How is botox produced

Botulinum toxin, one of the most poisonous biological substances known, is a neurotoxin produced by the bacterium Clostridium botulinum. All serotypes interfere with neural transmission by blocking the release of acetylcholine, the principal neurotransmitter at the neuromuscular junction, causing muscle paralysis.

The weakness induced by injection with botulinum toxin A usually lasts about three months. Botulinum toxins now play a very significant role in the management of a wide variety of medical conditions, especially strabismus and focal dystonias, hemifacial spasm, and various spastic movement disorders, headaches, hypersalivation, hyperhidrosis, and some chronic conditions that respond only partially to medical treatment.

The list of possible new indications is rapidly expanding. The cosmetological applications include correction of lines, creases and wrinkling all over the face, chin, neck, and chest to dermatological applications such as hyperhidrosis. Injections with botulinum toxin are generally well tolerated and side effects are few. A precise knowledge and understanding of the functional anatomy of the mimetic muscles is absolutely necessary to correctly use botulinum toxins in clinical practice.

Scott[ 2 ] first demonstrated the effectiveness of botulinum toxin type A for the management of strabismus in humans. Subsequently, botulinum toxin was approved for the treatment of numerous disorders of spasticiy[ 1 ] and a host of other conditions. Currently it is used in almost every sub-specialty of medicine.

Type A is the most potent toxin, followed by types B and F toxin. Types A, B and E are commonly associated with systemic botulism in humans.

The polypeptide chain consists of a heavy H chain and a light L chain of roughly and 50 kDa respectively, linked by a disulfide bond. All the serotypes interfere with neural transmission by blocking the release of acetylcholine, which is the principal neurotransmitter at the neuromuscular junction. Intramuscular administration of botulinum toxin acts at the neuromuscular junction to cause muscle paralysis by inhibiting the release of acetylcholine from presynaptic motor neurons.

The disulphide bond between the two chains is cleaved and the toxin escapes into the cytoplasm. The light L chain interact with different proteins synaptosomal associated protein SNAP 25, vesicle associated membrane protein and syntaxin in the nerve terminals to prevent fusion of acetylcholine vesicles with the cell membrane.

Doses of all commercially available botulinum toxins are expressed in terms of units of biologic activity. One unit of botulinum toxin corresponds to the calculated median intraperitoneal lethal dose LD 50 in female Swiss-Webster mice. Function can be recovered by the sprouting of nerve terminals and formation of new synaptic contacts; this usually takes two to three months. Botulinum toxin induces weakness of striated muscles by inhibiting transmission of alpha motor neurones at the neuromuscular junction.

This has led to its use in conditions with muscular overactivity, such as dystonia. Transmission is also inhibited at gamma neurones in muscle spindles, which may alter reflex overactivity. This has generated interest in its use as a treatment for overactive smooth muscles for example, in achalasia or abnormal activity of glands for example, hyperhidrosis.

The toxin requires hours to take effect, reflecting the time necessary to disrupt the synaptosomal process. In very rare circumstances, some individuals may require as many as five days for the full effect to be observed. Peaking at about 10 days, the effect of botulinum toxin lasts nearly weeks. Risk factors associated with the development of neutralizing antibodies include, injection of more than units per session and repeat or booster injections given within one month of treatment.

Limited information is available on whether neutralizing antibodies resolve over time and, consequently, whether attempts at reinjection should be made after a prolonged period.

An investigation is underway to determine whether injections of botulinum toxin type B are useful in patients with neutralizing antibodies to type A. Using the lowest dose of toxin necessary to achieve the desired clinical effect and avoiding reinjection within one month appear prudent in an effort to keep antibody formation as low and unlikely as possible.

Serotype A is the only commercially available form of botulinum toxin for clinical use, although experience is emerging with development of other serotypes: B, C, and F preparations. Unfortunately, there has been much confusion over the doses and units of potency of the two preparations. It is produced from a culture of the Hall strain of C.

It was replaced by a new neurotoxin complex batch designated BCB The new bulk batch is five to six times more potent on a weight basis. In a unit vial, only 4.

Differences in these toxins may relate to differences in the strain of bacterium, preparation, diffusion, and potency testing. Myobloc is a botulinum toxin type B preparation. Its safety is well established. The drawback is that once the contents of a vial are dissolved, the reconstituted product loses its potency.

