|IM (approved), SC, intradermal, into glands|
|CAS Registry Number|
|Molecular mass||149 kDa|
|(what is this?)|
|PDB structures||RCSB PDB PDBe PDBsum|
|Gene Ontology||AmiGO / EGO|
Botulinum toxin (BTX) is a neurotoxic protein produced by the bacterium Clostridium botulinum and related species. It is also produced commercially for medical, cosmetic, and research use. There are two main commercial types: botulinum toxin type A and botulinum toxin type B.
Infection with the bacterium may result in a potentially fatal disease called botulism. Botulinum is the most acutely lethal toxin known, with an estimated human median lethal dose (LD50) of 1.3–2.1 ng/kg intravenously or intramuscularly and 10–13 ng/kg when inhaled.
Botulinum toxin type A and B is used in medicine for, among others, upper motor neuron syndrome, focal hyperhidrosis, blepharospasm, strabismus, chronic migraine and bruxism. It is also widely used in cosmetic treatments. The U.S. Food and Drug Administration requires a boxed warning stating that when locally administered the toxin may spread from the injection site to other areas of the body, causing symptoms similar to those of botulism. The warning was the result of deaths associated with its uses. The commercial form is marketed under the brand name Botox, among others.
- 1 Uses
- 2 Adverse effects
- 3 Mechanism of action
- 4 History
- 5 Society and culture
- 6 Research
- 7 See also
- 8 References
- 9 External links
- cervical dystonia (spasmodic torticollis), a neuromuscular disorder of the head and neck, which makes someone involuntarily jolt their head to one side;
- blepharospasm, uncontrolled muscle contraction or twitch of the eyelid;
- severe primary axillary hyperhidrosis, a condition of excessive sweating;
- chronic migraine, defined by patient history and high frequency of occurrence;
- strabismus, improper alignment of the eyes (heterotropia; colloquially "crossed eyes").
Other adult uses of botulinum toxin type A include:
- oesophageal achalasia, failure of smooth muscle relaxation, such that the oesophageal sphincter fails to open when needed;
- bruxism, parafunctional teeth grinding/jaw clenching, by injection into masticating muscles (e.g., the masseter);
- chronic focal neuropathies: It has been reported that local intradermal injection of BTX-A may be helpful, as the analgesic effects are independent of changes in muscle tone;
- idiopathic and neurogenic detrusor overactivity;
- vaginismus to reduce spasm of the vaginal muscles;
- movement disorders associated with injury or disease of the central nervous system, including trauma, stroke, multiple sclerosis, Parkinson's disease, or cerebral palsy;
- focal dystonias affecting the limbs, face, jaw, or vocal cords;
- obesity, i.e., as an aid in weight loss, by increasing the gastric emptying time;
- detrusor sphincter dyssynergia and benign prostatic hyperplasia;
- vocal cord dysfunction, including spasmodic dysphonia and tremor;
- painful bladder syndrome;
- anal fissure;
- gastric cancer;
- allergic rhinitis.
Uses of botulinum toxin type A in children include:
- muscle spasms in cerebral palsy;
- incontinence, including incontinence due to overactive bladder and incontinence due to neurogenic bladder.
Emerging uses for botulinum toxin type A include chronic musculoskeletal pain.
In cosmetic applications, injection of botulinum toxin can be used to prevent development of wrinkles by paralyzing facial muscles.[better source needed] Following treatment, visible results of Botox Cosmetic are usually seen within 3–5 days, however it can take up to 2 weeks to see full results.
Off-target, or side effects, that have been reported are consistent with the mechanism of the protein toxin's function, and its known modes of action; there are, consequently, two major areas of off-target effects: allergic reaction, and paralysis of the wrong muscle group.
Adverse events or reactions from cosmetic use include facial paralysis resulting in inappropriate facial expression, drooping eyelid, and double vision, bruising, swelling, or redness at the site of injection, headaches, dysphagia, flu-like syndromes, blurred vision, dry mouth, fatigue, and allergic reactions. Cosmetic treatments are of limited duration; they can be as short as six weeks, but can last from two to three months; hence paralysis side-effects can have the same durations. The results of inappropriate facial expression, drooping eyelid, and double vision are foremost,[better source needed] but the list extends to uneven smiling, and loss of the ability to close ones eyes; at least in some cases, these effects are reported to dissipate in the weeks after treatment. Bruising at the site of injection is not a side effect of the toxin but rather of the mode of administration, and is reported as preventable if the clinician applies pressure to the injection site; when it occurs, it is reported in specific cases to last 7–11 days. When injecting the masseter muscle of the jaw, loss of muscle function can result in a loss or reduction of power to chew solid foods.
Individuals who are pregnant, have egg allergies, or a neuromuscular disorder are advised to avoid botulinum toxin drugs, and breastfeeding mothers are advised to consult their doctors.[better source needed]
The psychological and emotional consequences associated with cosmetic treatments is not yet well documented, and reports are not yet consistent. A study of treatment of glabellar lines with consequent reduction of ability to frown correlated with a "more positive mood[s]",[non-primary source needed] while a study on the treatment of "crow's feet" or "laughter lines" suggested the opposite effect as a consequence of the impact of the treatment on the patient's ability to smile.[better source needed][disputed ]
If the symptoms of botulism are diagnosed early, an equine antitoxin, use of enemas, and extracorporeal removal of the gut contents can be used to treat the food-borne illness. Wound infections can be treated surgically. Information regarding methods of safe canning, and public education about the disease are methods of prevention. Tests to detect botulism include a brain scan, a nerve conduction test, and a tensilon test for myasthenia gravis to differentiate botulism from other diseases that manifest in the same way. Electromyography can be used to differentiate myasthenia gravis and Guillain-Barré syndrome, diseases that botulism often mimics. Toxicity testing of serum specimens, wound tissue cultures, and toxicity testing, and stool specimen cultures are the best methods for identifying botulism. Laboratory tests of the patient's serum or stool, which are then injected into mice, are also indicative of botulism. The faster way to detect botulinum toxin in people, however, is using the mass spectrometer technology, because it reduces testing time to three or four hours and at the same time can identify the type of toxin present.
The case fatality rate for botulinum poisoning between 1950 and 1996 was 15.5%, down from about 60% over the previous 50 years. Death is generally secondary to respiratory failure due to paralysis of the respiratory muscles, so treatment consists of antitoxin administration and artificial ventilation until the neurotoxins are excreted or metabolised. If initiated on time, these treatments are quite effective, although antisera can not affect toxin polypeptides that have already entered cells. Occasionally, functional recovery may take several weeks to months or more.
Two primary botulinum antitoxins are available for treatment of botulism.
- Trivalent (A,B,E) botulinum antitoxin is derived from equine sources using whole antibodies (Fab and Fc portions). This antitoxin is available from the local health department via the CDC in the USA.
