JEADV
DOI: 10.1111/jdv.12408
ORIGINAL ARTICLE
Double-blind, randomized non-inferiority trial of a novel botulinum toxin A processed from the strain CBFC26, compared with onabotulinumtoxin A in the treatment of glabellar lines B.J. Kim,1,† H.H. Kwon,2,3,† S.Y. Park,2,3,† S.U. Min,2,3 J.Y. Yoon,3 Y.M. Park,4 S.H. Seo,5 J.Y. Ahn,6 H.K. Lee,7 D.H. Suh2,3,* 1
Department of Dermatology, Chung-Ang University College of Medicine, Seoul, Korea Department of Dermatology, Seoul National University College of Medicine, Seoul, Korea 3 Acne & Rosacea Research Laboratory, Seoul National University Hospital, Seoul, Korea 4 Department of Dermatology, Seoul St Mary’s Hospital, Catholic University of Korea, Seoul, Korea 5 Department of Dermatology, Korea University College of Medicine, Seoul, Korea 6 Department of Dermatology, National Medical Center, Seoul, Korea 7 Department of Dermatology, College of Medicine, Eulji University, Seoul, Korea *Correspondence: D.H. Suh. E-mail: [email protected] 2
Abstract Background Botulinum toxins have been widely used in cosmetic dermatology. Neurotoxin from the CBFC26 strain (NTC) is a recently developed botulinum toxin type A product manufactured through refined procedures. Objective A double-blinded, randomized, multicentre-designed, phase III trial to investigate the non-inferiority of NTC to existing botulinum toxin A, onabotulinumtoxin A in the treatment of moderate to severe glabellar lines. Methods A total of 272 subjects were randomized in a 1 : 1 ratio to receive 20 U of NTC or onabotulinumtoxin A. The primary endpoint was the response rate of physicians’ assessment (PA) using the Facial Wrinkle Scale at week 4. The secondary endpoints included the response rate of PA at weeks 8, 12 and 16, and photographic assessment at weeks 4, 8, 12 and 16. Subjects’ improvement assessment and subjective self-satisfaction levels were also investigated. Results Response rates for maximum frown were 89.3% in the NTC group and 81.9% in the onabotulinumtoxin A group at week 4. NTC also resulted in comparable results for both the response rates of the other evaluation points and incidence of adverse events compared to those of onabotulinumtoxin A. In subjects’ improvement assessment and photographic evaluations, NTC even demonstrated better results compared with onabotulinumtoxin A in the early phase after treatment. Analysis of these results strongly supports the non-inferiority of NTC to onabotulinumtoxin A in the efficacy and safety. Conclusion NTC is as effective as onabotulinumtoxin A in the treatment of glabellar lines, and both products were well tolerated. Received: 9 October 2013; Accepted: 19 January 2014
Conflicts of interest None declared.
Funding sources This study was supported by SNUH research fund (H 1106-010-364).
Introduction Botulinum toxins have been widely used over 20 years for aesthetic purposes.1,2 Since Food and Drug Administration (FDA) approved botulinum toxin type A for cosmetic uses in †
These authors equally contributed the work as the first authors.
JEADV 2014, 28, 1761–1767
2002, its range of aesthetic uses has expanded, and a consensus about injection techniques has become well established.3,4 Among many possible cosmetic applications, targeting glabellar frown lines has been consistently regarded as one of the most popular indications in dermatology practices.5–9 Several botulinum toxin type A products are available, and a few clinical
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trials have compared their efficacies for the glabellar lines.10,11 However, rigorous investigation of efficacy and safety of newly introduced botulinum toxin type A products in the view of both dermatologists and patients is consistently required considering potential danger of botulinum toxin A and need for standardizations before its universal uses. Both neurotoxin from CBFC26 strain (NTC; Botulaxâ, Hugel, Chuncheon, Korea) and onabotulinumtoxin A (Botox/ Vistabelâ; Allergan, Irvine, CA, USA) are processed type A botulinum toxin products. Onabotulinumtoxin A is one of the most widely used botulinum toxin type A product in dermatology field. NTC is a newly manufactured product from the C. botulinum strain CBFC26, which is cloned by polymerase chain reactions after screening of various food products under appropriate culture conditions. Among several candidates discovered, CBFC26 showed the highest toxicity in mice, and its 16S rRNA and toxin sequences were completely identical to those of the ATCC 3502 Hall A strain, which is an onabotulinumtoxin A producing bacterium. In addition, NTC passes through additional steps to improve the quality level, which are enzyme-free purification processes to remove nucleic acids by protamine sulphate precipitation and diethylaminoethanol-sepharose chromatography. This step has been expected at least partly to resolve safety issues of the botulinum toxin products that may be caused by the use of enzymes of animal origins and by remnant nucleic acids. Furthermore, the market price of NTC is lower than that of onabotulinumtoxin A. NTC has been approved in treating blepharospasm by FDA of many Asian, European and Latin American countries. The purpose of this large head-to-head study was to demonstrate the non-inferiority of NTC to onabotulinumtoxin A for treating moderate-to-severe glabellar lines when injected at a 1 : 1 dose ratio.
Materials and methods This study was a double-blinded, randomized, multicentredesigned, phase III clinical trial performed at six hospitals in Korea. This study was overseen by the institutional review board of each hospital and was performed according to the standards of Good Clinical Practice and the International Conference on
Harmonization between July 2011 and December 2012 under the same protocol. This study followed the ethical principles of the Declaration of Helsinki. Each participant gave informed consents before any procedure.