Therefore, dermatologists tend to schedule the treatments for several patients on the same day so that they can use the entire contents of the vial. This scheduling may be inconvenient for some patients, who may decide not to proceed. It is a Clostridium botulinum type - B neurotoxin complex which became available in the U. There is limited experience in the use of this type of toxin, and the product does not currently have approval for cosmetic use anywhere in the world.

This feature is advantageous in terms of patient scheduling. Antibody formation against this product may occur more often because of its higher protein content. The package insert recommends reconstitution using sterile saline without preservative; 0. Some investigators suggest that reconstitution with sterile saline solution with preservative 0.

Theoretically, more concentrated solutions reduce reliability in delivering a specific unit dose, and more dilute solutions lead to greater diffusion of the toxin. Botulinum toxin is injected into affected muscles or glands using a gauge 1-inch needle. Doses are tailored according to the mode of use and individual patients, and the dose depends on the mass of muscle being injected: The larger the muscle mass the higher the dose required.

However, lower doses may be required in patients with preexisting weakness and in females. In localized muscle overactivity, especially, in delicate places such as strabismus, the injections are usually guided by electromyography. Many authors[ 18 ] have chosen to administer injections under the guidance of electromyograph EMG monitoring.

This technique involves using a gauge 1. The patient is asked to contract the muscle in question. The injection is placed where the maximal EMG recording can be found within the muscle. This technique ensures that the injection is at the point of the muscle that is contributing most to the hyperfunctional facial line.

As these injections have become routine, many centers have obtained satisfactory results without EMG guidance. Many physicians use a readily available gauge insulin syringe instead. However, EMG-guided injections remain a useful adjunct in patients who have residual function after their initial injection. This is to minimize toxins dislodging and traveling due to increased blood circulation or direct pressure to the surrounding muscles.

Hence, further injections at regular intervals are required and the interval varies widely depending on the dose and individual susceptibility. Response after the injections should be assessed both by subjective and by objective measures. Most patients treated with botulinum toxin require repeated injections over many years. Some patients who respond well initially develop tolerance to the injections due to development of neutralizing antibodies to the toxin. Patients who receive higher individual doses or frequent booster injections seem to have a higher risk of developing antibodies.

Injections should therefore be given at the lowest effective dose and as infrequently as possible. Several types of antibody assay are available. Botulinum toxins now play a very significant role in the management of a wide variety of medical conditions, especially strabismus and focal dystonias, hemifacial spasm, and various spastic movement disorders.

Sometimes it can be used as an alternative to surgical intervention. Presently it's application ranges from correction of lines, creases and wrinkling all over the face, chin, neck, and chest, depressor anguli oris, nasolabial folds, mentalis, medial and lateral brow lifts, to lessen shadows on one's face and maintain a smooth outline of the jaw and cheeks from all directions, to dermatological applications such as localized axillary or palmar hyperhidrosis that is nonresponsive to topical or systemic treatment [ Table 1 ].

Generalized idiosyncratic reactions are uncommon, generally mild, and transient. There can be mild injection pain and local edema, erythema, transient numbness, headache, malaise or mild nausea. Its effect diminishes with increasing distance from the injection site, but spread to nearby muscles and other tissues is possible. It usually resolves in several months and in some patients in a few weeks, depending on the site, strength of the injections, and the muscles made excessively weak.

This results from migration of the botulinum toxin to the levator palpebrae superioris muscle. Patients often are instructed to remain in an upright position for three to four hours following injection and avoid manual manipulation of the area. Active contraction of the muscles under treatment may increase the uptake of toxin and decrease its diffusion.

Although the same purified protein may be produced, any differences in the manufacturing processes may result in differences in the final product. In addition, the methods of product potency assay are different between the BoNT-A products, resulting in one LD50 unit of one product not being the same as an LD 50 unit of another.

Despite differences in the final products, the manufacturing process for biologic products must ensure that every batch of the resulting product meets detailed specifications and standards for protein composition and has consistent biochemical characteristics and biologic activity.

After fermentation from a proprietary Ipsen C botulinum Hall strain, the unique proprietary manufacturing process for the BoNTA-ABO formulation of Dysport includes the purification steps of acid precipitation followed by column chromatography to yield the highly potent DS.