- The second antitoxin is Heptavalent (A,B,C,D,E,F,G) botulinum antitoxin, which is derived from "despeciated" equine IgG antibodies, which have had the Fc portion cleaved off, leaving the F(ab')2 portions. This less immunogenic antitoxin is effective against all known strains of botulism where not contraindicated, and is available from the United States Army. On June 1, 2006, the US Department of Health and Human Services awarded a $363 million contract with Cangene Corporation for 200,000 doses of heptavalent botulinum antitoxin over five years for delivery into the Strategic National Stockpile beginning in 2007.
Links to deaths
The US Food and Drug Administration (FDA) has formally linked complications from use of botulinum drug products to patient deaths. In September 2005, the Journal of American Academy of Dermatology communicated information from the FDA reporting 28 deaths between 1989 and 2003 associated with the use of botulinum toxin products, though none attributed to cosmetic use.
In January 2008, a petition filed by Public Citizen with the FDA requested regulatory action concerning the possible spread of the effects of botulinum toxin injectable products, including Botox and Myobloc, from the site of injection to other parts of the body.
On February 8, 2008, the FDA announced its conclusion that this class of drugs had "been linked in some cases to adverse reactions, including respiratory failure and death, following treatment of a variety of conditions using a wide range of doses", due to its ability to spread to areas distant from the site of the injection. The communication was a result of ongoing FDA safety reviews of the on-market product, and found adverse reactions associated with uses that were both FDA-approved and non-approved, the most severe being in children with cerebral palsy treated for limb spasticity (not approved for either adult or pediatric use).
On April 30, 2009, based on a continuing safety evaluation of on-market botulinum toxin products, the FDA reported its conclusion that the prescribing information for Botox, Botox Cosmetic, and Myobloc must be updated to ensure their continued safe use. On July 31, 2009, FDA, under the authorities granted by the Food and Drug Administration Amendments Act of 2007, approved revisions to the prescribing information (see following).
Further, on April 30, the FDA announced an update to its mandatory boxed warnings for four on-market products—Botox, Botox Cosmetic, Myobloc, and Dysport—and on July 31, it approved revisions to the prescribing information for the four drugs. In the revisions, it made clear that the effects of botulinum toxin may spread from the area of injection to other body areas, causing symptoms similar to those of botulism, including potentially life-threatening swallowing and breathing difficulties resulting in patient death. Most accumulated adverse reactions were again reported for pediatric palsy patients (off-label use, see above), though adverse reaction reports were also fielded for adult patients involved in both approved and unapproved uses; the FDA emphasized that at recommended/approved doses there were few serious adverse reactions for common, standard treatments for focal hyperhidrosis, blepharospasm, or strabismus, or for cosmetic/dermatologic treatments, e.g., for glabellar lines (i.e., when label instructions were followed). The FDA further emphasized that the activity units of each product do not interconvert, specifically that "different botulinum toxin products are not interchangeable, because the units used to measure the products are different", and required a change in the established drug names of older drugs, from:
- Botox and Botox Cosmetic to onabotulinumtoxinA,
- Dysport to abobotulinumtoxinA (already in place, so no change), and from
- Myobloc to rimabotulinumtoxinB,
A further FDA communication aimed at health care professionals reiterated the approved drugs for each adult indication:
- cervical dystonia: OnabotulinumtoxinA (Botox), AbobotulinumtoxinA (Dysport), and RimabotulinumtoxinB (Myobloc);
- blepharospasm, severe primary axillary hyperhidrosis, strabismus: OnabotulinumtoxinA (Botox); and
- temporary cosmetic treatment of glabellar lines: OnabotulinumtoxinA (Botox), AbobotulinumtoxinA (Dysport).
These have been extended, through later announcement, to include:
- adult headache prevention in cases of chronic migraine: OnabotulinumtoxinA (Botox),
which is defined for patients having a history of migraine, and experiencing a headache on most days of the month."
In the 2009 communication to professionals, the FDA reiterated the foregoing adverse reaction observations and the possibility of "unexpected loss of strength or muscle weakness", leading to:
- double vision, blurred vision or drooping eyelids;
- dysphonia (hoarseness, trouble talking), dysarthria (trouble enunciating words), or trouble swallowing;
- trouble breathing; or
- loss of bladder control
and that "swallowing and breathing difficulties can be life-threatening" (i.e., that there have been "deaths related to the effects of spread of botulinum toxin"). The communication to professionals reiterated that pediatric spasticity patients were at greatest risk from existing treatment practices, but also that approved and lower doses used to treat cervical dystonia and adult spasticity were also seen among the "cases of toxin spread", so that in all cases of drug administration, patients and their caregivers needed to:
"Pay close attention for any signs or symptoms of adverse events. [and] Seek immediate medical attention… [in the case of] difficulty swallowing or talking, trouble breathing, or muscle weakness…"
and that these events may occur "as late as several weeks after treatment."
In January 2009, the Canadian government warned that botulinum toxin products can have the adverse effect of spreading to other parts of the body, which could cause muscle weakness, swallowing difficulties, pneumonia, speech disorders and breathing problems.
In April 2009, the FDA updated its mandatory boxed warning cautioning that the effects of the botulinum toxin may spread from the area of injection to other areas of the body, causing symptoms similar to those of botulism, and that these adverse reactions, which were more likely in cases ignoring approved use guidance and label directions, could result in patient death (see above).
Mechanism of action
|This section needs additional citations for verification. (February 2015)|
The toxin produced by Clostridum species is a two-chain protein composed of a 100-kDa heavy chain polypeptide joined via disulfide bond to a 50-kDa light chain polypeptide. The seven serologically distinct toxin types possessing different tertiary structures and significant sequence divergence are designated A to G; six of the seven have subtypes, and five further subtypes of target molecules of botulinum A have been described.[clarification needed] The A, B, and E serotypes cause human botulism, with the activities of types A and B enduring longest in vivo (from several weeks to months).
The terminals of specific axons must internalize the toxin to cause paralysis, and the heavy chain of the toxins is implicated in targeting the toxin to such axon terminals; following the attachment of the toxin heavy chain to proteins on the surface of the terminals, toxin molecules enter the neurons by endocytosis. The light chain, which has zinc metalloprotease activity, is released from the endocytotic vesicles and reaches the cytoplasm.[clarification needed] Specific serotypes of the toxin cleave synaptosomal-associated protein (25 kDa) (SNAP-25), a protein from the soluble N-ethylmaleimide-sensitive factor attachment receptor (SNARE) family involved in vesicle fusion and mediating release of neurotransmitter, in particular acetylcholine, from axon endings.[non-primary source needed] Cleavage of the SNARE proteins inhibits release of acetylcholine. Hence, botulinum toxins A, B, and E specifically cleave SNAREs, preventing "neurosecretory vesicles" from docking/fusing with the interior surface of the plasma membrane of the nerve synapse, and so block release of neurotransmitter. In inhibiting acetylcholine release, nerve impulses are blocked, causing the flaccid (sagging) paralysis of muscles characteristic of botulism (in contrast to the distinct spastic paralysis seen in tetanus).