Subjects A total of 272 participants aged 18–65, with moderate-to-severe glabellar lines [severity score of 2 or 3 on the Facial Wrinkle Scale (FWS)] at maximum frown, were included (supplementary information for FWS). Exclusion criteria were as follows: previous facial plastic surgery or other procedures that may have affected glabellar lines within 6 months, any skin diseases or scars in the glabellar area, marked facial palsy or ptosis, neuromuscular junction disorders, previous injection of botulinum toxin within 3 months (type A) or 4 months (type B), administration of muscle relaxants within 4 weeks, scheduled facial cosmetic procedure during the study period, wrinkles that could not be physically flattened, past history of hypersensitivity to botulinum toxins or additional ingredient, pregnant or breastfeeding status, and any other medical condition that could be risky for patients injected with botulinum toxins. Study design
Participants were randomized into two groups at a 1 : 1 (NTC: onabotulinumtoxin A) ratio. The study duration was 16 weeks after the injections with a 2-week screening period. Eligible patients were randomized and treated with either onabotulinumtoxin A or NTC. A blocked random allocation sequence was created by computer-generated random numbers, and allocation to the either one of the two was performed by a third party. All dermatologists, managing nurses and patients were unaware of group assignments. Randomization codes were secured until all data entry was complete. Participants attended clinics at weeks 4, 8, 12 and 16 during the whole observation period. Efficacy and safety were assessed, and digital photographs of the treated area were taken at each visit. The total injected dose was 20 U NTC or onabotulinumtoxin A. Total injection volume was 0.5 mL, which was divided into five separate injections of 0.1 mL (4 U) into the procerus muscle and medial and middle parts of both corrugator muscles (Fig. 1).
Figure 1 Treatment injection sites.
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Efficacy and safety assessment
Statistical analysis
For the efficient comparisons of different evaluation methods, response rate was defined for all evaluation methods respectively. Grades for physicians’ assessment (PA) severity of both maximum frown and rest states of glabellar lines were designated as follows: 0 (free), 1 (mild), 2 (moderate), 3 (severe) respectively. The PA response rate was defined as the proportion of subjects whose posttreatment PA grade was 0 or 1. In addition, response rates of photograph assessment by three independent raters from digital photographs (same criterion as PA), subjects’ improvement assessment (proportion of subjects whose improvement grade was >2 in a 9-point scale from 4 (very marked worsening) to +4 (complete improvement) and subjects’ self-satisfaction assessment (proportion of subjects whose satisfaction grade was >6 in a 7-point scale from 1 (very dissatisfied) to 7 (very satisfied) were defined respectively. Detailed information of each evaluation grade is presented in supplementary information. The primary endpoint was the response rate of the PA using the FWS at maximum frown at week 4. The secondary endpoints included response rates of PA in other visits after week 4, photograph assessments, subjects’ improvement assessments and subjects’ self-improvement assessment in every visit. Adverse events (AEs) were defined as all unintended and harmful signs, symptoms, or diseases. Every AE was recorded in accordance with the National Cancer Institute Common Terminology Criteria for Adverse Events v 4.0. Laboratory tests (blood tests including complete blood count and electrolyte panel, urinalysis and urine human chorionic gonadotropin), vital signs, physical exams and botulinum toxin type A antibody test (mouse bioassay) were also conducted.
Randomized subjects with at least one efficacy evaluation method were included in the full analysis set (FAS). Per protocol set (PPS) included the FAS subjects without major protocol violations. A two-sided 95% confidence interval (CI) by the Chow test was calculated for the primary endpoint. If the lower boundary of the CI was not less than the non-inferiority margin of 0.15, non-inferiority of NTC to onabotulinumtoxin A was concluded. The analysis was based on the PPS, the main analysis group in the study. An additional FAS analysis was performed for the evidential basis of the efficacy evaluation. Among the secondary endpoints, those related to the response rate were compared using the chi-squared test. Likelihood ratio test was used to analyse categorical variables for AEs dictated. All subjects who received treatment were part of the safety evaluation set (SES). Safety analyses were performed based on the SES. Statistical analysis was performed using software (SPSS package for Windows, Release 17.0.1, SPSS Inc, Chicago, IL, USA).
Results Disposition of patients
In total, 272 participants were randomized at first, but one withdrew for personal reasons; thus, 271 subjects were treated with NTC or onabotulinumtoxin A and included in the SES. Among them, 268 (n = 134, NTC; n = 134, onabotulinumtoxin A) subjects whose primary efficacy analysis was performed were included in the FAS. As 19 subjects showed major protocol violations, the PPS included 249 subjects (n = 122, NTC; n = 127, onabotulinumtoxin A) finally. In summary, 262 subjects
Figure 2 Flow diagram showing the fate of patients in this RCT study (FAS, full analysis set; PPS, per protocol set).
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(n = 130, NTC; n = 132, onabotulinumtoxin A) completed the study (Fig. 2). No significant differences were observed between the demographics or baseline characteristics related to the botulinum toxins in the FAS (Table 1). Efficacy assessments – primary endpoint
The analysis of the primary endpoint (PA response rate at maximum frown 4 weeks after injection) resulted in high response rates in both treatment groups (Fig. 3). The NTC group had a higher response rate (89.3%) than the onabotulinumtoxin A group (81.9%) in the PPS (Table 2). As the lower boundary of the 95% CI ( 1.24) for the difference in response rate between the two groups was not lower than the non-inferiority margin ( 14.57), this result strongly supported the non-inferiority of NTC to onabotulinumtoxin A. Furthermore, the NTC group showed a higher PA response rate (P < 0.05) than the onabotulinumtoxin A group with a positive lower 95% CI boundary of 0.63 in the FAS.
