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Botox vs Xeomin for axillary hyperhidrosis

IncobotulinumtoxinA (Xeomin, Merz Aesthetics) is a “suitable” alternative to onabotulinumtoxinA (Botox, Allergan) for the treatment of axillary hyperhidrosis, according to a small evaluation presented in October at the American Society for Dermatologic Surgery (ASDS) Annual Meeting in Phoenix, Ariz.

While onabotulinumtoxinA is the only FDA-approved botulinum toxin for the indication, it can be an expensive option for large health systems like The U.S. Department of Veterans Affairs (VA). The VA negotiated better pricing for incobotulinumtoxinA and, therefore, designated incobotulinumtoxinA as the preferred botulinum toxin A treatment for veterans with a number of indications, including axillary hyperhidrosis, according to the poster’s description in the ASDS’s meeting program.

The negotiated price difference between the two drugs is substantial, according to the presented poster. VA pricing for onabotulinumtoxinA (100 u) is $428.64, versus incobotulinumtoxinA (100 u) at $285.87. That’s a per-unit savings of about 33%, according to the poster.

Researchers reported their experience in a retrospective review of 12 patients, including nine treated previously with onabotulinumtoxinA and later with incobotulinumtoxinA and three treated with incobotulinumtoxinA only, during a 12-month period. Providers informed the patients treated at the VA Palo Alto Health Care System that incobotulinumtoxinA was an off-label treatment for axillary hyperhidrosis.

Nearly 90% of the patients treated with both botulinum toxins reported comparable efficacy; 11% reported incobotulinumtoxinA’s effects didn’t last as long as those from onabotulinumtoxinA.

None of the patients reported adverse effects including muscle weakness or the drug’s spread to distant sites. Additionally, patients’ reports of pain with injection were about the same between the toxins.

The longest duration of effect for both toxins was nine months. Patients reported an on-average duration between five and six months for both toxins.

A special consideration in the veteran population is that some have been immunized for botulinum toxoid, which could result in treatment resistance. But in this report, none of the patients reported having the vaccination.

Presentation coauthor Stephen Lewellis, M.D., Ph.D., a dermatology resident in his final year of training at Stanford University, tells The Aesthetic Channel that it’s his gut feeling onabotulinumtoxinA and incobotulinumtoxinA are interchangeable for treatment of axillary hyperhidrosis.

“We are still gathering data from our experience to make an evidence-based conclusion based on our practice. However, there is available data in the literature that provides reassurance. For example, there was a randomized controlled trial published in 2010 showing no detectable difference in efficacy or adverse effects with use of incobotulinumtoxinA compared to onabotulinumtoxinA for axillary hyperhidrosis (Dressler 2010),” Dr. Lewellis says.

Dosing is also the same.

“Given the 1:1 dosing equivalence that is generally accepted for incobotulinumtoxinA and onabotulinumtoxinA, I administer them both in the same manner,” he says.

Dr. Lewellis says that because of the small number of patients evaluated he’s hesitant to put too much weight on the finding that 11% indicated the duration of effect was longer with onabotulinumtoxinA.

Available evidence, including this poster, may be enough to suggest the move from using onabotulinumtoxinA to incobotulinumtoxinA is a good one for the health system and patients, according to the authors. 

Although larger, controlled studies are needed, this study suggests that incobotulinumtoxinA is a safe and effective alternative to onabotulinumtoxinA for the treatment of axillary hyperhidrosis, according to the poster.

“This supports the decision to transition to a more cost-effective botulinum toxin in this large single payer system,” the authors write.