BOTOX (Botulinum toxin A) - Medical Uses of a Neurotoxin

BOTOX or Botulinum toxin is a neurotoxin that causes denervation by inhibiting the calcium-dependent acetylcholine release in the presynaptic neurons. It is used to treat the following conditions:

  • Treatment of patients with axillary sweating also called axillary hyperhidrosis in adults that do not respond to topical therapy. 

    • Therapy with BOTOX should be initiated only when secondary causes like hyperthyroidism have been ruled out.
    • Treatment of hyperhidrosis other than the axillary area may be associated with adverse effects such as weakness.
  • Treatment of Cervical dystonia in patients aged 16 years or more.


  • For the prophylaxis of chronic migraine headaches lasting more than four hours a day for 15 days or more per month.


  • For the relief of lower limb spasticity in adults.


  • For the treatment of overactive bladder and urge incontinence in patients who have a poor or inadequate response to anticholinergic medicines.


  • For the treatment of Strabismus and blepharospasm associated with dystonia including benign blepharospasm in patients older than 12 years of age.


  • For the treatment of Upper limb spasticity.


  • For the treatment of Urinary incontinence due to detrusor overactivity in patients with neurologic conditions like multiple sclerosis and spinal cord injury.


  • In patients with Dynamic equinus foot deformity in children with cerebral palsy.


  • Off-Label Uses of BOTOX in Adults include:

BOTOX use for cosmetic purposes

  • For the temporary treatment of moderate to severe Glabellar lines.

  • For the temporary treatment of moderate to severe wrinkling and forehead lines.

  • For the treatment (temporary) of moderate to severe lateral canthus lines of the eye. 

BOTOX Dose in Adults

BOTOX Dose in various conditions:

  • When initiating therapy, the lowest recommended dose should be used.
  • The maximum cumulative dose should be less than 400 units per 3 months or 6 units/kg over 3 months

BOTOX Use in the treatment of Bladder dysfunction:

  • Detrusor overactivity associated with neurologic conditions:
    • 30 injections of 1 mL (6.7 units/mL) for a total dose of 200 units/30 mL and a maximum dose of 200 units injected in the detrusor muscle
    • The final injection should be followed by 1 mL of sterile Normal saline
    • Re-treatment may be considered 12 weeks after the last dose.
  • Overactive bladder:
    • 20 injections of 0.5 mL (10 units/mL) for a total dose of 100 units/10 mL and a maximum dose of 100 units in the detrusor muscle.
    • The final injection should be followed by 1 mL of sterile Normal saline
    • Re-treatment may be considered 12 weeks after the last dose.

NOTE:

  • Prophylactic antibiotics 1 - 3 days before, on the day of, and 1 - 3 days after the injection should be administered to reduce the risk of Urinary tract infections.
  • Antiplatelets should be discontinued for at least 3 days before BOTOX administration.

Use in the treatment of Blepharospasm: 

[caption id="attachment_5260" align="aligncenter" width="600"]Botox for blepharospasm Closeup of botox injection in wrinkle near eye[/caption]

  • 1.25 to 2.5 units injected intramuscularly (into the medial and lateral pretarsal orbicularis oculi of the upper lid and lateral pretarsal orbicularis oculi of the lower lid).
  • If the response is inadequate, the next dose may be doubled to a maximum of 5 units per site.
  • The Cumulative dose according to the US labeling should not exceed 200 units in 30 days or 200 units in a 2-month period (according to the Canadian labeling).

Use in the treatment of Cervical dystonia: 

[caption id="attachment_5261" align="aligncenter" width="220"]treatment of cervical dystonia Injection BOTOX for cervical dystonia[/caption]

  • The mean dose is 236 units divided among the affected muscles in patients previously treated with botulinum toxin (maximum dose per site is 50 units or less).
  • A lower dose may be used in previously untreated patients
  • Sequential dosing of BOTOX should be based on the patient's head and neck position, pain, muscle hypertrophy, patient response, and previous response to therapy including adverse reactions.
  • The total dose injected into the sternocleidomastoid muscles should not exceed 100 units.
  • According to Canadian labeling:
    • The effective BOTOX range of 200 - 360 units intramuscular has been used in clinical practice and should be administered at a minimum interval of 2 months.

