Reconstitution and Dosing of Neurotoxins

Preparation is key to the outcome of neurotoxin treatment and is considered as important as the dose. The five commercially available botulinum neurotoxin type A (BoNT/A) preparations are either lyophilized as in abobotulinumA (Dysport®), daxibotulinumtoxinA (Daxxify®), and incobotulinumA (Xeomin®), or vacuum-dried powder as in onabotulinumA (Botox®) and prabotulinumtoxinA-xvfs (Jeuveau), and all are reconstituted with a diluent. Storage of the medication is also an important aspect of BoNT/A handling. All brands must be stored at 2–8 °C (36–46 °F) after reconstitution, and it should to be used within 24 h. Alternatively, it is not recommended to freeze the medication after it has been reconstituted. Sterile, preservative-free 0.9% sodium chloride is the recommended diluent although some practitioners use sterile 0.9% sodium chloride with preservative with no apparent difference in treatment onset, duration, or effect of the BoNT/A. The ratio of diluent to BoNT/A determines the amount of solution drawn into the syringe and ultimately injected into the muscle(s) of the patient.