Efficacy assessments – secondary endpoints
Among the secondary endpoints, PA response rates of the FAS and PPS were higher in the NTC group than those in the onabotulinumtoxin A group both at maximum frown and at rest at weeks 8, 12 and 16, while they were not significantly different. At maximum frown, PA response rates of the PPS were 72.0%, 60.2%, 47.5% for the NTC group and 65.9%, 49.6%, 37.6% for the onabotulinumtoxin A group at weeks 8, 12 and 16 respectively (P = 0.30, 0.10, 0.12). At rest, PA response rates of the PPS were 83.1%, 82.2%, 73.7% for the NTC group and 77.8%, 72.8%, 70.4% for the onabotulinumtoxin A group at weeks 8, 12 and 16 respectively (P = 0.30, 0.08, 0.56). Similar results were observed about the other secondary endpoints such as response rates of photographic assessments and the subjects’ improvement assessments (Fig. 4a,b). In the photograph assessment, response rates of NTC at maximum frown were higher than those of onabotulinumtoxin A, especially at weeks 4 and 8 with statistical significance (P = 0.02, 0.05). None of treatment-related TEAEs were reported as severe, and no abnormalities related to treatment were observed in any of the laboratory tests, vital signs, or physical exams in either group. All subjects were negative on the botulinum toxin type A antibody tests.
Discussion This is the first double-blind, randomized clinical trial of NTC for treating glabellar lines. In this large head-to-head comparison study, NTC and onabotulinumtoxin A had slightly higher or (b)
Figure 4 Response rates at every visit by different evaluation methods (a) photograph panel assessment at maximum frown and (b) subjects’ improvement assessments (*P < 0.05 between two different botulinum toxins in each follow-up visit, †P < 0.05 between comparison of mean response rates of photograph assessments and subjects’ improvement assessment at each follow-up visit). Response rates of NTC at maximum frown were higher than those of onabotulinumtoxin A at weeks 4 and 8. Differences in average response rates between two evaluation methods were observed at weeks 12 and 16.
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Figure 5 Response rates of subjects’ self-satisfactions for patients during follow-up visit. There was no significant difference between two groups.
comparable response rates consistently from both at maximum frown in week 4 and every other posttreatment visit from rigorous evaluations of different parties including an independent panel, the investigator and the patient. These results generally confirm the clinical equipotency of both products when used at a 1 : 1 dose ratio. In addition to objective assessments, patients’ subjective self-satisfactions are quite important in botulinum toxin procedures. In this study, both products induced good subjects’ improvement assessments and subjects’ self-satisfaction. Notably, NTC injections even resulted in a significantly better subjects’ improvement assessment at weeks 4 and 8, indicating better evaluation of NTC than that of onabotulinumtoxin A during the early phase after treatment. Response rates for maximum frown at week 4 in NTC was 89.3% and this level of effectiveness was consistent with previous
studies showing higher efficacy rates for Asian ethnic origins. General responder rates for maximum frown at week 4 were around 80.0% in pivotal research conducted in Western countries.11–13 This may reflect differences in muscle mass size, anatomic variance or frowning habits between various ethnic origins. Therefore, we strongly believe that individual dosage and injection techniques should be applied after considering patients’ ethnic origins or anatomic variations. And we also found that mean differences in response rates between photograph assessment at maximum frown and subjects’ improvement assessments increased after 12 weeks of injection. Patients seem to be more satisfied with efficacy of botulinum toxin subjectively comparing with objective assessments by an independent panel. Since leading to the agreement for the duration of efficacy from the perspective of both patients and practitioner is another quite important issue of determining injection period, further studies should be followed about this subject. About safety issues, both groups had a low incidence of TEAEs, and results were similar to safety profiles of previous studies about botulinum toxins used for the treatment of glabellar frown lines.7,8 Almost all TEAEs were not severe, and NTC even showed slightly lower incidences of TEAEs related to treatment than those of onabotulinumtoxin A in some points with no significance. New purification techniques might be helpful by eliminating the impurities. In addition, no abnormalities of laboratory tests, vital signs, or physical exams were observed and formation of neutral antibodies for botulinum toxin type A is not detected at all. A study reported that neutralizing antibody formation after onabotulinumtoxin A injection is rarely observed when used for therapeutic indications.14 Thus, NTC
Table 3 Full data of TEAEs, overall and related to study drugs (SES) NTC (n = 134)
Onabotulinumtoxin A (n = 137)
Total (n = 271)
P-value
Subjects with at least one TEAE
38 (28.4)
45 (32.8)
83 (30.6)
0.43
Infections and infestations
10 (7.5)
9 (6.6)
19 (7.0)
0.82
General disorders and administration site conditions
6 (4.5)
12 (8.8)
18 (6.6)
0.22
Injection site reaction
4 (3.0)
11 (8.0)
15 (5.5)
0.38
Eye disorders
10 (7.5)
7 (5.1)
17 (6.3)
0.46
Eyelid ptosis
6 (4.5)
3 (2.2)
9 (3.3)
0.33
Nervous system disorders
2 (1.5)
6 (4.4)
8 (3.0)
1.0
Respiratory, thoracic and mediastinal disorders
2 (1.5)
6 (4.4)
8 (3.0)
1.0
Skin and subcutaneous tissue disorders
6 (4.5)
2 (1.5)
8 (3.0)
0.17
Injury, poisoning and procedural complications
5 (3.7)
2 (1.5)
7 (2.6)
0.28 0.55
System organ class preferred term TEAEs, n (%)
TEAEs related to treatment, n (%) Subjects with at least one TEAE
12 (9.0)
16 (11.7)
28 (10.3)
General disorders and administration site conditions
5 (3.7)
11 (8.0)
16 (5.9)
0.20
Injection site reaction
4 (3.0)
11 (8.0)
15 (5.5)
0.11
Eye disorders
7 (5.2)
3 (2.2)
10 (3.7)
0.21
Eyelid ptosis
6 (4.5)
3 (2.2)
9 (3.3)
0.33
NTC, neurotoxin from the CBFC26 strain; SES, safety evaluation set; TEAEs, treatment-emergent adverse events.
