Note: Descriptions are shown in the official language in which they were submitted.
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Method for Treating Dysphagia
FIELD OF THE INDENTION
The present invention provides novel methods for
treating various disorders and conditions, with Botu-
linum toxins. Importantly, the present invention
provides methods useful in relieving pain related to
muscle activity or contracture and therefore is of
advantage in the treatment of, for example, muscle
spasm such as Temporomandibular Joint Disease, low
- _ _, back pain, myofascial pain, pain related to spasticity
and dystonia, as well as sports injuries, and pain
related to contractures in arthritis.
BACKGROUND OF TFiE INDENTION
Heretofore, Botulinum toxins, in particular
Botulinum toxin type A, has been used in the treatment
of a number of neuromuscular disorders and conditions
involving muscular spasm; for example, strabismus,
blepharospasm, spasmodic torticollis (cervical
dystonia), oromandibular dystonia and spasmodic
dysphonia (laryngeal dystonia). The toxin binds
rapidly and strongly to presynaptic cholinergic nerve _.
terminals and inhibits'the exocytosis of acetylcholine
by decreasing the freguency of acetylcholine release.
This results in local paralysis and hence relaxation
of the muscle afflicted by spasm.
For one example of treating neuromuscular
disorders, see U.S. Patent No. 5,053,005 to Borodic,
which suggests treating curvature of the juvenile
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spine, i.e., scoliosis, with an acetylcholine release
inhibitor, preferably Botulinum toxin A.
For the treatment of strabismus with Botulinum
toxin type A, see Elston, J.S., et al., British
Journal of Ophthalmology, 1985, 69, 718-724 and 891-
896. For the treatment of blepharospasm with
Botulinum toxin type A, see Adenis, J.P., et al.,
J. Fr. Ophthalmol., 1990, 13 (5) at pages 259-264.
For treating squint, see Elston, J.S., Eye, 1990,
4(4):VII. For treating spasmodic and oromandibular
dystonia torticollis, see Jankovic et al., Neurology,
1987, 37, 616-623.
Spasmodic dysphonia has been treated with
Botulinum toxin type A. See Blitzer et al., Ann.
Otol. Rhino. Laryngol, 1985, 94, 591-594. Lingual
dystonia was treated with Botulinum toxin type A
according to Brin et al., Adv. Neurol. (1987) 50, 599-
608. Finally, Cohen et al., Neurology (1987) 37
(Suppl. 1), 123-4, discloses the treatment of writer's
cramp with Botulinum toxin type A.
The term Botulinum toxin is a generic term
embracing the family of toxins produced by the anae-
robic bacterium Clostridium botulinum and, to date,
seven immunologically distinct neurotoxins have been
identified. These have been given the designations A,
B, C', D, E, F and G. For further information con-
cerning the properties of the various Botulinum
toxins, reference is made to the article by Jankovic
and Brin, The New England Journal of Medicine, No. 17,
1990, pp. 1186-1194, and to the review by Charles L.
Hatheway in Chapter 1 of the book entitled Botulinum
Neurotoxin and Tetanus Toxin, L. L. Simpson, Ed.,
i ~~
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published by Academic Press Inc. of San Diego,
California, 1989.
The neurotoxic component of Botulinum toxin has
a molecular weight of about 150 kilodaltons and is
thought to comprise a short polypeptide chain of about
50 kD which is considered to be responsible for the
toxic properties of the toxin, i.e., by interfering
with the exocytosis of acetylcholine, by decreasing
the frequency of acetylcholine release, and a larger
polypeptide chain of about 100 kD which is believed to
be necessary to enable the toxin to bind to the pre-
synaptic membrane.
The "short" and "long" chains are linked together
by means of-a simple disulfide bridge. (It is noted
that certain serotypes of Botulinum toxin, e.g., type
E, may exist in the form of a single chain un-nicked
protein, as opposed to a dichain. The single chain
form is less active but may be converted to the
corresponding dichain by nicking with a protease,
e.g., trypsin. Both the single and the dichain are
useful in the method of the present invention.)
