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Monday
Jun112012

Botox, Dysport, Xeomin: How Many Neuromodulators Should Your Practice Offer?

Botox, Dysport, XeominWith Botox, Dysport, and Xeomin available and being marketed directly to your patients by their manufacturers, how many — and which ones — do you need?

In the United States, we currently have three neuromodulator products (Botox - Allergan, Dysport - Medicis and Xeomin - Merz) approved by the FDA for treatment of the glabella complex.

These products are also frequently used “off-label” for treatment of the upper-, mid- and lower-face. Botox has over a ten year-track record of safe and effective use and is the best-selling neuromodulator worldwide. Dysport was similarly approved as a cosmetic treatment in 2009. Of note, a recent injunction against Merz unrelated to safety or efficacy has delayed the nationwide rollout of Xeomin.

Given that we have multiple agents to choose from, there are a number of issues to consider when choosing which neuromodulator(s) to offer to your patients. I’ll focus on Botox and Dysport as Xeomin is currently unavailable and has yet to receive its nationwide rollout pending the legal controversy.

Is one agent safer and/or more effective?

Clearly safety and efficacy are paramount when it comes to choosing a neuromodulator. All available neuromodulators are FDA-approved for treatment of the glabella and are frequently used off label with a favorable safety profile. There is evidence that Dysport has a greater tendency to diffuse and most injectors at some point will experience this. The risk of diffusion appears to be higher with more dilute/ larger volume injections. This is worth considering if you have less experienced injectors in your practice.

With regard to effectiveness, an important point that should be well understood by all injectors is that 2.5 Dysport units are typically required to provide an effect and duration similar to 1 unit of Botox. The issues that we often see with the effectiveness of Dysport are often remedied when patients are treated with an adequate dose of Dysport. When patients are treated with adequate amounts of either agent, similar clinical effects are typically observed.

Does one injectable last longer or have faster onset?

In some studies, Dysport has a slight advantage in time to effect over Botox but this is a small difference. Duration of action will clearly differ depending upon the number of units administered and treatment must be tailored to the patient’s muscle bulk. While Dysport is often touted as having longer duration of action, I have not found this to be the case in practice. In my experience Botox and Dysport have similar onset (about 3 days) and length of efficacy (about 3 months). Again, the issue of appropriate dosing is critical. As long as a 2.5: 1 unit ratio of Dysport to Botox is provided, most patients can expect at least three months of benefit. Those patients who require a higher dose of one agent due to relatively greater muscle mass typically require similarly elevated doses of another agent. This reinforces the point that treatment must be tailored to the patient's anatomy regardless of which agent is chosen. 

Is there a certain facial region that is more suited to a certain agent?

While several studies have suggested that one agent is more effective than another in certain facial regions, I have found the difference to be negligible in practice. 

Does one drug have a higher incidence of "non-responders" or "resistance"?

“Resistance” to neuromodulator is highly uncommon. I have not seen this in the past four years of using both Botox and Dysport. I have experienced the patient who describes a neuromodulator “not working” who then responded beautifully to a repeat treatment. There are obviously numerous injector and toxin preparation explanations for this failure but this is clearly not immunologically-based resistance to treatment. Further, in my experience, patients who do require higher doses of one agent typically require higher doses of another. 

With regard to the newcomer Xeomin, it’s formulated as a “naked” toxin without other associated proteins. Thus, it is possible that the risk of immunologic reactivity will be lower following Xeomin treatment but this theory will takes years to be fully investigated. 

Is one neuromodulator “cheaper”?

While Dysport was initially touted as being cheaper to the patient than Botox, this has not been the case. When patients are treated to effect, most injectors will agree that a ratio of 2.5 Dysport U: 1 Botox U is most appropriate. At current pricing in the Denver area ($12/ Botox U and $5/ Dysport U) the cost to the consumer is actually slightly higher for Dysport than Botox. 

Does one company offer better rebates to our patients?

Both Allergan and Medicis offer consumer rebates of similar dollar amounts to assist patients in purchasing their products. Allergan typically provides instant rebates for product which reduces the point of sale cost to patients. Medicis provides mail-in rebates that are received after the treatment is rendered. 

Allergan also offers the Brilliant Distinctions program that provides “points” for future purchases of Botox, Juvederm and Vivité skin care products. This builds brand loyalty for Allergan by reducing the cost of future treatments but also appears to build practice loyalty. Although, these points can be used at any practice we find that the vast majority of these patients return to our practice to use their points for future treatments, aiding us with patient retention. 

Does one manufacturer offer better customer (physician) support?

Both Allergan and Medicis offer significant support of injectors. Both companies also provide product and experts to train new injectors and expand the skill set of advanced injectors. Both offer volume discounts that increase as practices begin ordering larger amounts of product. Of note, Allergan also makes available marketing and practice building experts to its higher volume customers. As far as I am aware, this service is not offered by Medicis. 

