muscle relaxants, ATC code: M03AX01
Mechanism of action
The primary pharmacodynamic effect of botulinum toxin type A is chemical denervation of the treated muscle, resulting in a measurable decrease in the compound muscle action potential. This causes a localised reduction in muscle activity.
Botulinum toxin type A is a muscle relaxant that temporarily weakens muscle activity. Following injection, botulinum toxin type A acts by blocking the transport of the neurotransmitter acetylcholine at the neuromuscular junctions located between the nerve terminal and the muscle fibre. The mechanism of action involves 4 main phases. For the effect to manifest, all of these phases must proceed correctly. The consequence is cessation of contractions in the target muscles. The effect persists until the junction recovers and muscle activity is restored.
Clinical efficacy and safety
In 2 pivotal studies, a total of 372 patients with moderate to severe glabellar lines were treated, 250 at the recommended dose of 50 Speywood units and 122 with placebo.
The majority of patients subjectively reported onset of effect within 2 to 3 days, including 23% of patients who reported effect within 1 day.
One month after injection, the responder rate as assessed by the investigator was statistically significantly higher in patients treated with Alluzience compared to placebo (primary efficacy endpoint), as well as at all other time points from 8 days to 6 months (Table 2).
Table 2: Investigator Live Assessment at maximum frown – response rate (%) at various time points
Post-injection visit
Alluzience (n=250)
Placebo (n=122)
8 days
80.0%
2.5%
1 month
87.6%
2.5%
2 months
76.8%
1.7%
3 months
57.6%
1.7%
4 months
36.3%
1.8%
Post-injection visit
Alluzience (n=250)
Placebo (n=122)
5 months
17.5%
0.9%
6 months
10.0%
0.9%
Note: A responder is defined as a person who has a severity grade of moderate or severe at baseline and a severity grade of none or mild at the given visit.
The response rate, the primary efficacy endpoint at Day 29, was statistically significantly different from placebo (p <0.0001). Response rates at other time points were nominally different from placebo (p-values ranging from ≤0.0001 to 0.0008).
The proportion of responders based on patient self-assessment was higher in patients treated with Alluzience compared to placebo at all time points from 8 days to 6 months (Table 3).
Table 3: Patient self-assessment – response rate (%) at various time points
Post-injection visit
Alluzience (n=250)
Placebo (n=122)
8 days
66.0%
4.9%
1 month
76.8%
5.7%
2 months
72.4%
2.5%
3 months
48.8%
3.4%
4 months
32.7%
4.3%
5 months
23.1%
4.3%
6 months
15.1%
2.6%
Note: A responder is defined as a person who has a severity grade of moderate or severe at baseline and a severity grade of none or mild at the given visit.
Response rates were nominally different from placebo, with p-values ≤0.0001 at all time points.
Patient satisfaction level 1 month after injection showed that 85.2% of patients following use of Alluzience were either satisfied or very satisfied, compared with 9% of placebo-treated patients.
Aesthetic and psychological improvement was monitored using Face-Q scales. For the overall facial appearance scale (which includes subject ratings for facial symmetry, appearance at end of day, facial freshness, rested appearance, appearance upon waking, and appearance under bright light) and the psychological well-being scale (which includes subject ratings for feeling well, self-acceptance, feeling comfortable with oneself, feeling that I like myself, feeling happy, feeling attractive, and feeling self-confident) at one month post-injection, patients treated with Alluzience showed improvement in scores for each of these scales compared with patients treated with placebo (nominal p <0.0001).
In a long-term, open-label, phase III study lasting 12 months, a total of 595 patients received up to 5 treatment cycles with Alluzience. Based on investigator assessment, patient assessment, patient satisfaction, and FACE-Q questionnaires, efficacy was maintained over 12 months.
The proportion of responders at maximum frown as determined by the assessor at 1 month post-injection was maintained across repeated injection cycles (between 82.2% and 87.8%). Corresponding proportions at 3 months post-injection ranged between 45.3% and 56.8% over 5 treatment cycles.
Patients (total of 595) who received Alluzience over 12 months were tested for antibody formation. No patients tested positive for toxin-neutralising antibodies.
⚠️ Warnings
Care should be taken to ensure that Alluzience is not injected into a blood vessel.
Injection of Alluzience is not recommended in patients with a history of dysphagia and aspiration.
Very rarely, adverse reactions probably related to the spread of toxin to sites distant from the site of administration have been reported with botulinum toxin. Swallowing and respiratory disorders are serious and may be a cause of death.
Very rarely, cases of death have been reported following treatment with botulinum toxin A or B, sometimes in association with dysphagia, pneumopathy (including dyspnoea, respiratory failure, respiratory arrest, and other symptoms) and/or in patients with significant asthenia.
Patients should be advised to seek immediate medical attention if they experience difficulties with swallowing, speaking, or breathing.
Alluzience should be used with caution in patients at risk for or with clinical signs of significant neuromuscular transmission disorder. These patients may have increased sensitivity to agents such as botulinum toxin, and excessive muscle weakness may follow treatment.
Before administration of Alluzience, it is essential to examine the patient's facial anatomy. Consideration should be given to facial asymmetry, ptosis, excessive dermatochalasis, scarring, and any changes in anatomy as a result of prior surgical intervention.
Cases of dry eye have been reported when Alluzience is used in the area around the eyes (see section 4.8). It is important to pay attention to this adverse effect, as dry eyes may predispose to corneal disorders. Protective drops, ointment, eye patching, or other measures to protect the eye may be necessary for the prevention of corneal disorders.
The recommended dose and frequency of administration of Alluzience must not be exceeded.
Patients treated at the recommended dose may experience exaggerated muscle weakness.
Caution is required if Alluzience is used in the presence of inflammation at the proposed injection site or if the target muscle(s) exhibit(s) excessive weakness or atrophy. Cases of muscle atrophy have been reported following the use of botulinum toxin (see section 4.8).
As with all intramuscular injections, the use of Alluzience is not recommended in patients who have a prolonged bleeding time.
One vial of Alluzience must be used for the treatment of one patient during a single session.
Any remaining unused product must be disposed of as indicated in section 6.6. Special care is required when inactivating and disposing of remaining unused solution (see section 6.6).
Antibody formation
Injections at more frequent intervals or at higher doses may increase the risk of formation of neutralising antibodies against botulinum toxin. Clinically, the formation of neutralising antibodies may reduce the efficacy of subsequent treatment.
Traceability
In order to improve the traceability of biological medicinal products, the name of the administered product and the batch number should be clearly recorded.
Sodium content
This medicinal product contains less than 1 mmol (23 mg) of sodium per vial containing 125 units, that is to say it is essentially 'sodium-free'.
PillsCard reference image