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seems not at least to be inferior with onabotulinumtoxin A from a long-term safety perspective. Limitations of this study include that all subjects were Korean, which may not represent a general patient population of various ethnic groups, and majority of enrolled patients were female. Total duration of the study was also relatively short to present long-term data. In conclusion, NTC is as effective as onabotulinumtoxin A in the treatment of moderate-to-severe glabellar lines over at least 16 weeks in our study. Both toxins were generally well tolerated. NTC could be a new alternative to onabotulinumtoxin A.
References 1 Carruthers A, Carruthers J. Botulinum toxin products overview. Skin Therapy Lett 2008; 13: 1–4. 2 Carruthers A, Kiene K, Carruthers J. Botulinum A exotoxin use in clinical dermatology. J Am Acad Dermatol 1996; 34: 788–797. 3 Carruthers JD, Glogau RG, Blitzer A, Facial Aesthetics Consensus Group Faculty. Advances in facial rejuvenation: botulinum toxin type a, hyaluronic acid dermal fillers, and combination therapies–consensus recommendations. Plast Reconstr Surg 2008; 121: 5S–30S; quiz 1S-6S. 4 Carruthers JD, Carruthers JA. Treatment of glabellar frown lines with C. botulinum-A exotoxin. J Dermatol Surg Oncol 1992; 18: 17–21. 5 Carruthers JA, Lowe NJ, Menter MA et al. A multicenter, double-blind, randomized, placebo-controlled study of the efficacy and safety of botulinum toxin type A in the treatment of glabellar lines. J Am Acad Dermatol 2002; 46: 840–849. 6 Carruthers JD, Lowe NJ, Menter MA, Gibson J, Eadie N. Botox Glabellar Lines II Study Group. Double-blind, placebo-controlled study of the safety and efficacy of botulinum toxin type A for patients with glabellar lines. Plast Reconstr Surg 2003; 112: 1089–1098. 7 Carruthers A, Carruthers J. Prospective, double-blind, randomized, parallel-group, dose-ranging study of botulinum toxin type A in men with glabellar rhytids. Dermatol Surg 2005; 31: 1297–1303.
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8 Ascher B, Zakine B, Kestemont P, Baspeyras M, Bougara A, Santini J. A multicenter, randomized, double-blind, placebo-controlled study of efficacy and safety of 3 doses of botulinum toxin A in the treatment of glabellar lines. J Am Acad Dermatol 2004; 51: 223–233. 9 Harii K, Kawashima M. A double-blind, randomized, placebo-controlled, two-dose comparative study of botulinum toxin type A for treating glabellar lines in Japanese subjects. Aesthetic Plast Surg 2008; 32: 724–730. 10 Won CH, Lee HM, Lee WS et al. Efficacy and safety of a novel botulinum toxin type A product for the treatment of moderate to severe glabellar lines: a randomized, double-blind, active-controlled multicenter study. Dermatol Surg 2013; 39: 171–178. 11 Sattler G, Callander MJ, Grablowitz D et al. Noninferiority of incobotulinumtoxinA, free from complexing proteins, compared with another botulinum toxin type A in the treatment of glabellar frown lines. Dermatol Surg 2010; 36(Suppl. 4): 2146–2154. 12 Lowe P, Patnaik R, Lowe N. Comparison of two formulations of botulinum toxin type A for the treatment of glabellar lines: a double-blind, randomized study. J Am Acad Dermatol 2006; 55: 975–980. 13 Wu Y, Zhao G, Li H et al. Botulinum toxin type A for the treatment of glabellar lines in Chinese: a double-blind, randomized, placebo-controlled study. Dermatol Surg 2010; 36: 102–108. 14 Brin MF, Comella CL, Jankovic J, Lai F, Naumann M, CD-017 BoNTA Study Group. Long-term treatment with botulinum toxin type A in cervical dystonia has low immunogenicity by mouse protection assay. Mov Disord 2008; 23: 1353–1360.
Supporting information Additional Supporting Information may be found in the online version of this article: Data S1 Guidelines of physician’s assessments & photographic assessments.