In 1820, Justinus Kerner, a small-town German medical officer and romantic poet, gave the first complete description of clinical botulism based on extensive clinical observations of so-called “sausage poisoning”. Following experiments on animals and on himself, he concluded that the toxin acts by interrupting signal transmission in the somatic and autonomic motor systems, without affecting sensory signals or mental functions. He observed that the toxin develops under anaerobic conditions, and can be lethal in minute doses. His prescience in suggested that the toxin might be used therapeutically to block both abnormal movements and hypersecretions earned him recognition as the intellectual founder of modern botulinum toxin therapy.
Seventy-five years later, Émile van Ermengem, professor of bacteriology and a student of Robert Koch, correctly described Clostridium botulinum as the bacterial source of the toxin. Thirty-four attendees at a funeral were poisoned by eating partially salted ham, an extract of which was found to cause botulism-like paralysis in laboratory animals. Van Ermengem isolated and grew the bacterium, and described its toxin, which was later purified by P Tessmer Snipe and Hermann Sommer.
Over the next three decades, as food canning was approaching a billion dollar a year industry, botulism was becoming a public health hazard. Karl Friedrich Meyer, a prodigiously productive Swiss-American veterinary scientist (and supervisor of Alan B Scott’s mother’s 1925 MA degree in bacteriology!), created a center at the Hooper Foundation in San Francisco, where he developed techniques for growing the organism and extracting the toxin, and conversely, for preventing organism growth and toxin production, and inactivating the toxin by heating. The California canning industry was thereby preserved.
With the outbreak of World War II, weaponization of botulinum toxin was investigated at Fort Detrick in Maryland. Carl Lamanna and James Duff  developed the concentration and crystallization techniques that Edward J Schantz used to create the first clinical product. When the Army’s Chemical Corps was disbanded, Schantz moved to the Food Research Institute in Wisconsin, where he manufactured toxin for experimental use and generously provided it to the academic community.
The mechanism of botulinum toxin action – blocking the release from nerve endings of the neurotransmitter acetylcholine – was elucidated in the mid-1900s, and remains an important research topic. Nearly all toxin treatments are based on this effect in various body tissues.
Eye muscle disorders
Ophthalmologists specializing in eye muscle disorders (strabismus) had developed the method of EMG-guided injection (using the electromyogram, the electrical signal from an activated muscle, to guide injection) of local anesthetics as a diagnostic technique for evaluating an individual muscle’s contribution to an eye movement. Because strabismus surgery frequently needed repeating, a search was undertaken for non-surgical, injection treatments using various anesthetics, alcohols, enzymes, enzyme blockers, and snake neurotoxins. Finally, inspired by Daniel Drachman’s work with chicks at Johns Hopkins, Alan B Scott and colleagues injected botulinum toxin into monkey extraocular muscles. The result was remarkable: a few picograms induced paralysis that was confined to the target muscle, long in duration, and without side-effects.
After working out techniques for freeze-drying, buffering with albumin, and assuring sterility, potency, and safety, Scott applied to the FDA for investigational drug use, and began manufacturing botulinum type A neurotoxin in his San Francisco lab. He injected the first strabismus patients in 1977, reported its clinical utility in 1980, and had soon trained hundreds of ophthalmologists in EMG-guided injection of the drug he named Oculinum™ (“eye aligner”).
Strabismus is caused by imbalances in the actions of muscles that rotate the eyes, and can sometimes be relieved by weakening a muscle that pulls too strongly, or pulls against one that has been weakened by disease or trauma. Muscles weakened by toxin injection recover from paralysis after several months, so it might seem that injection would then need to be repeated. However, muscles adapt to the lengths at which they are chronically held, so that if a paralyzed muscle is stretched by its antagonist, it grows longer, while the antagonist shortens, yielding a permanent effect. If there is good binocular vision, the brain mechanism of motor fusion, which aligns the eyes on a target visible to both, can stabilize the corrected alignment.
Other muscle disorders
By 1982, eye muscles had been injected for strabismus and nystagmus (jerky, involuntary eye movements), eyelid muscles for retraction and blepharospasm (sustained, involuntary contractions of muscles around the eye), facial muscles for hemifacial spasm, and limb muscles for dystonia (sustained muscle spasm), all as predicted in Scott’s 1973 study.
Scott also injected the first cases of torticollis (painful, spastic twisting of the neck), which were later published by Joseph Tsui of Vancouver. But even a century and a half after Kerner’s work, it was difficult for many to accept that the specificity and molecular tenacity that made ingested toxin so deadly also made it remarkably safe when injected directly into a target muscle, and no Bay Area neurology, orthopedic, or rehabilitation physician would try toxin for muscle contractures with stroke, dystonia, torticollis, or cerebral palsy. L Andrew Koman of Wake Forest University in North Carolina pioneered use of toxin to treat pediatric leg spasm in cerebral palsy.
Patient groups quickly spread the word that there were now effective treatments for previously untreatable motility disorders such as blepharospasm, which can result in functional blindness despite an otherwise normal visual system. Torticollis patients discovered that their pain could be markedly reduced by toxin injection, motility increased, head position somewhat improved, even if tremor was not. In 1993, Scott, Pankaj Pasricha, and colleagues showed that botulinum toxin could be used for the treatment of achalasia, a spasm of the lower esophageal sphincter. Spasmodic dysphonia (difficulty speaking), various gastroenteric and urinary sphincter spasms, muscle spasm in stroke, and many other muscle disorders, were also treated with botulinum toxin injection.
In January 2014, botulinum toxin was approved by UK's Medicines and Healthcare Products Regulatory Agency (MHRA) for treatment of restricted ankle motion due to lower limb spasticity associated with stroke in adults.
Botulinum toxin has not been approved for pediatric use. However, it has been used off-label for several pediatric conditions, including infantile esotropia and spastic conditions in cerebral palsy.
In 1986, Oculinum Inc, Scott's micromanufacturer and distributor of botulinum toxin, was unable to obtain product liability insurance, and could no longer supply the drug. As supplies became exhausted, patients who had come to rely on periodic injections became desperate. For 4 months, as liability issues were resolved, American blepharospasm patients traveled to Canadian eye centers for their injections.
Based on data from thousands of patients collected by 240 investigators, under the 1983 US Orphan Drug Act, Scott got FDA approval in 1989 to market Oculinum for clinical use in the United States to treat adult strabismus and blepharospasm. Allergan served as the drug’s distributor for almost 2 years, and in 1991 took over the licenses and changed the drug’s name to Botox®.
Finally pursuing Kerner’s suggestion 175 years earlier, Khalafalla Bushara and David Park in England made the first non-muscular use of botulinum toxin in humans with a demonstration that injections could inhibit excess sweating.
