Dysport Injection, Powder, Lyophilized, For Solution
FDA Label NDC 15054-0500

Postmarketing reports indicate that the effects of DYSPORT^® and all botulinum toxin products may spread from the area of injection to produce symptoms consistent with botulinum toxin effects. These may include asthenia, generalized muscle weakness, diplopia, blurred vision, ptosis, dysphagia, dysphonia, dysarthria, urinary incontinence and breathing difficulties. These symptoms have been reported hours to weeks after injection. Swallowing and breathing difficulties can be life threatening and there have been reports of death. The risk of symptoms is probably greatest in children treated for spasticity but symptoms can also occur in adults treated for spasticity and other conditions, particularly in those patients who have underlying conditions that would predispose them to these symptoms. In unapproved uses, including upper limb spasticity in children, and in approved indications, cases of spread of effect have been reported at doses comparable to or lower than the maximum recommended total dose [see Warnings and Precautions (5.2)].

DYSPORT^® is indicated for the treatment of adults with cervical dystonia.

DYSPORT^® is indicated for the temporary improvement in the appearance of moderate to severe glabellar lines associated with procerus and corrugator muscle activity in adult patients less than 65 years of age.

DYSPORT^® is indicated for the treatment of spasticity in adult patients.

DYSPORT^® is indicated for the treatment of lower limb spasticity in pediatric patients 2 years of age and older.

The potency Units of DYSPORT^® are specific to the preparation and assay method utilized. They are not interchangeable with other preparations of botulinum toxin products and, therefore, units of biological activity of DYSPORT^® cannot be compared to or converted into units of any other botulinum toxin products assessed with any other specific assay method [see Description (11)].

Reconstituted DYSPORT^® is intended for intramuscular injection only.

Reconstitution instructions are specific for each of the 300 Unit vial and the 500 Unit vial. These volumes yield concentrations specific for the use for each indication (Table 1).

After reconstitution, DYSPORT^® should be used for only one injection session and for only one patient. Once reconstituted, DYSPORT^® should be stored in the original container, in a refrigerator at 2 °C to 8°C (36 °F to 46°F), protected from light for up to 24 hours. It must be discarded if not used within 24 hours. Do not freeze reconstituted DYSPORT^®. Discard the vial and needle in accordance with local regulations.

The recommended initial dose of DYSPORT^® for the treatment of cervical dystonia is 500 Units given intramuscularly as a divided dose among affected muscles in patients with or without a history of prior treatment with botulinum toxin. (A description of the average DYSPORT^® dose and percentage of total dose injected into specific muscles in the pivotal clinical trials can be found in Table 12 of Section 14.1, Clinical Studies – Cervical Dystonia.). Limiting the dose injected into the sternocleidomastoid muscle may reduce the occurrence of dysphagia. Clinical studies with DYSPORT^® in cervical dystonia suggest that the peak effect occurs between two and four weeks after injection. Simultaneous EMG-guided application of DYSPORT^® may be helpful in locating active muscles.

Dose Modification

Where dose modification is necessary for the treatment of cervical dystonia, uncontrolled open-label studies suggest that dose adjustment can be made in 250 Unit steps according to the individual patient's response, with re-treatment every 12 weeks or longer, as necessary, based on return of clinical symptoms. Uncontrolled open-label studies also suggest that the total dose administered in a single treatment should be between 250 Units and 1000 Units. Re-treatment, if needed, should not occur in intervals of less than 12 weeks. Doses above 1000 Units have not been systematically evaluated.

Special Populations

Adults and elderly

The starting dose of 500 Units recommended for cervical dystonia is applicable to adults of all ages [see Use in Specific Populations (8.5)].

Pediatric Patients

The safety and effectiveness of DYSPORT^® in the treatment in pediatric patients less than 18 years of age has not been assessed [see Warnings and Precautions (5.2)].

Instructions for Preparation and Administration for the Treatment of Cervical Dystonia

DYSPORT^® is supplied as a single-use vial. Only use sterile preservative-free 0.9% Sodium Chloride Injection, USP for reconstitution of DYSPORT^®. Each 500 Unit vial of DYSPORT^® is to be reconstituted with 1 mL of preservative-free 0.9% Sodium Chloride Injection USP to yield a solution of 50 Units per 0.1 mL or reconstituted with 2 mL of preservative-free 0.9% Sodium Chloride Injection USP to yield a solution of 25 Units per 0.1 mL. Each 300 Unit vial of DYSPORT^® is to be reconstituted with 0.6 mL of preservative-free 0.9% Sodium Chloride Injection USP to yield a solution equivalent to 50 Units per 0.1 mL.

