Botox in MND Ben Messer

NEAVS

December 2017

Contents

• Case studies

• Physiology/Pharmacology

• Training

• Technique

• Our numbers

• Evidence

Case Study

• 41m

• Recently diagnosed with respiratory failure post-PEG

• Cough Assist & NIV

• Sialorrhoea to the point of not being able to use NIV

• Glycopyrolate infusion

• Home with Botox to parotids locally

Case study

• 34m

• Tetraplegic with TV

• Regular attendance for botox • Parotids

Case study

• 57m

• Bulbar MND

• Cough Assist

• Submandibular and parotid botox

Physiology/Pharmacology

• 20-30% parotid

• 50-60% submandibular

• 10% sublingual

• 10% other

• Inhibition of ACh secretion

Training

Technique

Technique

Technique

• Dysport 300MU total • Diluted to 3mls

• Botox:Dysport 1:4

• Parotids • 1ml anterior

• 0.5ml posterior

• Submandibular & Parotids • 0.5mls into 6 sites

Newcastle numbers

• 23 MND patients since 2013 • 21 on the NEAVS programme

• 4 repeat injections

• 5 other patients

• 1 Bulbar dysfunction post Botox (DMD)

Newcastle numbers

• Variable outcomes • Symptomatic measurement

• 7/10 benefit

• Repeat when symptomatic • 3-6 months

• Usually continue anticholinergics

UK evidence

UK evidence

• Botox only used in 17/119 patients in 10 centres

• 14/17 third line

• 57% improvement

• 50% adverse effects • 2 bulbar impairment

International evidence

International evidence

• 10-145MU Dysport per parotid

• 80MU Dysport per Submandibular

• Small comparison study of USS Vs Landmark • 15 patients

• Better early symptom control with USS

International evidence

International evidence

• 50% Parotid

• 10% Submandibular

• 40% Both

Conclusions

• Limited but growing Newcastle experience

• Results consistent with UK data

• Bespoke approach

• Increasing numbers of requests for repeat injections