In general, four physiologic groups of C. botuli-
num axe recognized (I, II, III, IV). The organisms
capable of producing a serologically distinct toxin
may come from more than one physiological group. For
example, Type B and F toxins can be produced by
strains from Group I or II. In addition, other
strains of clostridial species (C. baratii, type F;
C. butyricum, type E; C. novyi, type C1 or D) have
been identified which can produce botulinum
neurotoxins.
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Immunotoxin conjugates of ricin and antibodies,
which are characterized as having enhanced cytotoxi-
city through improving cell surface affinity, are
disclosed in European Patent Specification 0 129 434.
The inventors note that botulinum toxin may be
utilized in place of ricin.
Botulinum toxin is obtained commercially by
establishing and growing cultures of C. botulinum in
a fermenter and then harvesting and purifying the
fermented mixture in accordance with known techniques.
Botulinum toxin type A, the toxin type generally
utilized in treating neuromuscular conditions, is
currently available commercially from several sources;
for example, from Porton Products Ltd. UK, under the
trade name "DYSPORT," and from Allergan, Inc., Irvine,
California, under the trade name BOTOX~.
It is one object of the invention to provide
novel treatments of neuromuscular disorders and
conditions with various Botulinum toxin types. It is
another object of the present invention to relieve
pain with various Botulinum toxin types.
SUMMARY OF THE INVENTION
The present invention provides a method for
relieving pain, associated with muscle contractions,
a composition and a method of treating conditions such
as cholinergic controlled secretions including
excessive sweating, lacrimation and mucus secretions
and a method for treating smooth muscle disorders
including, but not limited to, spasms in the sphincter
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of the cardiovascular arteriole, gastrointestinal
system, urinary, gall bladder and rectum, which method
comprises administering to the patient suffering from
said disorder or condition a therapeutically effective
amount of Botulinum toxin selected from the group
consisting of Botulinum toxin types B, C, D, E, F and
G.
Each serotype of Botulinum toxin has been
identified as immunologically different proteins
through the use of specific antibodies. For example,
if~'the antibody (antitoxin) recognizes, that is,
neutralizes the biological activity of, for example,
type A it will not recognize types B,C,D, E, F or G.
_.
While all of the Botulinum toxins appear to be
zinc endopeptidases, the mechanism of action of
different serotypes, for example, A and E within the
neuron appear to be different than that of Type B. In
addition, the neuronal surface "receptor" for the
toxin appears to be different for the serotypes.
In the area of use of the Botulinum toxins in
accordance with the present invention with regard to
organ systems which involve the release of neurotrans-
mitter, it is expected to introduce the toxins A, B,
C, D, E, F, and G directly by local injections.
DETAILED DESCRIPTION
The Botulinum toxins used according to the
present invention are Botulinum toxins type A, B, C,
D, E, F and G.
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The physiologic groups of Clostridium botulinum
types are listed in Table I.
Table I. Physiologic Groups of Clostridium botulinrun
Torin Gluoosc P~~ Phcnotypically
GroupScro-Biochemistry ~k Pcrmco->:~pax
Type D taboo Plasmids
~
~~O~LOpgCnlC~
I A,B,Fproteolytic ~. + + .f. C. snorooenes
saccharolytic
11 B nonprotcolytic
F saccharolytic
E
, psychotrophic
,
III C,D nonproteolytic ~ + ~. .+ C. nowi
saccharolytic
IV G proteolytic .+. _ _ _ C. suhterminale
nonsaccharolytic
These toxin types may be produced by selection from
the appropriate physiologic group of Clostridium
botulinum organisms. the organisms designated as
Group I are usually referred to as proteolytic and
produce Botulinum toxins of types A, B and F. The
organisms designated as Group II are saccharolytic and
produce Botulinum toxins of types B, E and F. The
organisms designated as Group III produce only
Botulinum toxin types C and D and are distinguished
from organisms of Groups I and II by the production of
significant amounts of propionic acid. Group IV
organisms only produce neurotoxin of type G. The
production of any and all of the Botulinum toxin types
A, B, C, D, E, F and G are described in Chapter 1 of
Botulinum Neurotoxin and Tetanus Toxin, cited above,
and/or the references cited therein. Botulinum toxins
types B, C, D, E, F and G are also available from
various species of clostridia.