Conclusion

As a Facial Plastic Surgeon with a busy medi-spa component to my practice, I've considered which products we need to offer to our patients. Our goals are to provide the safest and most effective treatments to our patients, to minimize our cost, to maximize our ability to generate revenue and to grow our business. Promoting a single neuromodulator product, in our case Botox, has allowed us to create a clear, consistent marketing message. We have also been able to boost our volume discounts and achieve a lower cost for Allergan products including Botox, Juvederm and Vivité products. This has allowed us to offer better package pricing and cross-promote neuromodulator, dermal filler and skincare products. We’ve also been able to tap the wealth of Allergan’s marketing expertise to better promote our practice at minimal additional cost.

An additional advantage we’ve noted is less confusion among our patients. When most new patients ask for “Botox” they’re actually requesting a result rather than a specific product. Patients are seeking an improvement in their appearance, not a fellowship in available neuromodulator products! It is our job to determine which product will be most effective at delivering that result while at the same time allowing us to cover our overhead. Thus, the choice of which neuromodulator(s) to offer is a very personal decision based on concrete data and anecdotal experience. I’ve tried to outline our reasoning for limiting our practice to a single agent and I hope you’ve found this to be helpful.

Reader Comments (14)

Excellent post. For my own part I've found that he practice-building programs that Allergan offers, even to their big spenders, are pretty much window dressing. Nice, but not hugely effective. I'd like to know more about Xeomin as well since I'm not familiar with it. Does anyone have any hands-on experience? Why was it recalled anyway?

06.11 | Unregistered Commentermedaholic

Off the posts specific topic but this is about the Xeomin court order: News Article

"Allergan Inc., the maker of anti-wrinkle treatment Botox, said Monday that a U.S. district court issued a permanent injunction preventing German drugmaker Merz Pharma GmbH and its unit Merz Aesthetics from selling a rival cosmetic product Xeomin in the facial aesthetics market for ten months.

Allergan said that U.S. District Judge Andrew Guilford, after conducting a full trial, ruled that Merz Pharmaceuticals and Merz Aesthetics violated California's Uniform Trade Secrets Act. The judge also concluded that Merz misappropriated important trade secrets belonging to Allergan.

Allergan has alleged that its trade secrets were stolen by Merz. According to the company, Merz recruits from Allergan brought in confidential materials, including sales statistics and client lists.

In 2010, Allergan sued Merz and its U.S. units as well as former Allergan sales representatives who where hired by Merz. The German company is alleged to have made the recruitment as it was preparing to sell Xeomin for the treatment of certain muscle spasms in 2010, putting the product in competition with Botox.

Judge Guilford noted that the trade secrets misappropriated by Merz include "the specific identities and financial details"- including sales targets, actual sales amounts, and product volumes over time - of Allergan's relationships with virtually all of its physician customers in the U.S. for Botox Cosmetic and Juvederm, and a large segment of Allergan's physician customers in the U.S. for Botox."

- So, it looks like Merc got all of our 'identities and financial details' from the Allergan Botox reps that were digging around in everyone's office.

06.11 | Unregistered CommenterBotox DO

"...a ratio of 2.5 Dysport U: 1 Botox U is most appropriate. At current pricing in the Denver area ($12/ Botox U and $5/ Dysport U) the cost to the consumer is actually slightly higher for Dysport than Botox. "

I would agree with the above completely. Unfortunately, I think that there are a number of clinics in my area that are not mixing Dysport at full strength since I've had at least three patients switch to me after being unhappy with their results from a competitor who is really promoting Dysport. I use Dysport as well and don't have any complaints with it. I'm not sure if they're diluting it too much on purpose or not.

06.11 | Unregistered CommenterCHIMD

Excellent info and if this model works for you then great. In business, I've never been a fan of monopolies and Allergan most definitely has monopolistic ideals to their core. This is one large reason why we have embraced other options such as Dysport & Xeomin. Competition is always good and will eventually lead to better pricing, practice support & innovation. If however the market does not embrace competition and simply yields a given segment to a monopolistic company, higher prices, less support and lack of innovation is also likely to occur.

Allergan as good as they are, for me at least did not value us as a customer. They felt a sense of entitlement to our business instead of trying to earn it. We will soon see 2-3 more Botox alternatives and if those companies are to survive the US market, we have to at least give them a chance as well.

Allergan provides us great support. We brought in Dysport but have not continued due to the lack of interest in our area and also because Medicis will not provide an on-site rep to "non-core" practices. Our rep was in AZ and available only by phone. Our Allergan rep comes to our events, provides free Botox for our office staff, etc. etc. It seems very short sighted for Medicis to snub non-core practices. We are the largest injector of Botox in our area. We also don't use Restylane. If anyone asks for it (they rarely do anymore), we offer them Juvederm and they are happy.