The toxin was also used by Drobik and Laskawi to treat hyperhidrosis in Frey’s Syndrome, in which facial sweating occurs after parotid gland surgery due to anomalous regrowth of injured salivary nerves to the face. It was a natural extension to use the toxin to ameliorate the poorly handled salivary secretions in amyotrophic lateral sclerosis and to decrease excessive lacrimal gland secretion. The concept of blocking cholinergic innervation to sweat glands as a treatment for hyperhidrosis in the axilla, hands, and elsewhere, followed.
Richard Clark, a plastic surgeon from Sacramento (CA), was the first to document a cosmetic use for botulinum toxin. He treated facial asymmetry caused by unilateral facial nerve paralysis by injecting toxin into the non-paralyzed frontal muscle.
Marrying ophthalmology to dermatology, Jean and Alistair Carruthers observed that blepharospasm patients who received injections around the eyes and upper face also enjoyed diminished facial glabellar lines (“frown lines” between the eyebrows), thereby initiating the highly-popular cosmetic use of the toxin. Brin, and a group at Columbia University under Monte Keen made similar reports. In 2002, following clinical trials, the FDA approved Botox Cosmetic, botulinum A toxin to temporarily improve the appearance of moderate-to-severe glabellar lines. The FDA approved a fully in vitro assay for use in the stability and potency testing of Botox® in response to increasing public concern that LD50 testing was required for each batch sold in the market.
William Binder reported that patients who had cosmetic injections around the face reported relief from chronic headache. This was initially thought to be an indirect effect of reduced muscle tension, but it is now known that the toxin inhibits release of peripheral nociceptive neurotransmitters, suppressing the central pain processing systems responsible for migraine headache. In 2010, the FDA approved intramuscular botulinum toxin injections for prophylactic treatment of chronic migraine headache.
Society and culture
As of 2013, botulinum toxin injections are the most common cosmetic operation, with 6.3 million procedures in the United States, according to the American Society of Plastic Surgeons. Qualifications for Botox injectors vary by county, state and country. Botox cosmetic providers include dermatologists, plastic surgeons, aesthetic spa physicians, dentists, nurse practitioners, nurses and physician assistants.
The global market for botulinum toxin products, driven by their cosmetic applications, is forecast to reach $2.9 billion by 2018. The facial aesthetics market, of which they are a component, is forecast to reach $4.7 billion ($2 billion in the U.S.) in the same timeframe.
The effects of botulinum toxin are different from those of nerve agents involved insofar in that botulism symptoms develop relatively slowly (over several days), while nerve agent effects are generally much more rapid and can be instantaneous. Evidence suggests that nerve exposure (simulated by injection of atropine and pralidoxime) will increase mortality by enhancing botulin toxin's mechanism of toxicity.
With regard to detection, current protocols using NBC detection equipment (such as M-8 paper or the ICAM) will not indicate a "positive" when samples containing botulinum toxin are tested. To confirm a diagnosis of botulinum toxin poisoning, therapeutically or to provide evidence in death investigations, botulinum toxin may be quantitated by immunoassay of human biological fluids; serum levels of 12–24 mouse LD50 units per milliliter have been detected in poisoned patients.
Botulinum toxin A is marketed under the brand names Botox (marketed by Allergan), Dysport (marketed by Ipsen), and Xeomin (marketed by Merz Pharma). Botulinum toxin B is marketed under the brand name Myobloc (marketed by Solstice Neurosciences).
In the United States, botulinum toxin products are manufactured by a variety of companies, for both therapeutic and cosmetic use. Allergan, Inc., a principal U.S. supplier through their Botox products, reported in its company materials in 2011 that it could "supply the world's requirements for 25 indications approved by Government agencies around the world" with less than one gram of raw botulinum toxin. Myobloc or Neurobloc, a botulinum toxin type B product, is produced by Solstice Neurosciences, a subsidiary of US WorldMeds. Dysport, a therapeutic formulation of the type A toxin manufactured by Galderma in the United Kingdom, is licensed for the treatment of focal dystonias and certain cosmetic uses in the U.S. and other countries.
After the three primary U.S. manufacturers, there many reports of other sources of production. Xeomin, manufactured in Germany by Merz, is also available for both therapeutic and cosmetic use in the U.S. Lanzhou Institute of Biological Products in China manufactures a BTX-A product; as of 2014 it was the only BTX-A approved in China. BTX-A is also sold as Lantox and Prosigne on the global market. Neuronox, a BTX-A product, was introduced by Medy-Tox Inc. of South Korea in 2009; Neuronox is also markets as Siax in the U.S.
Botulism toxins are produced by bacteria of the genus Clostridium, namely Clostridium botulinum, C. butyricum, C. baratii and C. argentinense, which are widely distributed, including in soil and dust. As well, the bacteria can be found inside homes on floors, carpet, and countertops even after cleaning. Some food products such as honey can contain amounts of the bacteria.
Food-borne botulism results, indirectly, from ingestion of food contaminated with Clostridium spores, where exposure to an anaerobic environment allows the spores to germinate, after which the bacteria can multiply and produce toxin. Critically, it is ingestion of toxin rather than spores or vegetative bacteria that causes botulism. Botulism is nevertheless known to be transmitted through canned foods not cooked correctly before canning or after can opening, and so is preventable. Infant botulism cases arise chiefly as a result of environmental exposure and are therefore more difficult to prevent. Infant botulism arising from consumption of honey can be prevented by eliminating honey from diets of children less than 12 months old.
Therapeutic and weaponisable forms of the toxin are sourced from strains of Clostriudium where both the growth and toxin isolation are under specialized conditions.
Organism and toxin susceptibilities
|This section requires expansion with: modern content and referencing on antibiotic susceptibilities. (February 2015)|
Proper refrigeration at temperatures below 3 °C (38 °F) retards the growth of Clostridium botulinum. The organism is also susceptible to high salt, high oxygen, and low pH levels. The toxin itself is rapidly destroyed by heat, such as in thorough cooking. The spores that produce the toxin are heat-tolerant and will survive boiling water for an extended period of time.
The botulinum toxin is denatured and thus deactivated at temperatures greater than 80 °C (176 °F). As a zinc metalloprotease (see below), the toxin's activity is also susceptible, post-exposure, to inhibition by protease inhibitors, e.g., zinc-coordinating hydroxamates.
Blepharospasm and strabismus
In the early 1980s, university-based ophthalmologists in the USA and Canada further refined the use of botulinum toxin as a therapeutic agent. By 1985, a scientific protocol of injection sites and dosage had been empirically determined for treatment of blepharospasm and strabismus. Side effects in treatment of this condition were deemed to be rare, mild and treatable. The beneficial effects of the injection lasted only 4–6 months. Thus, blepharospasm patients required re-injection two or three times a year.
In 1986, Scott's micromanufacturer and distributor of Botox was no longer able to supply the drug because of an inability to obtain product liability insurance. Patients became desperate, as supplies of Botox were gradually consumed, forcing him to abandon patients who would have been due for their next injection. For a period of four months, American blepharospasm patients had to arrange to have their injections performed by participating doctors at Canadian eye centers until the liability issues could be resolved.