© 2014 European Academy of Dermatology and Venereology
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DOI: 10.1111/jdv.12408
ORIGINAL ARTICLE
Double-blind, randomized non-inferiority trial of a novel botulinum toxin A processed from the strain CBFC26, compared with onabotulinumtoxin A in the treatment of glabellar lines B.J. Kim,1,† H.H. Kwon,2,3,† S.Y. Park,2,3,† S.U. Min,2,3 J.Y. Yoon,3 Y.M. Park,4 S.H. Seo,5 J.Y. Ahn,6 H.K. Lee,7 D.H. Suh2,3,* 1
Department of Dermatology, Chung-Ang University College of Medicine, Seoul, Korea Department of Dermatology, Seoul National University College of Medicine, Seoul, Korea 3 Acne & Rosacea Research Laboratory, Seoul National University Hospital, Seoul, Korea 4 Department of Dermatology, Seoul St Mary’s Hospital, Catholic University of Korea, Seoul, Korea 5 Department of Dermatology, Korea University College of Medicine, Seoul, Korea 6 Department of Dermatology, National Medical Center, Seoul, Korea 7 Department of Dermatology, College of Medicine, Eulji University, Seoul, Korea *Correspondence: D.H. Suh. E-mail: [email protected] 2
Abstract Background Botulinum toxins have been widely used in cosmetic dermatology. Neurotoxin from the CBFC26 strain (NTC) is a recently developed botulinum toxin type A product manufactured through refined procedures. Objective A double-blinded, randomized, multicentre-designed, phase III trial to investigate the non-inferiority of NTC to existing botulinum toxin A, onabotulinumtoxin A in the treatment of moderate to severe glabellar lines. Methods A total of 272 subjects were randomized in a 1 : 1 ratio to receive 20 U of NTC or onabotulinumtoxin A. The primary endpoint was the response rate of physicians’ assessment (PA) using the Facial Wrinkle Scale at week 4. The secondary endpoints included the response rate of PA at weeks 8, 12 and 16, and photographic assessment at weeks 4, 8, 12 and 16. Subjects’ improvement assessment and subjective self-satisfaction levels were also investigated. Results Response rates for maximum frown were 89.3% in the NTC group and 81.9% in the onabotulinumtoxin A group at week 4. NTC also resulted in comparable results for both the response rates of the other evaluation points and incidence of adverse events compared to those of onabotulinumtoxin A. In subjects’ improvement assessment and photographic evaluations, NTC even demonstrated better results compared with onabotulinumtoxin A in the early phase after treatment. Analysis of these results strongly supports the non-inferiority of NTC to onabotulinumtoxin A in the efficacy and safety. Conclusion NTC is as effective as onabotulinumtoxin A in the treatment of glabellar lines, and both products were well tolerated. Received: 9 October 2013; Accepted: 19 January 2014
Conflicts of interest None declared.
Funding sources This study was supported by SNUH research fund (H 1106-010-364).
Introduction Botulinum toxins have been widely used over 20 years for aesthetic purposes.1,2 Since Food and Drug Administration (FDA) approved botulinum toxin type A for cosmetic uses in †
These authors equally contributed the work as the first authors.
JEADV 2014, 28, 1761–1767
2002, its range of aesthetic uses has expanded, and a consensus about injection techniques has become well established.3,4 Among many possible cosmetic applications, targeting glabellar frown lines has been consistently regarded as one of the most popular indications in dermatology practices.5–9 Several botulinum toxin type A products are available, and a few clinical
© 2014 European Academy of Dermatology and Venereology
Kim et al.
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trials have compared their efficacies for the glabellar lines.10,11 However, rigorous investigation of efficacy and safety of newly introduced botulinum toxin type A products in the view of both dermatologists and patients is consistently required considering potential danger of botulinum toxin A and need for standardizations before its universal uses. Both neurotoxin from CBFC26 strain (NTC; Botulaxâ, Hugel, Chuncheon, Korea) and onabotulinumtoxin A (Botox/ Vistabelâ; Allergan, Irvine, CA, USA) are processed type A botulinum toxin products. Onabotulinumtoxin A is one of the most widely used botulinum toxin type A product in dermatology field. NTC is a newly manufactured product from the C. botulinum strain CBFC26, which is cloned by polymerase chain reactions after screening of various food products under appropriate culture conditions. Among several candidates discovered, CBFC26 showed the highest toxicity in mice, and its 16S rRNA and toxin sequences were completely identical to those of the ATCC 3502 Hall A strain, which is an onabotulinumtoxin A producing bacterium. In addition, NTC passes through additional steps to improve the quality level, which are enzyme-free purification processes to remove nucleic acids by protamine sulphate precipitation and diethylaminoethanol-sepharose chromatography. This step has been expected at least partly to resolve safety issues of the botulinum toxin products that may be caused by the use of enzymes of animal origins and by remnant nucleic acids. Furthermore, the market price of NTC is lower than that of onabotulinumtoxin A. NTC has been approved in treating blepharospasm by FDA of many Asian, European and Latin American countries. The purpose of this large head-to-head study was to demonstrate the non-inferiority of NTC to onabotulinumtoxin A for treating moderate-to-severe glabellar lines when injected at a 1 : 1 dose ratio.
Materials and methods This study was a double-blinded, randomized, multicentredesigned, phase III clinical trial performed at six hospitals in Korea. This study was overseen by the institutional review board of each hospital and was performed according to the standards of Good Clinical Practice and the International Conference on
Harmonization between July 2011 and December 2012 under the same protocol. This study followed the ethical principles of the Declaration of Helsinki. Each participant gave informed consents before any procedure.
