Rimabotulinumtoxinb
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Turky Alkathery, M.D. [2]
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Black Box Warning
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DISTANT SPREAD OF TOXIN EFFECT
See full prescribing information for complete Boxed Warning.
Postmarketing reports indicate that the effects of MYOBLOC and all botulinum toxin products may spread from the area of injection to produce symptoms consistent with botulinum toxin effects. These 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. The risk of symptoms is probably greatest in children treated for spasticity but symptoms can also occur in adults treated for spasticity and other conditions, 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, cases of spread of effect have occurred at doses comparable to those used to treat cervical dystonia and at lower doses.
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Overview
Rimabotulinumtoxinb is a neurotoxic protein that is FDA approved for the treatment of adults with cervical dystonia to reduce the severity of abnormal head position and neck pain associated with cervical dystonia. There is a Black Box Warning for this drug as shown here. Common adverse reactions include dry mouth, dysphagia, dyspepsia, and injection site pain.
Adult Indications and Dosage
FDA-Labeled Indications and Dosage (Adult)
Indications
- MYOBLOC is indicated for the treatment of adults with cervical dystonia to reduce the severity of abnormal head position and neck pain associated with cervical dystonia.
Off-Label Use and Dosage (Adult)
Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Rimabotulinumtoxinb in adult patients.
Non–Guideline-Supported Use
There is limited information regarding Off-Label Non–Guideline-Supported Use of Rimabotulinumtoxinb in adult patients.
Pediatric Indications and Dosage
FDA-Labeled Indications and Dosage (Pediatric)
There is limited information regarding Rimabotulinumtoxinb FDA-Labeled Indications and Dosage (Pediatric) in the drug label.
Off-Label Use and Dosage (Pediatric)
Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Rimabotulinumtoxinb in pediatric patients.
Non–Guideline-Supported Use
There is limited information regarding Off-Label Non–Guideline-Supported Use of Rimabotulinumtoxinb in pediatric patients.
Contraindications
MYOBLOC is contraindicated in patients with a known hypersensitivity to any botulinum toxin preparation or to any of the components in the formulation.
MYOBLOC is contraindicated for use in patients with infection at the proposed injection site(s).
Warnings
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DISTANT SPREAD OF TOXIN EFFECT
See full prescribing information for complete Boxed Warning.
Postmarketing reports indicate that the effects of MYOBLOC and all botulinum toxin products may spread from the area of injection to produce symptoms consistent with botulinum toxin effects. These 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. The risk of symptoms is probably greatest in children treated for spasticity but symptoms can also occur in adults treated for spasticity and other conditions, 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, cases of spread of effect have occurred at doses comparable to those used to treat cervical dystonia and at lower doses.
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Lack of Interchangeability between Botulinum Toxin Products The potency Units of MYOBLOC are specific to the preparation and assay method utilized. They are not interchangeable with other preparations of botulinum toxin products and, therefore, units of biological activity of MYOBLOC cannot be compared to or converted into units of any other botulinum toxin products assessed with any other specific assay method (see DESCRIPTION).
Spread of Toxin Effect Postmarketing safety data from MYOBLOC 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 spread of toxin effects. The risk of symptoms is probably greatest in children treated for spasticity but symptoms can also 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.
Dysphagia and Breathing Difficulties in Treatment of Cervical Dystonia Treatment with MYOBLOC 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.
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 a critical loss of breathing capacity in patients with respiratory disorders who may have become dependent upon these accessory muscles. There have been postmarketing reports of serious breathing difficulties, including respiratory failure, in cervical dystonia patients. 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 ADVERSE REACTIONS, CLINICAL PHARMACOLOGY).
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 MYOBLOC (see ADVERSE REACTIONS).
Human Albumin 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) also is considered extremely remote. No cases of transmission of viral diseases or CJD have ever been identified for albumin.
Precations
Only 9 subjects without a prior history of tolerating injections of type A botulinum toxin have been studied. Treatment of botulinum toxin naïve patients should be initiated at lower doses of MYOBLOC (see ADVERSE REACTIONS: OVERVIEW).
Adverse Reactions
Clinical Trials Experience
There is limited information regarding Rimabotulinumtoxinb Clinical Trials Experience in the drug label.
Postmarketing Experience
There is limited information regarding Rimabotulinumtoxinb Postmarketing Experience in the drug label.
Drug Interactions
Co-administration of MYOBLOC and aminoglycosides or other agents interfering with neuromuscular transmission (e.g., curare-like compounds) should only be performed with caution as the effect of the toxin may be potentiated.
The effect of administering different botulinum neurotoxin serotypes at the same time or within less than 4 months of each other is unknown. However, neuromuscular paralysis may be potentiated by co-administration or overlapping administration of different botulinum toxin serotypes.