Use in the treatment of Chronic migraine:

[caption id="attachment_5262" align="aligncenter" width="1024"]BOTOX for migraine Migraine protocol - BOTOX injection[/caption] Administer 5 units/0.1 mL per site.​​​​​​​

  • The recommended total dose is 155 units administered as intramuscular injections in divided doses (into 31 different sites) bilaterally once every 12 weeks.
  • The following are the recommended sites of administration:
    • Corrugator:
      • 5 units to each side (two sites)
    • Procerus:
      • 5 units (one site only)
    • Frontalis:
      • 10 units to each side (divided into two sites per side)
    • Temporalis:
      • 20 units to each side (divided into four sites per side)
    • Occipitalis:
      • 15 units to each side (divided into three sites per side)
    • Cervical paraspinal:
      • 10 units to each side (divided into two sites per side)
    • Trapezius:
      • 15 units to each side (divided into three sites per side)

Use in the treatment of Spasticity: ​​​​​​​

  • Treatment should be individualized based on the severity, size of the muscle, the extent of the disease, location of the muscle, and response to prior treatment.
  • The dose may be repeated at 3 months or more than 3 months interval.
  • Lower limb spasticity:
    • The minimum recommended dose should be used and 50 units/site or less should be administered divided into separate injections as follows:
      • Flexor digitorum longus:
        • 50 units divided into 2 sites.
      • Flexor hallucis longus:
        • 50 units divided into 2 sites
      • The lateral head of Gastrocnemius:
        • 75 units divided into 3 sites.
      • The medial head of Gastrocnemius:
        • 75 units divided into 3 sites.
      • Soleus:
        • 75 units divided into 3 sites
      • Tibialis posterior:
        • 75 units divided into 3 sites
  • Upper limb spasticity:
    • The minimum recommended dose should be used and 50 units/site or less should be administered as the following dosage recommendations:
      • Adductor pollicis:
        • 20 units - 1 site
      • Biceps brachii:
        • 100 - 200 units divided into 4 sites
      • Flexor digitorum profundus:
        • 30 - 50 units - 1 site
      • Flexor digitorum sublimes:
        • 30 - 50 units - 1 site
      • Flexor carpi radialis:
        • 12.5 - 50 units - 1 site
      • Flexor carpi ulnaris:
        • 12.5 - 50 units - 1 site
      • Flexor pollicis longus:
        • 20 units - 1 site

Use in the treatment of Strabismus: 

[caption id="attachment_5263" align="aligncenter" width="696"]strabismus botox Strabismus treatment with BOTOX injection[/caption] Note: Before BOTOX therapy, administer local anesthetic and ocular decongestant drops.​​​​​​​

  • Vertical muscles and for horizontal strabismus less than 20 prism diopters:
    • 1.25 to 2.5 units in any one muscle intramuscularly.
  • Horizontal strabismus of 20 - 50 prism diopters:
    • 2.5 - 5 units in any one muscle
  • Persistent sixth nerve palsy of more than 1 month:
    • 1.25 - 2.5 units in the medial rectus muscle.
  • The patient must be reassessed after one to two weeks to assess the effect of the injection.
  • Subsequent doses may be increased to twice the previous dose, up to the maximum recommended dose of 25 units (as a single injection for any one muscle).
  • Subsequent injections must be delayed until the effects of the previous injections are present.

Use in the treatment of Primary axillary hyperhidrosis:

  • 50 units/axilla intradermally.
  • Injection area should be defined by standard staining techniques as mentioned below in the "How to administer BOTOX?"
  • Injections should be distributed evenly into multiple sites (10 - 15), and administered in 0.1 - 0.2 mL aliquots, about 1 - 2 cm apart.
  • The dose may be repeated when the clinical effect diminishes.

BOTOX dose for Cosmetic use:

  • Reduction of forehead lines
    • Inject into 5 injection sites of 0.1 mL (4 units) intramuscular for a total dose of 0.5 mL (20 units) in the frontalis muscle administered at an interval of at least 3 months.
    • Glabellar lines should be treated in conjunction with the forehead lines to reduce the risk of brow ptosis.
  • [caption id="attachment_5264" align="aligncenter" width="644"]BOTOX for glabellar lines BOTOX for glabellar lines before and after[/caption]
  • Reduction of glabellar lines:
    • Inject 0.1 mL or 4 units dose intramuscular into each of the five sites, two in each corrugator muscle and one in the procerus muscle for a total dose 0.5 mL or 20 units administered no more frequently than every 3 - 4 months.
  • Reduction of lateral canthus lines:
    • Inject 0.1 mL or 4 units intramuscular into 3 injection sites per side (6 total injection points) in the lateral orbicularis oculi muscle for a total dose of 0.6 mL or 24 units administered at an interval of at least 3 months.