Currently fourteen species of clostridia are
considered pathogenic. Most of the pathogenic strains
produce toxins which are responsible for the various
pathological signs and symptoms. Organisms which pro-
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duce Botulinum toxins have been isolated from botulism
outbreaks in humans (types A, B, E and F) and animals
(types C and D). Their identities were described
through the use of specific antitoxins (antibodies)
developed against the earlier toxins. Type G toxin
was found in soil and has low toxigenicity. However,
it has been isolated from autopsy specimens, but thus
far there has not been adequate evidence that type G
botulism has occurred in humans.
Preferably, the toxin is administered by means of
intramuscular injection directly into a local area
such as a spastic muscle, preferably in the region of
the neuromuscular junction, although alternative types
of administration (e.g., subcutaneous injection ),
which can deliver the toxin directly to the affected
region, may be employed where appropriate. The toxin
can be presented as a sterile pyrogen-free aqueous
solution or dispersion and as a sterile powder for
reconstitution into a sterile solution or dispersion.
Where desired, tonicity adjusting agents such as
sodium chloride, glycerol and various sugars can be
added. Stabilizers such as human serum albumin may
also be included. The formulation may be preserved by
means of a suitable pharmaceutically acceptable pre-
servative such as a paraben, although preferably it is
unpreserved.
It is preferred that the toxin is formulated in
unit dosage form; for example, it can be provided as
a sterile solution in a vial or as a vial or sachet
containing a lyophilized powder for reconstituting a
suitable vehicle such as saline for injection.
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_g _
In one embodiment, the Botulinum toxin is
formulated in a solution containing saline and pas-
teurized human serum albumin, which stabilizes the
toxin and minimizes loss through~non-specific adsorp-
tion. The solution is sterile filtered (0.2 micron
filter) , filled into individual vials and then vacuum
dried to give a sterile lyophilized powder. In use,
the powder can be reconstituted by the addition of
sterile unpreserved normal saline (sodium chloride
0.9% for injection).
The dose of toxin administered to the patient
will depend upon the severity of the condition; e.g.,
the number of muscle groups requiring treatment, the
age and size of the patient and the potency of the
toxin. The potency of the toxin is expressed as a
multiple of the LDSO value for the mouse, one unit (U)
of toxin being defined as being the equivalent
to that amount, on a per mouse basis, that kills 50%
20-~ of a group of Swiss-Webster mice weighing between 17 and
22 grams each.
The dosages used in human therapeutic
applications are roughly proportional to the mass of
muscle being injected. Typically, the dose admin-
istered to the patient may be up from about 0.01 to
about 1,000 units; for example, up to about 500 units,
and preferably in the range from about 80 to about 460
units per patient per treatment, although smaller of
larger doses may be administered in appropriate cir-
cumstances such as up to about 50 units for the relief
of pain and in controlling ~holinergic secretions.
As the physicians become more familiar with the
use of this product, the dose may be changed. In the
Botulinum toxin type A, available from Porton,
i
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_g_
O
DYSPORT, 1 nanogram (ng) contains 40 units. 1 ng of
the Botulinum toxin type A, available from Allergan,
Inc., i.e., BOTOX~, contains 4 units. The potency of
Botulinum toxin and its long duration of action mean
that doses will tend to be administered on an
infrequent basis. Ultimately, however, both the
quantity of toxin administered and the frequency of
its administration will be at the discretion of the
physician responsible for the treatment and will be
commensurate with questions of safety and the effects
produced by the toxin.
w
In some circumstances, particularly in the relief
of pain associated with sports injuries, such as, for
----- .15 example, charleyharse, botulinum type F, having a
short duration activity, is preferred.
The invention will now be illustrated by
' reference to the following nonlimiting examples.