Interbatch reproducibility and comparability of the toxin—hemagglutinin complex in the final formulation ensure the consistency of clinical material. The Dysport formulation of BoNTA-ABO has a consistent batch-to-batch toxin protein load per vial of product the amount of foreign protein per vial with a mean toxin protein content of 4.

The US package insert for Botox notes that the product contains approximately 5 ng of toxin protein and provides no additional supporting information. The use of BoNT-A formulations for the aesthetic treatment of facial lines is both safe and effective if the unique characteristics of each formulation are considered and specific dosing and administration recommendations are followed.

Based on analysis of long-term manufacturing data, the Dysport formulation has been shown to have a high degree of consistency in protein load over the long-term, and similar consistency in biochemical and functional characteristics such as endopeptidase activity. The authors were compensated for their contributions to this manuscript and as investigators for the study. Pickett is employed by Ipsen Biopharm, the manufacturer of Dysport. Wortzman is employed by Medicis Pharmaceutical Corp.

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Dermatol Surg ; 33 1 spec no. Dressler D Hallett M. Most people associate botulinum toxin injections with the treatment of wrinkles ; however, this remarkable agent is extremely versatile and used for many other conditions, including spasticity, eye twitch i.

The story of how we came to inject this microbial toxin into our bodies to treat wrinkles is both fascinating and serendipitous. Botox or botulinum toxin is produced by the bacterium Clostridium botulinum. In the wild, infection with Clostridium botulinum causes botulism , a rare but disabling paralytic illness. When botulism paralyzes the muscles used in breathing, death can ensue.

Of note, in May , there was a botulism outbreak in California traced back to nacho cheese sauce sold at a gas station. After injection into the muscle, botulinum toxin suffuses the nerve terminal and binds thus preventing the release of acetylcholine, a neurotransmitter.

Without acetylcholine, muscle activity stops. This focal, or site-specific, paralysis is what smoothes wrinkles and stops spasms. In other words, Botox works by "paralyzing" the wrinkles away.

In addition to interfering with acetylcholine release, botulinum toxin also interferes with the release of pain and inflammatory mediators including substance P and glutamine, which explains why botulinum toxin is used to treat migraine headaches. Adverse effects after treatment with botulinum toxin include bruising, swelling, headaches, discomfort as well as muscle weakness which may affect muscles surrounding the muscle that was injected.

Before injection with botulinum toxin, the use of anticoagulants should be discontinued for two weeks to minimize bruising. Furthermore, treatment with botulinum toxin should be started at a lower dose and gradually increased. The effects of botulinum toxin wear off during time.

Specifically, after initial chemical de-nervation, the nerve ends sprout or regenerate and functionality is restored after days. In other words, after altering nerve ending, Botox works for about days before the nerves regenerate. There is a generic version of Botox—Botulinum toxin type A. Several propriety formulations are on the market, including Botox and Dysport.

These formulations are not interchangeable and are dosed differently. Clostridium botulinum was first discovered by a Belgian scientist named Emile Pierre van Ermengem following a botulism outbreak in Belgium. However, it took 20 years before the botulinum toxin was finally isolated in crystalline form by Dr. Edward Schantz. In the s, scientists started using botulinum toxin to treat strabismus i.

The glabella is the skin between the eyebrows and above the nose. After botulinum toxin proved successful in the treatment of strabismus, Allergan licensed the treatment and branded it Botox. Please note that although physicians use botulinum toxin to treat many types of facial wrinkles, much of this treatment is off label.

In other words, your physician uses clinical judgment to treat facial wrinkles with Botox. In the annals of medicine, botulinum toxin is probably most notable because it was the first microbial injection used to treat disease. The injection of bacterial products into the human body represents a new invention. With each passing year, researchers develop more formulations of this versatile agent and find more uses for it.

Botox is a versatile agent commonly used to treat many types of wrinkles. Overall, the use of Botox is relatively safe, with few adverse effects. If interested in receiving Botox treatments, please speak with your dermatologist. Sign up for our Health Tip of the Day newsletter, and receive daily tips that will help you live your healthiest life.

American Society of Plastic Surgeons.