Use in Specific Populations
Pregnancy
Pregnancy Category (FDA): C
Animal reproduction studies have not been conducted with MYOBLOC. It is also not known whether MYOBLOC can cause fetal harm when administered to a pregnant woman or can affect reproduction capacity. MYOBLOC should be given to a pregnant woman only if clearly needed.
Pregnancy Category (AUS):
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Rimabotulinumtoxinb in women who are pregnant.
Labor and Delivery
There is no FDA guidance on use of Rimabotulinumtoxinb during labor and delivery.
Nursing Mothers
It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when MYOBLOC is administered to a nursing woman.
Pediatric Use
Safety and effectiveness in pediatric patients have not been established.
Geriatic Use
In the controlled studies summarized in CLINICAL STUDIES, for MYOBLOC treated patients, 152 (74.5%) were under the age of 65, and 52 (25.5%) were aged 65 or greater. For these age groups, the most frequent reported adverse events occurred at similar rates in both age groups. Efficacy results did not suggest any large differences between these age groups.
Very few patients aged 75 or greater were enrolled, therefore no conclusions regarding the safety and efficacy of MYOBLOC within this age group can be determined.
Gender
There is no FDA guidance on the use of Rimabotulinumtoxinb with respect to specific gender populations.
Race
There is no FDA guidance on the use of Rimabotulinumtoxinb with respect to specific racial populations.
Renal Impairment
There is no FDA guidance on the use of Rimabotulinumtoxinb in patients with renal impairment.
Hepatic Impairment
There is no FDA guidance on the use of Rimabotulinumtoxinb in patients with hepatic impairment.
Females of Reproductive Potential and Males
There is no FDA guidance on the use of Rimabotulinumtoxinb in women of reproductive potentials and males.
Immunocompromised Patients
There is no FDA guidance one the use of Rimabotulinumtoxinb in patients who are immunocompromised.
Administration and Monitoring
Administration
There is limited information regarding Rimabotulinumtoxinb Administration in the drug label.
Monitoring
There is limited information regarding Rimabotulinumtoxinb Monitoring in the drug label.
IV Compatibility
There is limited information regarding the compatibility of Rimabotulinumtoxinb and IV administrations.
Overdosage
Excessive doses of MYOBLOC may be expected to produce neuromuscular weakness with a variety of symptoms. Respiratory support may be required where excessive doses cause paralysis of respiratory muscles. In the event of overdose, the patient should be medically monitored for symptoms of excessive muscle weakness or muscle paralysis (see WARNINGS and PRECAUTIONS).Symptomatic treatment may be necessary.
Symptoms of overdose are likely not to be present immediately following injection. Should accidental injection or oral ingestion occur, the person should be medically supervised for several weeks for signs and symptoms of excessive muscle weakness or muscle paralysis.
In the event of overdose, antitoxin raised against botulinum toxin is available from the Centers for Disease Control and Prevention (CDC) in Atlanta, GA. However, the antitoxin will not reverse any botulinum toxin-induced effects already apparent by the time of antitoxin administration. In the event of suspected or actual cases of botulinum toxin poisoning, please contact your local or state Health Department to process a request for antitoxin through the CDC.
Pharmacology
There is limited information regarding Rimabotulinumtoxinb Pharmacology in the drug label.
Mechanism of Action
There is limited information regarding Rimabotulinumtoxinb Mechanism of Action in the drug label.
Structure
There is limited information regarding Rimabotulinumtoxinb Structure in the drug label.
Pharmacodynamics
There is limited information regarding Rimabotulinumtoxinb Pharmacodynamics in the drug label.
Pharmacokinetics
There is limited information regarding Rimabotulinumtoxinb Pharmacokinetics in the drug label.
Nonclinical Toxicology
No long-term carcinogenicity studies in animals have been performed.
Clinical Studies
There is limited information regarding Rimabotulinumtoxinb Clinical Studies in the drug label.
How Supplied
There is limited information regarding Rimabotulinumtoxinb How Supplied in the drug label.
Storage
There is limited information regarding Rimabotulinumtoxinb Storage in the drug label.
Images
Drug Images
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Package and Label Display Panel
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Patient Counseling Information
The physician should provide a copy of the FDA-Approved Patient Medication Guide and review the contents with the patient. Patients should be advised to inform their doctor or pharmacist if they develop any unusual symptoms (including difficulty with swallowing, speaking or breathing), or if any existing symptom worsens.
Patients should be counseled that if loss of strength, muscle weakness, or impaired vision occur, they should avoid driving a car or engaging in other potentially hazardous activities.
Precautions with Alcohol
Alcohol-Rimabotulinumtoxinb interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.
Brand Names
There is limited information regarding Rimabotulinumtoxinb Brand Names in the drug label.
Look-Alike Drug Names
There is limited information regarding Rimabotulinumtoxinb Look-Alike Drug Names in the drug label.
Drug Shortage Status
Price
References
The contents of this FDA label are provided by the National Library of Medicine.