In each of the examples, appropriate areas of
each patient are injected with a sterile solution con-
taining the confirmation of Botulinum toxin. Total
patient doses range from about 0.01 units to 460
units. Before injecting any muscle group, careful
consideration is given to the anatomy of the muscle
group, the aim being to inject the area with the
highest concentration of neuromuscular junctions, if
known. Before injecting the muscle, the position of
the needle in the muscle is confirmed by putting the
muscle through its range of motion and observing the
resultant motion of the needle end. General
anaesthesia, local anaesthesia and sedation are used
according to the age of the patient, the number of
sites to be injected, and the particular needs of the
i ~
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patient. More than one injection and/or sites of
injection may be necessary to achieve the desired
result. Also, some injections, depending on the
muscle to be injected, may require the use of fine,
hollow, teflon~ oated needles, guided by
electromyography.
Following injection, it is noted that there are
no systemic or local side effects and none of the
patients are found to develop extensive local hypoton-
icity. The majority of patients show an improvement
in 'function both subjectively and when measured
objectively.
Example 1
The Use of Botulinum toxin Type in the Treatment
of Tardive Dyskinesia
A male patient, age 45, suffering from tardive
dyskinesia resulting from the treatment with an
antipsychotic drug, such as Thorazine or Haldol, is
treated with 150 units of Botulinum toxin type B by
direct injection of such toxin into the facial
muscles. After 1-3 days, the symptoms of tardive
dyskinesia, i.e., orofacial dyskinesia, athetosis,
dystonia, chorea, tics and facial grimacing, etc. are
markedly reduced.
Example 1(a)
The method of Example 1 is repeated, except that
a patient suffering from tardive dyskinesia is
injected with 50-200 units of Botulinum toxin type C.
A similar result is obtained.
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Example 1(b)
The method of Example 1 is repeated, except that
a patient suffering from tardive dyskinesia is
injected with 50-200 units of Botulinum toxin type D.
A similar result is obtained.
Example 1(c)
The method of Example 1 is repeated, except that
a patient suffering from tardive dyskinesia is
injected with 50-200 units of Botulinum toxin type E.
A similar result is obtained.
__ .. 15 Examp-1-a 1 ( d )
The method of Example 1 is repeated, except that
a patient suffering from tardive dyskinesia is
injected with 50-200 units of Botulinum toxin type F.
A similar result is obtained.
Example 1(e)
The method of Example 1 is repeated, except that
a patient suffering from tardive dyskinesia is
injected with 50-200 units of Botulinum toxin type G.
A similar result is obtained.
Example 2
The Use of Botulinum toxin Type B in the Treatment
of Spasmodic Torticollis
A male, age 45, suffering from spasmodic
torticollis, as manifested by spasmodic or tonic
contractions of the neck musculature, producing
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stereotyped abnormal deviations of the head, the chin
being rotated to one side, and the shoulder being
elevated toward the side at which the head is rotated,
is treated by injection with 100-1,000 units of
Botulinum toxin type E. After 3-7 days, the symptoms
are substantially alleviated; i.e., the patient is
able to hold his head and shoulder in a normal
position.
Example 2 (a)
The method of Example 2 is repeated, except that
a patient suffering from spasmodic torticollis is
injected with 100-1,000 units of Botulinum toxin type
B. A similar result is obtained.
Example 2(b)
The method of Example 2 is repeated, except that
a patient suffering from spasmodic torticollis is
injected with 100-1,000 units of Botulinum toxin type
C: A similar result is obtained.
Example 2(c)
The method of Example 2 is repeated, except that
a patient suffering from spasmodic torticollis is
injected with 100-1,000 units of Botulinum toxin type
D. A similar result is obtained.
Example 2 (d)
The method of Example 2 is repeated, except that
a patient suffering from spasmodic torticollis is
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injected with 100-1,000 units of Botulinum toxin type
E. A similar result is obtained.
Example 2 (e)
The method of Example 2 is repeated, except that
a patient suffering from spasmodic torticollis is
injected with 100-1,000 units of Botulinum toxin type
F. A similar result is obtained.
Example 2(f)
The method of Example 2 is repeated, except that
--- 15 a patient suffering from spasmodic torticollis is
injected with 100-1,000 units of Botulinum toxin type
G. A similar result is obtained.
, Example 3
The Use of Botulinum toxin in the Treatment of
Essential Tremor
A male, age 45, suffering from essential tremor,
which is manifested as a rhythmical oscillation of
head or hand muscles and is provoked by maintenance of
posture or movement, is treated by injection with 50-
1,000 units of Botulinum toxin type B. After two to
eight weeks, the symptoms are substantially
alleviated; i.e., the patient's head or hand ceases to
oscillate.