Using an appropriately sized sterile syringe, needle and aseptic technique, draw up 2 mL or 1 mL of sterile, preservative- free 0.9% Sodium Chloride Injection USP for the 500 Unit vial or 0.6 mL of sterile, preservative-free 0.9% Sodium Chloride Injection USP for the 300 Unit vial. Insert the needle into the DYSPORT^® vial. The partial vacuum will begin to pull the saline into the vial. Any remaining required saline should be expressed into the vial manually. Do not use the vial if no vacuum is observed. Swirl gently to dissolve. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration. Reconstituted DYSPORT^® should be a clear, colorless solution, free of particulate matter, otherwise it should not be injected.

Expel any air bubbles in the syringe barrel. Remove the needle used to reconstitute the product and attach an appropriately sized new sterile needle.

Discard the vial and needle in accordance with local regulations.

Special Populations

Adults

A total dose of 50 Units of DYSPORT^®, in five equal aliquots, should be administered to achieve clinical effect.

The clinical effect of DYSPORT^® may last up to four months. Repeat dose clinical studies demonstrated continued efficacy with up to four repeated administrations. It should be administered no more frequently than every three months. When used for re-treatment, DYSPORT^® should be reconstituted and injected using the same techniques as the initial treatment.

Pediatric Patients

DYSPORT^® for glabellar lines is not recommended for use in pediatric patients less than 18 years of age [see Warnings and Precautions (5.2)].

Instructions for Preparation and Administration for the Treatment of Glabellar Lines

DYSPORT^® is supplied as a single-use vial. Only use sterile preservative-free 0.9% Sodium Chloride Injection, USP for reconstitution of DYSPORT^®. Each 300 Unit vial of DYSPORT^® is to be reconstituted with 2.5 mL of preservative-free 0.9% Sodium Chloride Injection USP prior to injection. The concentration of the resulting solution will be 10 Units per 0.08 mL (12 Units per 0.1 mL) to be delivered in five equally divided aliquots of 0.08 mL each. DYSPORT^® may also be reconstituted with 1.5 mL of preservative-free 0.9% Sodium Chloride Injection USP for a solution of 10 Units per 0.05 mL (20 Units per 0.1 mL) to be delivered in five equally divided aliquots of 0.05 mL each.

Using an appropriately sized sterile syringe, needle and aseptic technique, draw up 2.5 mL or 1.5 mL of preservative-free 0.9% Sodium Chloride Injection USP Insert the needle into the DYSPORT^® vial. The partial vacuum will begin to pull the saline into the vial. Any remaining required saline should be expressed into the vial manually. Do not use the vial if no vacuum is observed. Swirl gently to dissolve. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration. Reconstituted DYSPORT^® should be a clear, colorless solution, free of particulate matter otherwise it should not be injected.

Draw a single patient dose of DYSPORT^® into a sterile syringe. Expel any air bubbles in the syringe barrel. Remove the needle used to reconstitute the product and attach a 30 gauge needle.

Discard the vial and needle in accordance with local regulations.

Injection Technique

Glabellar facial lines arise from the activity of the lateral corrugator and vertical procerus muscles. These can be readily identified by palpating the tensed muscle mass while having the patient frown. The corrugator depresses the skin creating a "furrowed" vertical line surrounded by tensed muscle (i.e., frown lines). The location, size, and use of the muscles vary markedly among individuals. Physicians administering DYSPORT^® must understand the relevant neuromuscular and/or orbital anatomy of the area involved and any alterations to the anatomy due to prior surgical procedures.

Risk of ptosis can be mitigated by careful examination of the upper lid for separation or weakness of the levator palpebrae muscle (true ptosis), identification of lash ptosis, and evaluation of the range of lid excursion while manually depressing the frontalis to assess compensation.

In order to reduce the complication of ptosis, the following steps should be taken:

• Avoid injection near the levator palpebrae superioris, particularly in patients with larger brow depressor complexes.
• Medial corrugator injections should be placed at least 1 centimeter above the bony supraorbital ridge.
• Ensure the injected volume/dose is accurate and where feasible kept to a minimum.
• Do not inject toxin closer than 1 centimeter above the central eyebrow.

To inject DYSPORT^®, advance the needle through the skin into the underlying muscle while applying finger pressure on the superior medial orbital rim. Inject patients with a total of 50 Units in five equally divided aliquots. Using a 30 gauge needle, inject 10 Units of DYSPORT^® into each of five sites, two in each corrugator muscle, and one in the procerus muscle (see Figure 1).

Figure 1



Figure 1 (Dysport 01)

Upper Limb Spasticity

In the clinical trial that assessed the efficacy and safety of DYSPORT® for treatment of upper limb spasticity in adults [see Clinical studies (14.3)], doses of 500 Units and 1000 Units were divided among selected muscles at a given treatment session (see Table 2 and Figure 2).