We did bring Xeomin in for the short time it was available. We were able to price it relatively low and brought in some new business. About half the people we treated liked it and the other half felt it wasn't as strong as Botox unit for unit. We likely won't bring it back unless they price it quite low to make up for the lack of rewards program (Brilliant Distinctions) and need for a few more units. Also, there are the logistics of having several open vials sitting in the refrigerator. Although studies with Botox have shown it's fine up to 6 weeks, I don't like keeping any product that long.

Relevant from a discussion thread on mixing Botox so that it doesn't burn by LH.

"Actually, the "preserved" saline is the one that burns the least. The the preservative is benzyl alcohol and it acts like a local anesthetic. If you do not believe me, try it on your staff. Do not let them know which is which and inject a small intradermal bleb with non-preserved sline into one arma and preserved saline into the ohter. I did this to all of my staff and ALL of them felt that the preserved saline hurt less than the non-preserved saline. I also had it done to me."

06.12 | Unregistered CommenterDexTex

We just contacted Allergan to purchase Botox and ask about training. For various reasons, we have not done these treatments before. They set up an account for us, but refused to offer any training. They told us to contact someone out side for specific training (they gave us a list of three companies that supposedly work in our area. The first we contacted said" we do not do any training outside of requests by Allergan for us to train specific Doctors or clinics." I told them that Allergan had told us to contact them.... then they just repeated what they told me in the first place??? I felt I was going around a big circle. So it appears that Allergan is not interested in our business at all! Perhaps they consider us not to be a high vol. purchaser since we are just entering the market. Anyway, Allergan will not be training us!!! And we will buy from someone else.

06.13 | Unregistered CommenterGBT

I really appreciate all of the toughtful responses to this article. Like most product- or medication-related decisions there are bound to be a variety of strong opinions.

@medaholic: I too have an interest in trying Xeomin when it's rolled out. Colleagues who had early access (high volume Merz customers) before the injunction seemed to be happy with it and has potential benefits as a "naked toxin." As @Botox DO posted, the injunction was not product safety related.

@CHIMD: I am not a fan of daily deal sites or low ball marketing tactics for injectables, surgery or other treatments. As 50% of the price paid for Groupon or other daily deal offers go to the daily deal company, this puts tremendous pressure on the practices to minimize their loss of revenue. This might be leading to a trend of undertreatment or overdilution of product. We've seen some of our patients stray to this type of practice only to return when their results are disappointing. This is an interesting trend that has been detrimental to many practices and non-medical businesses.

@Brian Sidella: I totally agree that competition is good. Unfortunately, competition hasn't driven product prices down as much as we had expected. Further, competition at the practice level has reduced the profitability of injectables especially among that segment of practices that competes on price rather than quality of their results. It'll be interesting what happens when Xeomin gets its rollout in terms of Botox and Dysport pricing.

@wrinkle free: I agree.

@GBT: That sounds very unfortunate. I've emailed our rep and copied your comment in the email. I'll try to figure out if there is a better option available if you like. Are you open to talking with someone else from Allergan if I can find a contact for you?

@Dr. Weber, Exceptional post and very thoughtful response to the comments. Looking forward to learning from you and the other new authors.

06.14 | Unregistered CommenterShaw MD

My practice has been using Xeomin for almost 1 year. Our experience is that it has unit for unit effectiveness when compared to Botox, has slightly faster onset in some patients, and is less expensive. The majority of our Botox patients tried Xeomin when we rolled it out as a Merz Elite Opportunity Participant. Of those patients only a handful switched back to Botox. The reason given for switching back was that Xeomin "didn't feel as rigid". That mirrors my personal experience but I prefer a softer feel. Pictures showed that Xeomin was as effective as Botox in achieving relaxation of target muscle groups.

I have heard from the legal dept at Merz that they hope to have the injunction lifted this month. There is weak evidence that Botox may be effective in helping prevent or relieving depression. If that information is extrapolated to Xeomin, an argument could be made that any Xeomin treatment was for medical purposes. The court injunction only covers Xeomin purchased from Merz Aesthetics; it does not include Xeomin purchased from Merz Pharmaceuticals. Just my 2 cents.

How about for Radiesse? Restylane? Juvederm? I would appreciate your input.

06.17 | Unregistered CommenterK.Riv

I have just started my cosmetic practice and I decided that we only offer Botox. Dysport diffuses faster.

06.21 | Unregistered Commentertine

BTW, great post. Just want to share my experience with Xeomin. I noticed that Xeomin provides a subtle effect than Botox. Little did I know that Xeomin requires a different mixing technique to fully disperse the fine powder (something which is not visible or advised with Botox). The fine powder can be blasted around the vial when the saline is added and if this is not then mixed carefully and fully, there is potential for a more diluted product. I have found this actually made a significant and positive difference.

I am offering only Botox in my practice..I am doing aesthetic practice as diffusion of Dysport is more than Botox so there is increased possibility of side effects with Dysport... No sufficient clinical data is available with Xeomin.. It is still not available in India.

11.20 | Unregistered CommenterAbhay T.

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