In December 1989, Botox, manufactured by Allergan, Inc., was approved by the US Food and Drug Administration (FDA) for the treatment of strabismus, blepharospasm, and hemifacial spasm in patients over 12 years old.
Botox has not been approved for any pediatric use. It has, however, been used off-label by physicians for several conditions. including spastic conditions in pediatric patients with cerebral palsy, a therapeutic course that has resulted in patient deaths. In the case of treatment of infantile esotropia in patients younger than 12 years of age, several studies have yielded differing results.[better source needed]
The cosmetic effect of BTX-A on wrinkles was originally documented by a plastic surgeon from Sacramento, California, Richard Clark, and published in the journal Plastic and Reconstructive Surgery in 1989. Canadian husband and wife ophthalmologist and dermatologist physicians, JD and JA Carruthers, were the first to publish a study on BTX-A for the treatment of glabellar frown lines in 1992. Similar effects had reportedly been observed by a number of independent groups (Brin, and the Columbia University group under Monte Keen.) After formal trials, on April 12, 2002, the FDA announced regulatory approval of botulinum toxin type A (Botox Cosmetic) to temporarily improve the appearance of moderate-to-severe frown lines between the eyebrows (glabellar lines). Subsequently, cosmetic use of botulinum toxin type A has become widespread. The results of Botox Cosmetic can last up to four months and may vary with each patient. The US Food and Drug Administration approved an alternative product-safety testing method in response to increasing public concern that LD50 testing was required for each batch sold in the market.
Upper motor neuron syndrome
BTX-A is now a common treatment for muscles affected by the upper motor neuron syndrome (UMNS), such as cerebral palsy, for muscles with an impaired ability to effectively lengthen. Muscles affected by UMNS frequently are limited by weakness, loss of reciprocal inhibition, decreased movement control and hypertonicity (including spasticity). In January 2014, Botulinum toxin was approved by UK's Medicines and Healthcare Products Regulatory Agency (MHRA) for the treatment of ankle disability due to lower limb spasticity associated with stroke in adults. Joint motion may be restricted by severe muscle imbalance related to the syndrome, when some muscles are markedly hypertonic, and lack effective active lengthening. Injecting an overactive muscle to decrease its level of contraction can allow improved reciprocal motion, so improved ability to move and exercise.
As noted, Bushara and Park were the first to demonstrate a nonmuscular use of BTX-A while treating patients with hemifacial spasm in England in 1993, showing that botulinum toxin injections inhibit sweating, and so are useful in treating hyperhidrosis (excessive sweating).[non-primary source needed] BTX-A has since been approved for the treatment of severe primary axillary hyperhidrosis (excessive underarm sweating of unknown cause), which cannot be managed by topical agents.[when?]
BTX-A is commonly used to treat cervical dystonia, but it can become ineffective after a time. Botulinum toxin type B (BTX-B) received FDA approval for treatment of cervical dystonia on December 21, 2000. Trade names for BTX-B are Myobloc in the United States, and Neurobloc in the European Union.
Onabotulinumtoxin A (trade name Botox) received FDA approval for treatment of chronic migraines on October 15, 2010. The toxin is injected into the head and neck to treat these chronic headaches. Approval followed evidence presented to the agency from two studies funded by Allergan, Inc. showing a very slight improvement in incidence of chronic migraines for migraine sufferers undergoing the Botox treatment.
Since then, several randomized control trials have shown botulinum toxin type A to improve headache symptoms and quality of life when used prophylactically for patients with chronic migraine who exhibit headache characteristics consistent with: pressure perceived from outside source, shorter total duration of chronic migraines (<30 years), "detoxification" of patients with coexisting chronic daily headache due to medication overuse, and no current history of other preventive headache medications.
- Montecucco C, Molgó J (2005). "Botulinal neurotoxins: revival of an old killer". Current Opinion in Pharmacology 5 (3): 274–279. doi:10.1016/j.coph.2004.12.006. PMID 15907915.
- American Society of Health-System Pharmacists (October 27, 2011). "Botulinum Toxin Type A". drugs.com. Retrieved 4 March 2015.
- Arnon, Stephen S.; Schechter R; Inglesby TV; Henderson DA; Bartlett JG; Ascher MS; Eitzen E; Fine AD; Hauer J; Layton M; Lillibridge S; Osterholm MT; O'Toole T; Parker G; Perl TM; Russell PK; Swerdlow DL; Tonat K; Working Group on Civilian Biodefense (February 21, 2001). "Botulinum Toxin as a Biological Weapon: Medical and Public Health Management" (PDF, 0.5 MB). Journal of the American Medical Association 285 (8): 1059–1070. doi:10.1001/jama.285.8.1059. PMID 11209178.
- FDA Notifies Public of Adverse Reactions Linked to Botox Use. Fda.gov. Retrieved on May 6, 2012.
- FDA Gives Update on Botulinum Toxin Safety Warnings; Established Names of Drugs Changed, FDA Press Announcement, August 3, 2009
- Barbano, Richard (November 8, 2006). "Risks of erasing wrinkles: Buyer beware!". Neurology 67 (10): E17–E18. doi:10.1212/01.wnl.0000250411.93526.9e. PMID 17130399.
- Edwards, Michael (2006). "Anal fissure". Dumas Ltd. Retrieved August 21, 2010.
- Bihari K (March 2005). "Safety, effectiveness, and duration of effect of BOTOX after switching from Dysport for blepharospasm, cervical dystonia, and hemifacial spasm dystonia, and hemifacial spasm". Current Medical Research and Opinion 21 (3): 433–438. doi:10.1185/030079905X36396. PMID 15811212.
- FDA, 2009, "Information for Healthcare Professionals, FDA ALERT [08/2009]: OnabotulinumtoxinA (marketed as Botox/Botox Cosmetic), AbobotulinumtoxinA (marketed as Dysport) and RimabotulinumtoxinB (marketed as Myobloc)", see , accessed 16 February 2015.
- FDA, 2010, "FDA News Release:FDA approves Botox to treat chronic migraine" see , accessed 17 February 2015.
- Brin MF, Lew MF, Adler CH, Comella CL, Factor SA, Jankovic J, O'Brien C, Murray JJ, Wallace JD, Willmer-Hulme A, Koller M (October 22, 1999). "Safety and efficacy of NeuroBloc (botulinum toxin type B) in type A-resistant cervical dystonia". Neurology 53 (7): 1431–1438. doi:10.1212/WNL.53.7.1431. PMID 10534247.
- Shukla HD, Sharma SK (2005). "Clostridium botulinum: a bug with beauty and weapon". Critical Reviews in Microbiology 31 (1): 11–18. doi:10.1080/10408410590912952. PMID 15839401.
- Eisenach JH, Atkinson JL, Fealey RD. (May 2005). "Hyperhidrosis: evolving therapies for a well-established phenomenon". Mayo Clinic Proceedings 80 (5): 657–666. doi:10.4065/80.5.657. PMID 15887434.