BOTOX dose in Children:


Use in the treatment of Blepharospasm:

  • Children older than 12 years and Adolescents:
    • 1.25 - 2.5 units injected intramuscularly into the medial and lateral pretarsal orbicularis oculi of the upper lid and into the lateral pretarsal orbicularis oculi of the lower lid.
    • If the response lasts for less than 2 months or is inadequate, the dose may be doubled up to a maximum dose of 5 units per site.
    • The maximum cumulative dose should not exceed 200 units in a 30-day period.

Use in the treatment of Cervical dystonia:

  • Adolescents 16 years of age or older:
    • The mean dose is 236 units intramuscularly divided among the affected muscles to a maximum of 50 units/site.
    • Treatment should be initiated with a lower dose and the subsequent doses are adjusted based on the patient's head and neck position, muscle hypertrophy, localization of pain, patient response, and previous adverse reactions.
    • To decrease the occurrence of dysphagia, the total dose injected into sternocleidomastoid muscles should be less than 100 units.

Use in the treatment of Strabismus in patients less than 12 years of age:

Note: Administer a local anesthetic and a decongestant drop before BOTOX injection.

  • Infants and Children 2 months to 11 years of age:
    • Horizontal or vertical deviations of less than 20 prism diopters:

      • Patients weighing 6 kgs or more:
        • 1.25 units into any one muscle
    • Horizontal or vertical deviations 20 - 50 prism diopters:

      • Patient weighing less than 6 kgs:
        • One unit into any one muscle
      • Patient weight 6 - 9 kg:
        • 1.25 units into any one muscle
      • Patient weight 10 - 12.5 kg:
        • 1.25 - 1.75 units into any one muscle
      • Patient weighing more than 12.5 kgs:
        • 1.25 - 2.5 units into any one muscle
    • Persistent Sixth nerve palsy of one month or more in duration:

      • Patient weighing less than 6 kgs:
        • One unit into the medial rectus muscle
      • Patient weighing 6 kgs or more:
        • 1.25 units into the medial rectus muscle
  • Children more than 12 years and Adolescents:
    • Vertical muscles and for horizontal strabismus of less than 20 prism diopters:
      • 1.25 - 2.5 units intramuscular into any one muscle
    • Horizontal strabismus 20 - 50 prism diopters:
      • 2.5 - 5 units into any one muscle
    • Persistent sixth nerve palsy of 1 month or more:
      • 1.25 - 2.5 units into the medial rectus muscle
    • The patient must be re-examined 7 - 14 days after each injection (to assess the effect of that dose).
    • Subsequent doses may be doubled to a maximum dose of 25 units as a single injection after the effects of the last dose are gone.

Use in the treatment of Spasticity associated with cerebral palsy: 

  • Children older than18 months and Adolescents:
    • Upper extremity:
      • 0.5 - 2 units/kg per muscle with a total dose of fewer than 13 units/kg per visit. (reported dosage range is between 0.3 - 4 units/kg per muscle to a maximum total dose of 400 units)
    • Lower extremity:
      • The total dosage range is 4 - 8 units/kg to a cumulative dose of 200 units in a three-month interval
      • For equinus foot:
        • A total dose of 4 units/kg is injected at two sites of the gastrocnemius muscle of the affected lower limb
      • For diplegia:
        • An initial total dose of 6 units/kg divided between the affected limbs has been used.

Pregnancy Risk Factor: C

  • Fetal harm has been reported with its use including decreased fetal body weight and delayed ossification.

Use during breastfeeding:

  • It should be used with caution in lactating women as excretion of the drug into breastmilk is not known.

BOTOX Dose in Renal Disease:

  • The manufacturer has not recommended any dose adjustment in patients with kidney diseases.

BOTOX Dose in Liver Disease:

  • The manufacturer has not recommended any dose adjustment in patients with hepatic impairment.

Adverse effects usually occur in one week and may last up to several months.

