Safety and efficacy of repeated injections of botulinum toxin A in peripheral neuropathic pain (BOTNEP) a randomised, double blind, placebo controlled trial
BACKGROUND Data from previous studies suggest that botulinum toxin A has analgesic effects against peripheral neuropathic pain, but the quality of the evidence is low. We aimed to assess the safety and efficacy of repeated administrations of botulinum toxin A in patients with neuropathic pain. METHODS We did a randomised, double blind, placebo controlled trial at two outpatient clinics in France (Clinical Pain Centre, Ambroise Pare Hospital, APHP, Boulogne Billancourt, and Neurological Centre, Hopital Dupuytren, Limoges) and one in Brazil (Neurological Department, Hospital das Clinicas da FMUSP, Sao Paulo) Patients aged 18 85 years with peripheral neuropathic pain were randomly assigned (1:1) by block randomisation, according to a centralised schedule, to receive two subcutaneous administrations of botulinum toxin A (up to 300 units) or placebo, 12 weeks apart. All patients and investigators were masked to treatment assignment. The primary outcome was the efficacy of botulinum toxin A versus placebo, measured as the change from baseline in self reported mean weekly pain intensity over the course of 24 weeks from the first administration. The primary efficacy analysis was a mixed model repeated measures analysis in the intention to treat population. This trial is registered with ClinicalTrials.gov, NCT01251211. FINDINGS Between Oct 2, 2010, and Aug 2, 2013, 152 patients were enrolled, of whom 68 were randomly assigned (34 per group) and 66 (37 [56% men) were included in the primary analysis (34 in the botulinum toxin A group and 32 in the placebo group) Botulinum toxin A reduced pain intensity over 24 weeks compared with placebo (adjusted effect estimate 0*77, 95% CI 0*95 to 0*59; p<0*0001) Pain on injection was the only adverse effect reported, and occurred in 19 (56% participants in the botulinum toxin A group and 17 (53% of those in the placebo group (p=1*0) Severe pain was experienced by ten (29% participants in the botulinum toxin A group and 11 (34% in the placebo group (p=0*8) INTERPRETATION Two administrations of botulinum toxin A, each of which comprised several injections, have a sustained analgesic effect against peripheral neuropathic pain. Several factors, such as the presence of allodynia and a limited thermal deficit, may be useful in predicting treatment response and should be investigated further. FUNDING Institut National de la Sante et de la Recherche Medicale (INSERM) and Fondation CNP (France)
The Lancet Neurology