- Felber, ES (2006). "Botulinum toxin in primary care medicine.". The Journal of the American Osteopathic Association 106 (10): 609–614. PMID 17122031.
- Approved indication as of 2010, though the area has a history of conflicting reports, see the following.
- Naumann M; So Y; Argoff CE; Childers, M. K.; Dykstra, D. D.; Gronseth, G. S.; Jabbari, B.; Kaufmann, H. C.; et al. (May 2008). "Assessment: Botulinum neurotoxin in the treatment of autonomic disorders and pain (an evidence-based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology". Neurology 70 (19): 1707–14. doi:10.1212/01.wnl.0000311390.87642.d8. PMID 18458231.
- Kowal, Lionel; Wong, Elaine; Yahalom, Claudia (December 2007). "Botulinum Toxin in the treatment of strabismus. A review of its use and effects". Disability and Rehabilitation 29 (23): 1823–1831. Retrieved 1 September 2015.
- Stavropoulos, S. N.; Friedel, D.; Modayil, R.; Iqbal, S.; Grendell, J. H. (20 December 2012). "Endoscopic approaches to treatment of achalasia". Therapeutic Advances in Gastroenterology 6 (2): 115–135. doi:10.1177/1756283X12468039. Retrieved 1 September 2015.
- Long, Hu; Liao, Zhengyu; Wang, Yan; Liao, Lina; Lai, Wenli (February 2012). "Efficacy of botulinum toxins on bruxism: an evidence-based review". International Dental Journal 62 (1): 1–5. doi:10.1111/j.1875-595X.2011.00085.x. Retrieved 1 September 2015.
- Ranoux D, Attal N, Morain F, Bouhassira D (September 2008). "Botulinum toxin type A induces direct analgesic effects in chronic neuropathic pain". Annals of Neurology 64 (3): 274–83. doi:10.1002/ana.21427. PMID 18546285.
- Mangera A, Andersson KE, Apostolidis A, Chapple C, Dasgupta P, Giannantoni A, Gravas S, Madersbacher S. (2005). "Contemporary management of lower urinary tract disease with botulinum toxin A: a systematic review of botox (onabotulinumtoxinA) and dysport (abobotulinumtoxinA)". European Urology 60 (4): 784–95. doi:10.1016/j.eururo.2011.07.001. PMID 21782318.
- Pacik, PT Botox Treatment for Vaginismus Plast Reconst Surg vol 124: 455e-456e Dec. 2009
- Coskun H, Duran Y, Dilege E, Mihmanli M, Seymen H, Demirkol MO (2005). "Effect on gastric emptying and weight reduction of botulinum toxin-A injection into the gastric antral layer: an experimental study in the obese rat model". Obesity surgery 15 (8): 1137–43. doi:10.1381/0960892055002275. PMID 16197786.
- Trzciński R, Dziki A, Tchórzewski M (2002). "Injections of botulinum A toxin for the treatment of anal fissures". The European journal of surgery = Acta chirurgica 168 (12): 720–3. doi:10.1080/11024150201680030. PMID 15362583.
- "Denervation suppresses gastric tumorigenesis". Science Translational Medicine 6 (250): 250. 2014. doi:10.1126/scitranslmed.3009569.
- Schurch B, Corcos J (2005). "Botulinum toxin injections for paediatric incontinence". Current Opinion in Urology 15 (4): 264–7. doi:10.1097/01.mou.0000172401.92761.86. PMID 15928517.
- Duthie J, Wilson D, Herbison G, Wilson D (2007). Duthi, James B, ed. "Botulinum toxin injections for adults with overactive bladder syndrome". Cochrane database of systematic reviews (Online) 3 (3): CD005493. doi:10.1002/14651858.CD005493.pub2. PMID 17636801.
- Akbar M, Abel R, Seyler TM, Gerner HJ, Möhring K (2007). "Repeated botulinum-A toxin injections in the treatment of myelodysplastic children and patients with spinal cord injuries with neurogenic bladder dysfunction". BJU Int. 100 (3): 639–45. doi:10.1111/j.1464-410X.2007.06977.x. PMID 17532858.
- Charles PD (2004). "Botulinum neurotoxin serotype A: a clinical update on non-cosmetic uses". American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists 61 (22 Suppl 6): S11–23. PMID 15598005.
- Markus, Ramsey (September 30, 2009). "Botox for Wrinkles". Baylor College of Medicine. Retrieved July 14, 2010.[better source needed]
- "BOTOX Cosmetic Onset Information". Injector 5280. January 22, 2014. Retrieved January 22, 2014.
- Coté TR, Mohan AK, Polder JA, Walton MK, Braun MM (September 2005). "Botulinum toxin type A injections: adverse events reported to the US Food and Drug Administration in therapeutic and cosmetic cases". J. Am. Acad. Dermatol. 53 (3): 407–15. doi:10.1016/j.jaad.2005.06.011. PMID 16112345.
- Lewis M.B., Bowler P.J. (2009). "Botulinum toxin cosmetic therapy correlates with a more positive mood". Journal of Cosmetic Dermatology 8: 24–26. doi:10.1111/j.1473-2165.2009.00419.x.
- "Disease Listing, Botulism Manual, Additional Information". CDC Bacterial, Mycotic Diseases. Retrieved January 21, 2010.
- Developing a Faster Method for Measuring Botulinum Toxin in People. cdc.gov. archived
- "Disease Listing, Botulism Manual, Additional Information – CDC Bacterial, Mycotic Diseases". Retrieved August 14, 2007.
- Turton K., Chaddock J. A., Acharya K. R. (2002). "Botulinum and tetanus neurotoxins: structure, function and therapeutic utility". Trends in Biochemical Sciences 27 (11): 552–558. doi:10.1016/S0968-0004(02)02177-1. PMID 12417130.
- "FEMA". Archived from the original on September 29, 2007. Retrieved August 14, 2007.
- Petition Requesting Regulatory Action Concerning the Spread of Botulinum Toxin (Botox, Myobloc) to Other Parts of the Body. HRG Publication #1834. Public Citizen. January 23, 2008
- "Botox chemical may spread, Health Canada confirms". CBC News. January 13, 2009.
- Le Canada met en garde contre les effets dangereux du Botox (French)
- Barr, John R. (2005). "Botulinum Neurotoxin Detection and Differentiation by Mass Spectrometry". Emerging Infectious Diseases 11 (10): 1578–1583. PMC 3366733. PMID 16318699.
- Bing, L. (2011). "Small Molecule Inhibitors as Countermeasures for Botulinum Neurotoxin Intoxication". Molecules 16: 202–220. doi:10.3390/molecules16010202.
- Hill, Karen K; Smith, Theresa J (2013). "Genetic Diversity Within Clostridium botulinum Serotypes, Botulinum Neurotoxin Gene Clusters and Toxin Subtypes". In Rummel, Andreas; Binz, Thomas. Botulinum neurotoxins. Heidelberg: Springer. ISBN 978-3-642-33569-3. Retrieved 1 September 2015.