Common side Effects Of BOTOX (ona botulinum toxin A) Include:

  • Bladder dysfunction:
    • Genitourinary:
      • Urinary tract infection
      • Bacteriuria
      • Urinary retention
      • Increased postvoid residual urine volume
  • Cervical dystonia:
    • Central nervous system:
      • Headache
    • Gastrointestinal:
      • Dysphagia
    • Neuromuscular & skeletal:
      • Neck pain
    • Respiratory:
      • Upper respiratory tract infection
  • Blepharospasm, forehead lines, glabellar lines, lateral canthal lines, primary axillary hyperhidrosis, and strabismus:
    • Ophthalmic:
      • Blepharoptosis
      • Vertical deviation of eyes

Less Common Side Effects Of Ona Botulinum Toxin A Include:

  • Bladder dysfunction:
    • Central nervous system:
      • Myasthenia
      • Abnormal gait
      • Falling
    • Gastrointestinal:
      • Constipation
    • Genitourinary:
      • Dysuria
      • Hematuria
    • Immunologic:
      • Antibody development
    • Neuromuscular & skeletal:
      • Muscle spasm
  • Cervical dystonia:
    • Central nervous system:
      • Dizziness
      • Hypertonia
      • Numbness
      • Speech disturbance
      • Drowsiness
    • Gastrointestinal:
      • Nausea
      • Xerostomia
    • Immunologic:
      • Antibody development
    • Local:
      • Injection site reaction:
        • Soreness
    • Neuromuscular & skeletal:
      • Back pain
      • Stiffness
      • Asthenia
    • Ophthalmic:
      • Blepharoptosis
      • Diplopia
    • Respiratory:
      • Cough
      • Dyspnea
      • Flu-like symptoms
      • Rhinitis
    • Miscellaneous:
      • Fever
  • Chronic migraines:
    • Cardiovascular:
      • Hypertension
    • Central nervous system:
      • Headache
      • Exacerbation of migraine headache
      • Facial paresis
    • Local:
      • Pain at the injection site
    • Neuromuscular & skeletal:
      • Neck pain
      • Myasthenia
      • Stiffness
      • Musculoskeletal pain
      • Myalgia
      • Muscle spasm
    • Ophthalmic:
      • Blepharoptosis
    • Respiratory:
      • Bronchitis
  • Lower limb spasticity:
    • Local:
      • Pain at the injection site
    • Neuromuscular & skeletal:
      • Arthralgia
      • Back pain
      • Myalgia
    • Respiratory:
      • Upper respiratory tract infection
  • Upper limb spasticity:
    • Central nervous system:
      • Fatigue
    • Gastrointestinal:
      • Nausea
    • Neuromuscular & skeletal:
      • Limb pain
      • Myasthenia
    • Respiratory:
      • Bronchitis
  • Blepharospasm, forehead lines, glabellar lines, lateral canthal lines, primary axillary hyperhidrosis, reduction of glabellar lines, and strabismus:
    • Central nervous system:
      • Headache
      • Facial pain
      • Facial paresis
      • Anxiety
      • Dizziness
      • Pain
    • Dermatologic:
      • Skin tightness
      • Diaphoresis
      • Pruritus
      • Skin rash
    • Gastrointestinal:
      • Nausea
    • Immunologic:
      • Antibody development
    • Infection:
      • Infection
    • Local:
      • Injection site reaction:
        • Hemorrhage
        • Pain
        • Soreness
    • Neuromuscular & skeletal:
      • Asthenia
      • Back pain
      • Neck pain
    • Ophthalmic:
      • Dry eye syndrome
      • Eyelid edema
      • Diplopia
      • Ectropion
      • Eye irritation
      • Eyelid entropion
      • Keratitis
      • Lacrimation
      • Superficial punctate keratitis
    • Respiratory:
    • Miscellaneous:
      • Fever

Contraindication to BOTOX (ona botulinum toxin A) include:

  • Allergic reactions to the drug or any component of the formulation.
  • Infection at the injection site.
  • Patients with a UTI or postvoid residual urine volume of more than 200 m for Intradetrusor injection