Subjects A total of 272 participants aged 18–65, with moderate-to-severe glabellar lines [severity score of 2 or 3 on the Facial Wrinkle Scale (FWS)] at maximum frown, were included (supplementary information for FWS). Exclusion criteria were as follows: previous facial plastic surgery or other procedures that may have affected glabellar lines within 6 months, any skin diseases or scars in the glabellar area, marked facial palsy or ptosis, neuromuscular junction disorders, previous injection of botulinum toxin within 3 months (type A) or 4 months (type B), administration of muscle relaxants within 4 weeks, scheduled facial cosmetic procedure during the study period, wrinkles that could not be physically flattened, past history of hypersensitivity to botulinum toxins or additional ingredient, pregnant or breastfeeding status, and any other medical condition that could be risky for patients injected with botulinum toxins. Study design
Participants were randomized into two groups at a 1 : 1 (NTC: onabotulinumtoxin A) ratio. The study duration was 16 weeks after the injections with a 2-week screening period. Eligible patients were randomized and treated with either onabotulinumtoxin A or NTC. A blocked random allocation sequence was created by computer-generated random numbers, and allocation to the either one of the two was performed by a third party. All dermatologists, managing nurses and patients were unaware of group assignments. Randomization codes were secured until all data entry was complete. Participants attended clinics at weeks 4, 8, 12 and 16 during the whole observation period. Efficacy and safety were assessed, and digital photographs of the treated area were taken at each visit. The total injected dose was 20 U NTC or onabotulinumtoxin A. Total injection volume was 0.5 mL, which was divided into five separate injections of 0.1 mL (4 U) into the procerus muscle and medial and middle parts of both corrugator muscles (Fig. 1).
Figure 1 Treatment injection sites.
JEADV 2014, 28, 1761–1767
© 2014 European Academy of Dermatology and Venereology
Neurotoxin from CBFC26 strain
1763
Efficacy and safety assessment
Statistical analysis
For the efficient comparisons of different evaluation methods, response rate was defined for all evaluation methods respectively. Grades for physicians’ assessment (PA) severity of both maximum frown and rest states of glabellar lines were designated as follows: 0 (free), 1 (mild), 2 (moderate), 3 (severe) respectively. The PA response rate was defined as the proportion of subjects whose posttreatment PA grade was 0 or 1. In addition, response rates of photograph assessment by three independent raters from digital photographs (same criterion as PA), subjects’ improvement assessment (proportion of subjects whose improvement grade was >2 in a 9-point scale from 4 (very marked worsening) to +4 (complete improvement) and subjects’ self-satisfaction assessment (proportion of subjects whose satisfaction grade was >6 in a 7-point scale from 1 (very dissatisfied) to 7 (very satisfied) were defined respectively. Detailed information of each evaluation grade is presented in supplementary information. The primary endpoint was the response rate of the PA using the FWS at maximum frown at week 4. The secondary endpoints included response rates of PA in other visits after week 4, photograph assessments, subjects’ improvement assessments and subjects’ self-improvement assessment in every visit. Adverse events (AEs) were defined as all unintended and harmful signs, symptoms, or diseases. Every AE was recorded in accordance with the National Cancer Institute Common Terminology Criteria for Adverse Events v 4.0. Laboratory tests (blood tests including complete blood count and electrolyte panel, urinalysis and urine human chorionic gonadotropin), vital signs, physical exams and botulinum toxin type A antibody test (mouse bioassay) were also conducted.
Randomized subjects with at least one efficacy evaluation method were included in the full analysis set (FAS). Per protocol set (PPS) included the FAS subjects without major protocol violations. A two-sided 95% confidence interval (CI) by the Chow test was calculated for the primary endpoint. If the lower boundary of the CI was not less than the non-inferiority margin of 0.15, non-inferiority of NTC to onabotulinumtoxin A was concluded. The analysis was based on the PPS, the main analysis group in the study. An additional FAS analysis was performed for the evidential basis of the efficacy evaluation. Among the secondary endpoints, those related to the response rate were compared using the chi-squared test. Likelihood ratio test was used to analyse categorical variables for AEs dictated. All subjects who received treatment were part of the safety evaluation set (SES). Safety analyses were performed based on the SES. Statistical analysis was performed using software (SPSS package for Windows, Release 17.0.1, SPSS Inc, Chicago, IL, USA).
Results Disposition of patients
In total, 272 participants were randomized at first, but one withdrew for personal reasons; thus, 271 subjects were treated with NTC or onabotulinumtoxin A and included in the SES. Among them, 268 (n = 134, NTC; n = 134, onabotulinumtoxin A) subjects whose primary efficacy analysis was performed were included in the FAS. As 19 subjects showed major protocol violations, the PPS included 249 subjects (n = 122, NTC; n = 127, onabotulinumtoxin A) finally. In summary, 262 subjects
Figure 2 Flow diagram showing the fate of patients in this RCT study (FAS, full analysis set; PPS, per protocol set).