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Example 3 (a)
The method of Example 3 is repeated, except that
a patient suffering from essential tremor is injected
with 100-1,000 units of Botulinum toxin type C. A
similar result is obtained.
Example 3(b)
The method of Example 3 is repeated, except that
a patient suffering from essential tremor is injected
with 100-1,000 units of Botulinum toxin type D. A
similar result is obtained.
.15 Example 3 (c) ---
The method of Example 3 is repeated, except that
a patient suffering from essential tremor is injected
with 100-1,000 units of Botulinum toxin type E. A
similar result is obtained.
Example 3(d)
The method of Example 3 is repeated, except that
a patient suffering from essential tremor is injected
with 100-1,000 units of Botulinum toxin type F. A
similar result is obtained.
Example 3 (e)
The method of Example 3 is repeated, except that
a patient suffering from essential tremor is injected
with 100-1,000 units of Botulinum toxin type G. A
similar result is obtained.
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Example 4
The Use of Botulinum toxin in the Treatment of
Spasmodic Dysphonia
A male, age 45, unable to speak clearly, due to
spasm of the vocal chords, is treated by injection of
the vocal chords with Botulinum toxin type B, having
an activity of 80-500 units. After 3-7 days, the
patient is able to speak clearly.
Example 4(a)
The method of Example 4 is repeated, except that
a patient suffering from spasmodic dysphonia is
injected with 80-500 units of Botulinum toxin type C.
A similar result is obtained.
Example 4 (b)
_ The method of Example 4 is repeated, except that
a patient suffering from spasmodic dysphonia is
injected with 80-500 units of Botulinum toxin type D.
A similar result is obtained.
Example 4(c)
The method of Example 4 is repeated, except that
a patient suffering from spasmodic dysphonia is
injected with 80-500 units of Botulinum toxin type E.
A similar result is obtained.
Example 4 (d)
The method of Example 4 is repeated, except that
a patient suffering from spasmodic dysphonia is
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injected with 80-500 units of Botulinum toxin type F.
A similar result is obtained.
Example 4(e)
10
The method of Example 4 is repeated, except that
a patient suffering from spasmodic dysphonia is
injected with 8-500 units of Botulinum toxin type G.
A similar result is obtained.
Example 5
wThe Use of Botulinum toxin Types A-G in the
Treatment of Excessive Sweating,,, Lacrimation or
Mucus Secretion or Other Cholinerdic Controlled
-- Secretions
A male, age 65, with excessive unilateral
sweating is treated by administering 0.01 to 50 units,
of Botulinum toxin, depending upon degree of desired
effect. The larger the dose, usually the greater
spread and duration of effect. Small doses are used
initially. Any serotype toxin alone or in combination
could be used in this indication. The administration
is to the gland nerve plexus, ganglion, spinal cord or
central nervous system to be determined by the
physician's knowledge of the anatomy and physiology of
the target glands and secretary cells. In addition,
the appropriate spinal cord level or brain area can be
injected with the toxin (although this would cause
many effects, including general weakness). Thus, the
gland (if accessible) or the nerve plexus or ganglion
are the targets of choice. Excessive sweating,
tearing (lacrimation), mucus secretion or
gastrointestinal secretions are positively influenced
by the cholinergic nervous system. Sweating and
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tearing are under greater cholinergic control than
mucus or gastric secretion and would respond better to
toxin treatment. However, mucus and gastric
secretions could be modulated through the cholinergic
system. All symptoms would be reduced or eliminated
with toxin therapy in about 1-7 days. Duration would
be weeks to several months.