Warnings & Precautions

  • Allergic reactions:
    • Anaphylactic reactions, serum sickness, urticaria, soft tissue edema, and dyspnea may occur.
  • Antibody formation:
    • Repeated and higher doses result in loss of efficacy due to antibody formation.
  • Autonomic dysreflexia:
    • Patients may develop dysautonomia after intradetrusor injection of BOTOX in patients with spinal cord injury.
    • Patients may develop resting tachycardia, fluctuating Blood Pressure readings, sweating, and may at times present with hypertensive crisis.
  • Cardiovascular events:
    • Patients with risk factors for cardiovascular diseases and those with preexisting heart disease may develop cardiac arrhythmias and myocardial infarction.
  • Dysphagia:
    • Patients with smaller neck muscles, injection into the levator scapulae, and those with bilateral injections are at risk of dysphagia.
    • Dysphagia may be severe enough to require alternative feeding methods and may put the patients at risk of aspiration.
  • Hematologic:
    • Patients with a bleeding disorder and those on anticoagulants should use the drug with caution.
  • Ophthalmic effects:
    • Patients may develop dry eyes, irritation, photophobia, ocular pain, and visual changes with injection in or near the orbicularis oculi muscle.
  • Respiratory effects:
    • Patients treated for upper or lower limb spasticity may develop bronchitis and upper respiratory tract infection.
  • Systemic toxicity: [US Boxed Warning]:
    • Dysphagia and life-threatening respiratory failure may occur as a result of systemic spread of the drug.
    • Patients may also develop diplopia, blurred vision, ptosis, asthenia, dysarthria, dysphonia, generalized muscle weakness, and urinary incontinence within hours or weeks following the injections.
  • Urinary retention:
    • Patients treated for overactive bladder or detrusor overactivity may develop urinary retention.
    • Treatment should be offered only if the patient is willing for posttreatment catheterization.
  • Urinary tract infections:
    • An increase in the incidence of UTIs has been reported with its use, following intradetrusor administration.
    • Patients who have had 2 or more episodes of UTIs in the past 6 months and diabetic patients are especially at risk.
  • Episodic migraines:
    • Efficacy of treatment in patients with less than 14 headaches per month has not been established.
  • Neuromuscular disease:
    • Patients with neuromuscular diseases like myasthenia gravis, Lambert-Eaton myasthenic syndrome, and motor neuron disease may experience worsening of the symptoms.
  • Ocular diseases:
    • Corneal exposure, Persistent corneal epithelial defect, and ulceration may occur due to reduced blinking when treating blepharospasm.
    • Needle penetration into orbit may result in retrobulbar hemorrhage when treating strabismus.
    • Patients with glaucoma should use the drug with caution.
  • Respiratory disease:
    • Patients with preexisting respiratory disease should use the drug with extreme caution as it may weaken the accessory muscles of respiration.

Monitor:

  • Detrusor overactivity:
    • Evaluate postvoid residual (PVR) urine volume within two weeks post-treatment and periodically for up to 12 weeks
    • Initiate catheterization with PVR urine volume of more than 200 mL and continue until PVR is less than 200 mL.

How to administer BOTOX (ona botulinum toxin A)?

  • Intradetrusor administration for Bladder dysfunction including overactive bladder and detrusor overactivity associated with the neurologic condition:

    • Prophylactic antimicrobial therapy other than aminoglycosides) should be administered 1 - 3 days prior to, on the day of, and for 1 - 3 days following BOTOX administration.
    • Antiplatelet therapy should be discontinued for at least 3 days before its administration.
    • If a local anesthetic is instilled into the bladder before therapy, drain the bladder and irrigate with normal saline before the injection.
    • Instill saline into the bladder to optimize visualization (avoid overdistention).
    • The syringe should be primed with about 1 mL of reconstituted BOTOX before the injection to remove any air.
    • Administer BOTOX via a flexible or rigid cystoscope.
    • Insert the needle 2mm into the detrusor with the recommended volume avoiding the trigone.
    • Injections should be spaced about 1 cm apart.
    • After the procedure, drain saline from the bladder and monitor the patient for 30 minutes or more.
    • In patients with overactive bladder, a spontaneous void should also occur prior to the patient leaving the clinic.
  • Blepharospasm:

    • Use a 27 or 30 gauge needle.
    • Avoid injecting near the levator palpebrae superioris and the medial lower lid.
    • Pressure should be applied at the injection site to prevent ecchymosis.

  • Cervical dystonia:

    • Use a 25, 27, or 30 gauge needle for the superficial muscles and a longer 22 gauge needle for the deep muscles. ( electromyography may be used to localize the involved muscles).

  • Chronic migraines:

    • Use a 0.5 inch, 30 gauge needle to administer 5 units per 0.1 mL to each of the 31 sites.

  • Spasticity as in cerebral palsy and related conditions:

    • Use a 23 to 26 gauge needle.
    • Administer into the medial and lateral heads of the gastrocnemius muscle of the affected limb.