- Foran PG; Mohammed N; Lisk GO; Nagwaney, S; Lawrence, GW; Johnson, E; Smith, L; Aoki, KR; Dolly, JO (2003). "Evaluation of the therapeutic usefulness of botulinum neurotoxin B, C1, E, and F compared with the long lasting type A. Basis for distinct durations of inhibition of exocytosis in central neurons". J. Biol. Chem. 278 (2): 1363–71. doi:10.1074/jbc.M209821200. PMID 12381720.[non-primary source needed]
- Pellizzari, R.; Rossetto, O.; Schiavo, G.; Montecucco, C. (28 February 1999). "Tetanus and botulinum neurotoxins: mechanism of action and therapeutic uses". Philosophical Transactions of the Royal Society B: Biological Sciences 354 (1381): 259–268. doi:10.1098/rstb.1999.0377. Retrieved 1 September 2015.
- Kerner, J. (1820). Neue Beobachtungen über die in Württemberg so häufig vorfallenden tödlichen Vergiftungen durch den Genuss geräucherter Würste. Tübingen: Osiander.
- Kerner, J. (1822). Das Fettgift oder die Fettsäure und ihre Wirkungen auf den thierischen Organismus, ein Beytrag zur Untersuchung des in verdorbenen Würsten giftig wirkenden Stoffes. Stuttgart, Tübingen: Cotta.
- Erbguth, F. J.; Naumann, M. (1999-11-10). "Historical aspects of botulinum toxin: Justinus Kerner (1786-1862) and the "sausage poison"". Neurology 53 (8): 1850–1853. ISSN 0028-3878. PMID 10563638.
- van Ermengem, E.P. (February 1897). "Ueber einen neuen anaëroben Bacillus und seine Beziehungen zum Botulismus". Zeitschrift für Hygiene und Infektionskrankheiten (in German) 26 (1): 1–56. doi:10.1007/BF02220526. PMID 399378.
- Snipe, P. Tessmer & Sommer, H. (August 1928). "Studies on Botulinus Toxin: 3. Acid Precipitation of Botulinus Toxin". The Journal of Infectious Diseases (University of Chicago Press) 43 (2): 152–160. doi:10.1093/infdis/43.2.152. JSTOR 30083772.
- Lamanna, C.; McELROY, O. E.; Eklund, H. W. (1946-05-17). "The purification and crystallization of Clostridium botulinum type A toxin". Science (New York, N.Y.) 103 (2681): 613. ISSN 0036-8075. PMID 21026141.
- A. S. V. Burgen, F. Dickens, and L. J. Zatman (August 1949). "The action of botulinum toxin on the neuro-muscular junction". The Journal of Physiology (University of Chicago Press) 109 (1–2): 10–24. PMC 1392572. PMID 15394302.
- Magoon, E., et al. (1982). "Diagnostic injection of Xylocaine into extraocular muscles." Ophthalmology 89(5): 489-491.
- Drachman, D. B. (1964-08-14). "ATROPHY OF SKELETAL MUSCLE IN CHICK EMBRYOS TREATED WITH BOTULINUM TOXIN". Science (New York, N.Y.) 145 (3633): 719–721. ISSN 0036-8075. PMID 14163805.
- Scott, A. B. (1973). "Pharmacologic weakening of extraocular muscles". Investigative Ophthalmology & Visual Science 12 (12): 924–927. PMID 4203467.
- Scott, A. B. (1980). "Botulinum toxin injection into extraocular muscles as an alternative to strabismus surgery." Ophthalmology 87(10): 1044-1049.
- Scott, A. B. (1994). "Change of eye muscle sarcomeres according to eye position." J Pediatr Ophthalmol Strabismus 31(2): 85-88.
- Tsui, J. K.; Eisen, A.; Mak, E.; Carruthers, J.; Scott, A.; Calne, D. B. (1985-11-01). "A pilot study on the use of botulinum toxin in spasmodic torticollis". The Canadian Journal of Neurological Sciences. Le Journal Canadien Des Sciences Neurologiques 12 (4): 314–316. ISSN 0317-1671. PMID 4084867.
- Koman, L. A.; Mooney, J. F.; Smith, B.; Goodman, A.; Mulvaney, T. (1993-08-01). "Management of cerebral palsy with botulinum-A toxin: preliminary investigation". Journal of Pediatric Orthopedics 13 (4): 489–495. ISSN 0271-6798. PMID 8370782.
- Scott AB, Pasricha, PJ. Ravich WJ, Kalloo AN (January 1993). "Botulinum toxin for achalasia". Lancet 341 (8839): 244–5. doi:10.1016/0140-6736(93)90109-T. PMID 8093528.
- UK Approves New Botox Use. dddmag.com. February 4, 2014
- Vicente Victor D Ocampo Jr.; C Stephen Foster (May 30, 2012). "Infantile Esotropia Treatment & Management". Medscape. Retrieved April 6, 2014.
- Boffey, Philip M. (October 14, 1986). "Loss Of Drug Relegates Many To Blindness Again". The New York Times. Retrieved July 14, 2010.
- Bushara KO, Park DM. (November 1994). "Botulinum toxin and sweating". Journal of Neurology, Neurosurgery, and Psychiatry 57 (11): 1437–1438. doi:10.1136/jnnp.57.11.1437. PMC 1073208. PMID 7964832.
- Drobik, C.; Laskawi, R. (1995-05-01). "Frey's syndrome: treatment with botulinum toxin". Acta Oto-Laryngologica 115 (3): 459–461. ISSN 0001-6489. PMID 7653272.
- Clark RP, Berris CE. (August 1989). "Botulinum Toxin: A treatment for facial asymmetry caused by facial nerve paralysis". Plastic and Reconstructive Surgery 84 (2): 353–355. doi:10.1097/01.prs.0000205566.47797.8d. PMID 2748749.
- Carruthers, J. D.; Carruthers, J. A. (1992-01-01). "Treatment of glabellar frown lines with C. botulinum-A exotoxin". The Journal of Dermatologic Surgery and Oncology 18 (1): 17–21. ISSN 0148-0812. PMID 1740562.
- Monte Keen, M.D., Joel E. Kopelman, M.D.,† Jonathan E. Aviv, M.D., William Binder, M.D.,* Mitchell Brin, M.D., and Andrew Blitzer, M.D., D.D.S. (April 1994). "Botulinum Toxin A: A novel Method to Remove Periorbital Wrinkles" (PDF) 10 (2). Thieme Medical Publishers. pp. 141–146.
- "Botulinum Toxin Type A Product Approval Information – Licensing Action 4/12/02". Food and Drug Administration. October 29, 2009. Retrieved July 26, 2010.
- "Allergan Receives FDA Approval for First-of-Its-Kind, Fully in vitro, Cell-Based Assay for BOTOX® and BOTOX® Cosmetic (onabotulinumtoxinA)". Allergan, Inc. News Provided by Acquire Media. June 24, 2011. Retrieved June 26, 2011.