Example 6
The Use of Botulinum toxin Types A-G in the
Treatment of Muscle Spasms in Smooth Muscle
Disorders Such As Sphincters of the Cardiovascular
Arteriole, Gastrointestinal System. Urinary or Gall
Bladder. Rectal, Etc.
A male, age 30-40, with a constricted pyloric
valve which prevents his stomach from emptying, is
treated by administering 1-50 units of Botulinum
toxin. The administration is to the pyloric valve
(which controls release of stomach contents into the
intestine) divided into 2 to 4 quadrants, injections
made with any endoscopic device or during surgery. In
about 1-7 days, normal emptying of the stomach,
elimination or drastic reduction in regurgitation
occurs.
Example 7
The Use of Botulinum toxin Types A-G in the
Treatment of Muscle Spasms and Control of Pain
Associated with Muscle Spasms in Temporal Mandibular
Joint Disorders
A female, age 35, is treated by administration of
0.1 to 50 units total of Botulinum toxin. The
administration is to the muscles controlling the
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closure of the jaw. Overactive muscles may be
identified with EMG (electromyography) guidance.
Relief of pain associated with muscle spasms, possible
reduction in jaw clenching occurs in about 1-3 days.
Example 8
The Use of Botulinum toxin Types A-G in the
Treatment of Muscle Spasms and Control of Pain
Associated with Muscle Spasms in Conditions
Secondary to Sports Iniuries (Charleyhorse)
A male, age 20, with severe cramping in thigh
after sports injury is treated by administration of a
short duration toxin, possible low dose (0.1-25 units)
of preferably type F to the muscle and neighboring
muscles which are in contraction ("cramped"). Relief
of pain occurs in 1-7 days.
Example 9
The Use of Botulinum toxin Types A-G in the
Treatment of Muscle Spasms and Control of Pain
Associated with Muscle Spasms in Smooth Muscle
Disorders Such as Gastrointestinal Muscles
A female, age 35, with spastic colitis, is
treated with 1-100 units of Botulinum toxin divided
into several areas, enema (1-5 units) delivered in the
standard enema volume, titrate dose, starting with the
lowest dose. Injection is to the rectum or lower
colon or a low dose enema may be employed. Cramps and
pain associated with spastic colon are relieved in
1-10 days.
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Examgle 10
The Use of Botulinum toxin Topes A-G in the
Treatment of Muscle Spasms and Control of Pain
Associated with Muscle Spasms in SpasticitY
Conditions Secondary to Stroke, Traumatic Brain or
Spinal Cord In~ury
A male, age 70, post-stroke or cerebral vascular
event, is injected with 50 to 300 units of Botulinum
toxin in the major muscles involved in severe closing
of hand and curling of wrist and forearm or. the
muscles involved in the closing of the legs such that
the patient and attendant have difficulty with
hygiene. Relief of these.symptoms occurs-rn 7 to 21
days.
~xamcye 11
The Use of Bctulinum toxin Types A-G in the
Treatment of Patients with Swallowing disorders
A patient with a swallowing disorder caused by
excessive throat muscle spasms is injected with about
1 to about 300 units of Botulinum toxin in the throat
muscles. Relief the swallowing disorder occurs in
about 7 to about 21 days.
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Examx~le 12
The Use of Botulinum toxin Tunes A-G in the
Treatment of.Patients with Tension Headache
A patient with a tension headache caused by
excessive throat muscle spasms is injected with about.
1 to about 300 units of Botulinum toxin in muscles of
the head and upper neck. Relief of the tension
headache occurs in about 1 to about 7 days.
Although there has been hereinabove described a
use of Botulinum toxins for treating various dis-
orders, conditions and pain, in accordance with the
present invention, for the purpose of illustrating the
manner in which the invention may be used to advan-
tage, it should be appreciated that the invention is
not limited thereto since many obvious modifications
can be made, and it is intended to include within this
invention any such modifications as will fall within
the scope of the appended claims. Accordingly, any
and all modifications, variations,. or equivalent
arrangements which may occur to those skilled in the
art, should be considered to be within the scope of
the present invention as defined in the appended
claims.