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(n = 130, NTC; n = 132, onabotulinumtoxin A) completed the study (Fig. 2). No significant differences were observed between the demographics or baseline characteristics related to the botulinum toxins in the FAS (Table 1). Efficacy assessments – primary endpoint
The analysis of the primary endpoint (PA response rate at maximum frown 4 weeks after injection) resulted in high response rates in both treatment groups (Fig. 3). The NTC group had a higher response rate (89.3%) than the onabotulinumtoxin A group (81.9%) in the PPS (Table 2). As the lower boundary of the 95% CI ( 1.24) for the difference in response rate between the two groups was not lower than the non-inferiority margin ( 14.57), this result strongly supported the non-inferiority of NTC to onabotulinumtoxin A. Furthermore, the NTC group showed a higher PA response rate (P < 0.05) than the onabotulinumtoxin A group with a positive lower 95% CI boundary of 0.63 in the FAS.
Efficacy assessments – secondary endpoints
Among the secondary endpoints, PA response rates of the FAS and PPS were higher in the NTC group than those in the onabotulinumtoxin A group both at maximum frown and at rest at weeks 8, 12 and 16, while they were not significantly different. At maximum frown, PA response rates of the PPS were 72.0%, 60.2%, 47.5% for the NTC group and 65.9%, 49.6%, 37.6% for the onabotulinumtoxin A group at weeks 8, 12 and 16 respectively (P = 0.30, 0.10, 0.12). At rest, PA response rates of the PPS were 83.1%, 82.2%, 73.7% for the NTC group and 77.8%, 72.8%, 70.4% for the onabotulinumtoxin A group at weeks 8, 12 and 16 respectively (P = 0.30, 0.08, 0.56). Similar results were observed about the other secondary endpoints such as response rates of photographic assessments and the subjects’ improvement assessments (Fig. 4a,b). In the photograph assessment, response rates of NTC at maximum frown were higher than those of onabotulinumtoxin A, especially at weeks 4 and 8 with statistical significance (P = 0.02, 0.05). None of treatment-related TEAEs were reported as severe, and no abnormalities related to treatment were observed in any of the laboratory tests, vital signs, or physical exams in either group. All subjects were negative on the botulinum toxin type A antibody tests.
Discussion This is the first double-blind, randomized clinical trial of NTC for treating glabellar lines. In this large head-to-head comparison study, NTC and onabotulinumtoxin A had slightly higher or (b)
Figure 4 Response rates at every visit by different evaluation methods (a) photograph panel assessment at maximum frown and (b) subjects’ improvement assessments (*P < 0.05 between two different botulinum toxins in each follow-up visit, †P < 0.05 between comparison of mean response rates of photograph assessments and subjects’ improvement assessment at each follow-up visit). Response rates of NTC at maximum frown were higher than those of onabotulinumtoxin A at weeks 4 and 8. Differences in average response rates between two evaluation methods were observed at weeks 12 and 16.
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Figure 5 Response rates of subjects’ self-satisfactions for patients during follow-up visit. There was no significant difference between two groups.
comparable response rates consistently from both at maximum frown in week 4 and every other posttreatment visit from rigorous evaluations of different parties including an independent panel, the investigator and the patient. These results generally confirm the clinical equipotency of both products when used at a 1 : 1 dose ratio. In addition to objective assessments, patients’ subjective self-satisfactions are quite important in botulinum toxin procedures. In this study, both products induced good subjects’ improvement assessments and subjects’ self-satisfaction. Notably, NTC injections even resulted in a significantly better subjects’ improvement assessment at weeks 4 and 8, indicating better evaluation of NTC than that of onabotulinumtoxin A during the early phase after treatment. Response rates for maximum frown at week 4 in NTC was 89.3% and this level of effectiveness was consistent with previous
studies showing higher efficacy rates for Asian ethnic origins. General responder rates for maximum frown at week 4 were around 80.0% in pivotal research conducted in Western countries.11–13 This may reflect differences in muscle mass size, anatomic variance or frowning habits between various ethnic origins. Therefore, we strongly believe that individual dosage and injection techniques should be applied after considering patients’ ethnic origins or anatomic variations. And we also found that mean differences in response rates between photograph assessment at maximum frown and subjects’ improvement assessments increased after 12 weeks of injection. Patients seem to be more satisfied with efficacy of botulinum toxin subjectively comparing with objective assessments by an independent panel. Since leading to the agreement for the duration of efficacy from the perspective of both patients and practitioner is another quite important issue of determining injection period, further studies should be followed about this subject. About safety issues, both groups had a low incidence of TEAEs, and results were similar to safety profiles of previous studies about botulinum toxins used for the treatment of glabellar frown lines.7,8 Almost all TEAEs were not severe, and NTC even showed slightly lower incidences of TEAEs related to treatment than those of onabotulinumtoxin A in some points with no significance. New purification techniques might be helpful by eliminating the impurities. In addition, no abnormalities of laboratory tests, vital signs, or physical exams were observed and formation of neutral antibodies for botulinum toxin type A is not detected at all. A study reported that neutralizing antibody formation after onabotulinumtoxin A injection is rarely observed when used for therapeutic indications.14 Thus, NTC
Table 3 Full data of TEAEs, overall and related to study drugs (SES) NTC (n = 134)
Onabotulinumtoxin A (n = 137)
Total (n = 271)
P-value
Subjects with at least one TEAE
38 (28.4)
45 (32.8)
83 (30.6)
0.43
Infections and infestations
10 (7.5)
9 (6.6)
19 (7.0)
0.82
General disorders and administration site conditions
6 (4.5)
12 (8.8)
18 (6.6)
0.22
Injection site reaction
4 (3.0)
11 (8.0)
15 (5.5)
0.38
Eye disorders
10 (7.5)
7 (5.1)
17 (6.3)
0.46
Eyelid ptosis
6 (4.5)
3 (2.2)
9 (3.3)
0.33
Nervous system disorders
2 (1.5)
6 (4.4)
8 (3.0)
1.0
Respiratory, thoracic and mediastinal disorders
2 (1.5)
6 (4.4)
8 (3.0)
1.0
Skin and subcutaneous tissue disorders
6 (4.5)
2 (1.5)
8 (3.0)
0.17
Injury, poisoning and procedural complications
5 (3.7)
2 (1.5)
7 (2.6)
0.28 0.55
System organ class preferred term TEAEs, n (%)
TEAEs related to treatment, n (%) Subjects with at least one TEAE
12 (9.0)
16 (11.7)
28 (10.3)
General disorders and administration site conditions
5 (3.7)
11 (8.0)
16 (5.9)
0.20
Injection site reaction
4 (3.0)
11 (8.0)
15 (5.5)
0.11
Eye disorders
7 (5.2)
3 (2.2)
10 (3.7)
0.21
Eyelid ptosis
6 (4.5)
3 (2.2)
9 (3.3)
0.33
NTC, neurotoxin from the CBFC26 strain; SES, safety evaluation set; TEAEs, treatment-emergent adverse events.
