Efficacy and Safety of OnabotulinumtoxinA 400 Units in Patients with Post-Stroke Upper Limb Spasticity: Final Report of a Randomized, Double-Blind, Placebo-Controlled Trial with an Open-Label Extension Phase

Abstract

In many countries, 400 units (U) is the maximum dose of onabotulinumtoxinA available to treat upper limb spasticity, but few studies have demonstrated the optimal use of this dose. In the double-blind phase of this randomized, controlled trial, we compared the efficacy and safety of 400 vs. 240 U onabotulinumtoxinA in patients with post-stroke upper limb spasticity. Both groups received 240 U onabotulinumtoxinA injected in the forearm. An additional 160 U onabotulinumtoxinA (400 U group) or placebo (240 U group) was injected in the elbow flexors. Both groups showed similar muscle tone reduction in the wrist, fingers, and thumb; muscle tone reduction in the elbow flexors was greater in the group treated with onabotulinumtoxinA (400 U group) compared to placebo (240 U group). Functional disabilities improved in both groups. No substantial difference was found in safety profiles. In the subsequent open-label phase, all participants received repeat injections of 400 U onabotulinumtoxinA (target muscles and doses per muscle determined by the physician). Similar efficacy and safety outcomes, as with the 400 U group in the double-blind phase, were confirmed. This final report demonstrates that injection of onabotulinumtoxinA 400 U relieves muscle tone in a wide range of areas and improves functional disabilities; generally, it was well-tolerated, and no new safety concerns were identified. The dosing data in the open-label phase will inform optimal use of onabotulinumtoxinA in clinical practice (ClinicalTrials.gov: NCT03261167).

Keywords: botulinum toxin; randomized controlled trial; stroke; upper limb spasticity.

Figure 1

Study design. BoNT/A, botulinum toxin type A (onabotulinumtoxinA). Reproduced with permission from Abo, M., et al., Progress in Medicine, published by Life Science Co., Ltd., 2019 [in Japanese].

Figure 2

Change from baseline in the Modified Ashworth Scale (MAS) scores across all treatment cycles for the 400 U group at (a) elbow, (b) wrist, (c) fingers, and (d) thumb. Treatment cycles are represented as: treatment cycle 1 (double-blind phase, purple), treatment cycle 2 (open-label phase, green), treatment cycle 3 (open-label phase, yellow), and treatment cycle 4 (open-label phase, red). CI, confidence interval.