Abstract
BackgroundBotulinum toxin A (BoNT‐A) is an effective treatment for cervical dystonia. Nevertheless, up to 30% to 40% patients discontinue treatment, often because of poor response. The British Neurotoxin Network (BNN) recently published guidelines on the management of poor response to BoNT‐A in cervical dystonia, but adherence to these guidelines has not yet been assessed.ObjectivesTo assess adherence to and usefulness of BNN guidelines in clinical practice.MethodsWe undertook a retrospective medical notes audit of adherence to the BNN guidelines in 3 United Kingdom tertiary neurosciences centers.ResultsOf 76 patients identified with poor response, 42 (55%) had a suboptimal response and, following BNN recommendations, 25 of them (60%) responded to adjustments in BoNT dose, muscle selection or injection technique. Of the remaining 34 (45%) patients with no BoNT response, 20 (59%) were tested for immune resistance, 8 (40%) of whom showed resistance. Fourteen (18%) of all patients were switched to BoNT‐B, and 27 (36%) were referred for deep brain stimulation surgery. In those not immune to BoNT‐A, clinical improvement was seen in 5 (41%) after adjusting their dose and injection technique.ConclusionOur audit shows that optimizing BoNT dose or injection strategy largely led to improvements in those with suboptimal response and in those reporting no response without resistance. It would be helpful to standardize investigations of potential resistance in those with no therapeutic response.
Highlights
Botulinum toxin A (BoNT-A) is an effective treatment for cervical dystonia
Data from patients with Cervical dystonia (CD) who had been identified as having secondary non-response to BoNT-A injections were collected using a standardized proforma encompassing the steps outlined in the British Neurotoxin Network (BNN) guidelines
We defined poor response as per the BNN guidelines as “two consecutive treatments with suboptimal response, where the patient has previously received a minimum of two successful injection cycles”
Summary
Botulinum toxin A (BoNT-A) is an effective treatment for cervical dystonia. up to 30% to 40% patients discontinue treatment, often because of poor response. The British Neurotoxin Network (BNN) recently published guidelines on the management of poor response to BoNT-A in cervical dystonia, but adherence to these guidelines has not yet been assessed. Results: Of 76 patients identified with poor response, 42 (55%) had a suboptimal response and, following BNN recommendations, 25 of them (60%) responded to adjustments in BoNT dose, muscle selection or injection technique. Fourteen (18%) of all patients were switched to BoNT-B, and 27 (36%) were referred for deep brain stimulation surgery In those not immune to BoNT-A, clinical improvement was seen in 5 (41%) after adjusting their dose and injection technique. Conclusion: Our audit shows that optimizing BoNT dose or injection strategy largely led to improvements in those with suboptimal response and in those reporting no response without resistance. It would be helpful to standardize investigations of potential resistance in those with no therapeutic response
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