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Neurotoxin from CBFC26 strain
seems not at least to be inferior with onabotulinumtoxin A from a long-term safety perspective. Limitations of this study include that all subjects were Korean, which may not represent a general patient population of various ethnic groups, and majority of enrolled patients were female. Total duration of the study was also relatively short to present long-term data. In conclusion, NTC is as effective as onabotulinumtoxin A in the treatment of moderate-to-severe glabellar lines over at least 16 weeks in our study. Both toxins were generally well tolerated. NTC could be a new alternative to onabotulinumtoxin A.
References 1 Carruthers A, Carruthers J. Botulinum toxin products overview. Skin Therapy Lett 2008; 13: 1–4. 2 Carruthers A, Kiene K, Carruthers J. Botulinum A exotoxin use in clinical dermatology. J Am Acad Dermatol 1996; 34: 788–797. 3 Carruthers JD, Glogau RG, Blitzer A, Facial Aesthetics Consensus Group Faculty. Advances in facial rejuvenation: botulinum toxin type a, hyaluronic acid dermal fillers, and combination therapies–consensus recommendations. Plast Reconstr Surg 2008; 121: 5S–30S; quiz 1S-6S. 4 Carruthers JD, Carruthers JA. Treatment of glabellar frown lines with C. botulinum-A exotoxin. J Dermatol Surg Oncol 1992; 18: 17–21. 5 Carruthers JA, Lowe NJ, Menter MA et al. A multicenter, double-blind, randomized, placebo-controlled study of the efficacy and safety of botulinum toxin type A in the treatment of glabellar lines. J Am Acad Dermatol 2002; 46: 840–849. 6 Carruthers JD, Lowe NJ, Menter MA, Gibson J, Eadie N. Botox Glabellar Lines II Study Group. Double-blind, placebo-controlled study of the safety and efficacy of botulinum toxin type A for patients with glabellar lines. Plast Reconstr Surg 2003; 112: 1089–1098. 7 Carruthers A, Carruthers J. Prospective, double-blind, randomized, parallel-group, dose-ranging study of botulinum toxin type A in men with glabellar rhytids. Dermatol Surg 2005; 31: 1297–1303.
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8 Ascher B, Zakine B, Kestemont P, Baspeyras M, Bougara A, Santini J. A multicenter, randomized, double-blind, placebo-controlled study of efficacy and safety of 3 doses of botulinum toxin A in the treatment of glabellar lines. J Am Acad Dermatol 2004; 51: 223–233. 9 Harii K, Kawashima M. A double-blind, randomized, placebo-controlled, two-dose comparative study of botulinum toxin type A for treating glabellar lines in Japanese subjects. Aesthetic Plast Surg 2008; 32: 724–730. 10 Won CH, Lee HM, Lee WS et al. Efficacy and safety of a novel botulinum toxin type A product for the treatment of moderate to severe glabellar lines: a randomized, double-blind, active-controlled multicenter study. Dermatol Surg 2013; 39: 171–178. 11 Sattler G, Callander MJ, Grablowitz D et al. Noninferiority of incobotulinumtoxinA, free from complexing proteins, compared with another botulinum toxin type A in the treatment of glabellar frown lines. Dermatol Surg 2010; 36(Suppl. 4): 2146–2154. 12 Lowe P, Patnaik R, Lowe N. Comparison of two formulations of botulinum toxin type A for the treatment of glabellar lines: a double-blind, randomized study. J Am Acad Dermatol 2006; 55: 975–980. 13 Wu Y, Zhao G, Li H et al. Botulinum toxin type A for the treatment of glabellar lines in Chinese: a double-blind, randomized, placebo-controlled study. Dermatol Surg 2010; 36: 102–108. 14 Brin MF, Comella CL, Jankovic J, Lai F, Naumann M, CD-017 BoNTA Study Group. Long-term treatment with botulinum toxin type A in cervical dystonia has low immunogenicity by mouse protection assay. Mov Disord 2008; 23: 1353–1360.
Supporting information Additional Supporting Information may be found in the online version of this article: Data S1 Guidelines of physician’s assessments & photographic assessments.
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