  • Spasticity in the upper or lower limb:

    • Use a 25, 27, or 30 gauge needle for superficial muscles and a longer 22 gauge needle for the deep muscles
    • Electromyography or nerve stimulation may be used to localize the involved muscles.

  • Strabismus injections:

    • Surgical exposure or electromyographic guidance is required for the use of BOTOX to treat strabismus.
    • The electrical activity recorded from the tip of the injections needle may be used as a guide to the placement of the medicine within the target muscle.
    • Before the injection, a local anesthetic and ocular decongestant should be given.
    • Per muscle 0.05 to 0.15 ml may be injected, however, most patients will require additional doses.

  • Primary axillary hyperhidrosis:

    • Inject intradermally to a depth of about 2 mm at a 45° angle.
    • The injection area should be defined by standard staining techniques such as Minor's Iodine-Starch Test and should be marked prior to the injection.
    • Instructions for Minor's Iodine-Starch Test:
      • The Patient should shave underarms and should not use deodorants or antiperspirants for 24 hours before the test.
      • The patient should rest for half-an-hour, and should not consume hot beverages.
      • The underarm area should be dried and iodine solution should be applied to the area.
      • After the area dries, the starch powder should be lightly sprinkled.
      • The excess powder should be blown off resulting in a deep blue-black color over the sweaty area in about 10 minutes.

Administration of BOTOX for cosmetic purpose

  • Reduction of forehead lines:

    • Use as 30 to 33 gauge needle.
    • Inject into 5 injection sites in the frontalis muscle.
  • Reduction of glabellar lines:

    • Use a 30 to 33 gauge needle.
    • Inject into each of the 5 sites (2 injections in each corrugator muscle and 1 injection in the procerus muscle).
    • Use the minimum possible volume and avoid injection near the levator palpebrae superioris.
  • Reduction of lateral canthal lines:

    • Use a 30 to 33 gauge needle
    • Inject with the needle bevel tip up and oriented away from the eye.
    • Inject into 3 sites per side (total 6 injection points) in the lateral orbicularis oculi muscle.

Mechanism of action of BOTOX (Botulinum toxin A):

  • BOTOX or Ona botulinum toxin A (previously known as botulinum toxin type A) is a neurotoxin that is produced by Clostridium botulinum.
  • Clostridium botulinum is a spore-forming anaerobic bacillus that produces the botox toxin which prevents the calcium-dependent release of acetylcholine in the presynaptic membrane of the neuromuscular junction in humans producing a state of denervation.
  • Until new fibrils grow from the nerves and form junction plates, muscle inactivation persists.
  • Intradetrusor injection of botox affects the efferent pathways of detrusor activity by inhibiting the release of acetylcholine.
  • Intradermal injection of botox results in the temporary denervation of sweat glands reducing local sweating.

Improvement in the symptoms may be noted as follows:

  • Improvement in blepharospasm is noted in 3 - 4 days.
  • Improvement in Cervical dystonia is noted in 2 weeks.
  • Improvement in Detrusor overactivity is noted in about 2 weeks.
  • Improvement in the reduction of glabellar lines may be seen in 1 - 2 days
  • Improvement in Spasticity in patients with focal and cerebral palsy may be noted in 2 weeks or less time.
  • Improvement in strabismus may be observed in 1 - 2 days

Duration of action of BOTOX:

It is effective for the following duration:

  • Blepharospasm:
    • 3 to 4 months
  • Cervical dystonia:
    • 3 - 4 months
  • Detrusor overactivity associated with the neurologic condition:
    • 42 - 48 weeks
  • Primary axillary hyperhidrosis:
    • For a mean duration of 201 days.
  • Reduction of glabellar lines:
    • 3 - 4 months
  • Spasticity:
    • 3 - 3.5 months
  • Strabismus:
    • 2 - 6 weeks

It is not absorbed when administered Intramuscularly at the recommended doses.

The Time to peak effect depends on the indication:

  • Blepharospasm:
    • 1 to 2 weeks
  • Cervical dystonia:
    • ~6 weeks
  • Focal Spasticity:
    • 4 to 6 weeks
  • Strabismus:
    • Within the first week

Botox (Botulinum toxin type A) international brands:

  • Botox
  • Lanzox
  • Vista

BOTOX brand in Pakistan:

BOTOX injection (Botulinum Toxin Type A)

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