- "In U.S., Few Alternatives To Testing On Animals". Washington Post. April 12, 2008. Retrieved June 26, 2011.
- Binder, W. J.; Brin, M. F.; Blitzer, A.; Schoenrock, L. D.; Pogoda, J. M. (2000-12-01). "Botulinum toxin type A (BOTOX) for treatment of migraine headaches: an open-label study". Otolaryngology--Head and Neck Surgery: Official Journal of American Academy of Otolaryngology-Head and Neck Surgery 123 (6): 669–676. doi:10.1067/mhn.2000.110960. ISSN 0194-5998. PMID 11112955.
- Jackson, Jeffrey L.; Kuriyama, Akira; Hayashino, Yasuaki (2012-04-25). "Botulinum toxin A for prophylactic treatment of migraine and tension headaches in adults: a meta-analysis". JAMA 307 (16): 1736–1745. doi:10.1001/jama.2012.505. ISSN 1538-3598. PMID 22535858.
- Ramachandran, Roshni; Yaksh, Tony L. (2014-09-01). "Therapeutic use of botulinum toxin in migraine: mechanisms of action". British Journal of Pharmacology 171 (18): 4177–4192. doi:10.1111/bph.12763. ISSN 1476-5381. PMC 4241086. PMID 24819339.
- Chapman, Paul (May 10, 2012). "The global botox market forecast to reach $2.9 billion by 2018". Retrieved October 5, 2012.
- Koirala, Janak; Basnet, Sangita (July 14, 2004). "Botulism, Botulinum Toxin, and Bioterrorism: Review and Update". Medscape. Cliggott Publishing. Retrieved July 14, 2010.
- Clostridium botulinum – Public Health Agency of Canada. Phac-aspc.gc.ca (April 19, 2011). Retrieved on May 6, 2012.
- Baselt RC (2014). Disposition of toxic drugs and chemicals in man. Seal Beach, Ca.: Biomedical Publications. pp. 260–261. ISBN 978-0-9626523-9-4.
- "2011 Allergan Annual Report" (PDF). Allergan. Retrieved May 3, 2012. See PDF page 7.
- "Information for Healthcare Professionals: OnabotulinumtoxinA (marketed as Botox/Botox Cosmetic), AbobotulinumtoxinA (marketed as Dysport) and RimabotulinumtoxinB (marketed as Myobloc)". fda.gov. Food and Drug Administration. Retrieved 1 September 2015.
- Walker, Thomas J; Dayan, Steven H (February 2014). "Comparison and Overview of Currently Available Neurotoxins". The Journal of Clinical and Aesthetic Dermatology 7 (2): 31–39.
- "Botulinum Toxin Type A". Hugh Source (International) Limited. Retrieved July 14, 2010.
- Petrou, Ilya (Spring 2009). "Medy-Tox Introduces Neuronox to the Botulinum Toxin Arena" (PDF). The European Aesthetic Guide.
- Schantz EJ, Johnson EA. (March 1992). "Properties and use of botulinum toxin and other microbial neurotoxins in medicine". Microbiological Reviews 56 (1): 80–99. PMC 372855. PMID 1579114.
- CDC – Botulism, General Information – NCZVED. Cdc.gov. Retrieved on May 6, 2012.
- Licciardello JJ, Nickerson JT, Ribich CA, Goldblith SA. (March 1967). "Thermal Inactivation of Type E Botulinum Toxin". Applied Microbiology 15 (2): 249–256. PMC 546888. PMID 5339838.
- Setlowa, Peter (April 2007). "I will survive: DNA protection in bacterial spores". Trends in Microbiology 15 (4): 172–180. doi:10.1016/j.tim.2007.02.004. PMID 17336071.
- Jay, James M., Loessner, Martin J., Golden, David A. (2005). "Chapter 24: Food Poisoning Caused by Gram-Positive Sporeforming Bacteria". Modern Food Microbiology: Seventh Edition. New York: Springer. p. 581. ISBN 0-387-23180-3.
- Capková, K. (2009). "Investigations into small molecule non-peptidic inhibitors of the botulinum neurotoxins". Toxicon 54 (5): 575–582. doi:10.1016/j.toxicon.2009.03.016. PMC 2730986. PMID 19327377.
- Flanders M, Tischler A, Wise J, Williams F, Beneish R, Auger N. (June 1987). "Injection of type A Botulinum toxin into extraocular muscles for correction of strabismus". Canadian Journal of Ophthalmology 22 (4): 212–217. PMID 3607594.
- Scott AB (September 1989). "Botulinum toxin therapy of eye muscle disorders: safety and effectiveness. Ophthalmic Procedures Assessment Recommendation". Ophthalmology (American Academy of Ophthalmology). Suppl: Suppl:37–41. PMID 2779991.
- United States Department of Health and Human Services (April 30, 2009). "Re: Docket No. FDA-2008-P-0061" (PDF, 8.2 MB). Food and Drug Administration. Retrieved July 26, 2010.
- Carruthers JD, Carruthers JA. (January 1992). "Treatment of Glabellar Frown Lines with C. Botulinum-A Exotoxin". The Journal of Dermatologic Surgery and Oncology 18 (1): 17–21. doi:10.1111/j.1524-4725.1992.tb03295.x. PMID 1740562.
- Giesler, Markus (2012). "How Doppelgänger Brand Images Influence the Market Creation Process: Longitudinal Insights from the Rise of Botox Cosmetic". Journal of Markeing 76 (6): 55–68. doi:10.1509/jm.10.0406.
- "BOTOX® Cosmetic (onabotulinumtoxinA) Product Information". Allergan, Inc. January 22, 2014. Retrieved January 22, 2014.
- Walsh, Sandy (October 15, 2010). "FDA approves Botox to treat chronic migraine". FDA Press Releases. Retrieved October 15, 2010.
- Watkins, Tom (October 15, 2010). "FDA approves Botox as migraine preventative". CNN (US).
- Dodick DW, Turkel, CC, DeGryse, RE, Aurora, SK, Silberstein, SD, Lipton, RB, Diener, HC, Brin, MF, PREEMPT Chronic Migraine Study Group (June 2010). "OnabotulinumtoxinA for treatment of chronic migraine: pooled results from the double-blind, randomized, placebo-controlled phases of the PREEMPT clinical program". Headache 50 (6): 921–36. doi:10.1111/j.1526-4610.2010.01678.x. PMID 20487038.
- Ashkenazi, A (March 2010). "Botulinum toxin type a for chronic migraine". Current neurology and neuroscience reports 10 (2): 140–6. doi:10.1007/s11910-010-0087-5. PMID 20425239.
- A Poison that can Heal from the U.S. Food and Drug Administration
- Does Botox get into the brain? Troubling research contradicts earlier findings about the treatment
- Government backs vital plans to make Botox safer
- BotDB: extensive resources on BoNT structures, inhibitors, kinetics, and literature
- A consumer sociological investigation of Botox Cosmetic's Rise