Table 2: DYSPORT^® Dosing by Muscle for Upper Limb Spasticity in Adult Patients

Muscles Injected	Recommended Dose DYSPORT®	Recommended Number of Injection(s) per Muscle
Flexor carpi radialis (FCR)	100 Units to 200 Units	1 to 2
Flexor carpi ulnaris (FCU)	100 Units to 200 Units	1 to 2
Flexor digitorum profundus (FDP)	100 Units to 200 Units	1 to 2
Flexor digitorum superficialis (FDS)	100 Units to 200 Units	1 to 2
Brachialis	200 Units to 400 Units	1 to 2
Brachioradialis	100 Units to 200 Units	1 to 2
Biceps Brachii (BB)	200 Units to 400 Units	1 to 2
Pronator Teres	100 Units to 200 Units	1

Figure 2: Muscles for Injection for Upper Limb Spasticity in Adults



Figure 2 (Dysport 02)

Repeat DYSPORT^® treatment should be administered when the effect of a previous injection has diminished, but no sooner than 12 weeks after the previous injection. A majority of patients in clinical studies were retreated between 12-16 weeks; however some patients had a longer duration of response, i.e. 20 weeks. The degree and pattern of muscle spasticity at the time of re-injection may necessitate alterations in the dose of DYSPORT^® and muscles to be injected. Clinical improvement may be expected one week after administration of DYSPORT^®.

Lower Limb Spasticity

In the clinical trial that assessed the efficacy and safety of DYSPORT® for treatment of lower limb spasticity in adults [see Clinical Studies (14.3)], doses of 1000 Units and 1500 Units were divided among selected muscles at a given treatment session (see Table 3 and Figure 3).

Table 3: DYSPORT^® Dosing by Muscle for Lower Limb Spasticity in Adults

Muscles Injected	Recommended Dysport Dose	Recommended Number of Injection Sites per Muscle
Distal Muscles
Gastrocnemius
Medial head	100 Units to150 Units	1
Lateral head	100 Units to 150 Units	1
Soleus	330 Units to 500 Units	3
Tibialis posterior	200 Units to 300 Units	2
Flexor digitorum longus	130 Units to 200 Units	1 to 2
Flexor hallucis longus	70 Units to 200 Units	1

Figure 3: Muscles for Injection for Lower Limb Spasticity in Adults



Figure 3 (Dysport 03)

Repeat DYSPORT^® treatment should be administered when the effect of a previous injection has diminished, but no sooner than 12 weeks after the previous injection. A majority of patients in clinical studies were retreated between 12-16 weeks. The degree and pattern of muscle spasticity at the time of re-injection may necessitate alterations in the dose of DYSPORT^® and muscles to be injected.

Instructions for Preparation and Administration for the Treatment of Spasticity in Adults

DYSPORT^® is supplied as a single-use vial. Only use sterile preservative-free 0.9% Sodium Chloride Injection, USP for reconstitution of DYSPORT^®. The recommended concentration is 100 Units/mL or 200 Units/mL with preservative-free 0.9% Sodium Chloride Injection USP) (see Table 1).

Using an appropriately sized sterile syringe, needle and aseptic technique, draw up the required volume (Table 1) of preservative-free 0.9% Sodium Chloride Injection USP.

Insert the needle into the DYSPORT^® vial. The partial vacuum will begin to pull the saline into the vial. No more than 2.5 mL of saline should be introduced into the vial (see footnote in Table 1). Do not use the vial if a vacuum is absent. Gently swirl to dissolve. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration. Reconstituted DYSPORT^® should be a clear, colorless solution, free of particulate matter; otherwise it should not be injected.

Expel any air bubbles in the syringe barrel. Remove the needle used to reconstitute the product and attach an appropriately sized new sterile needle.

Discard the vial and needle in accordance with local regulations.

Lower Limb Spasticity in Pediatric Patients 2 years of age and older

DYSPORT^® dosing for pediatric lower limb spasticity is based on Units per kilogram of body weight. Table 4 describes the recommended Units/kg dose of DYSPORT^® per muscle of the Gastrocnemius-Soleus Complex (GSC). The recommended total DYSPORT^® dose per treatment session is 10 to 15 Units/kg for unilateral lower limb injections or 20 to 30 Units/kg for bilateral lower limb injections. However, the total dose of DYSPORT^® administered per treatment session must not exceed 15 Units/kg for unilateral lower limb injections or 30 Units/kg for bilateral lower limb injections or 1000 units, whichever is lower. The total dose administered should be divided between the affected spastic muscles of the lower limb(s). When possible, the dose should be distributed across more than 1 injection site in any single muscle (see Table 4). No more than 0.5 mL of DYSPORT^® should be administered in any single injection site.

Dosing in initial and sequential treatment sessions should be tailored to the individual patient based on the size, number and location of muscles involved, severity of spasticity, the presence of local muscle weakness, the patient's response to previous treatment, and/or adverse event history with botulinum toxins.

Table 4: DYSPORT^® Dosing by Muscle for Lower Limb Spasticity in Pediatric Patients

Muscle Injected	Recommended DYSPORT® Dose Range per muscle per leg (Units/kg Body Weight)	Recommended number of injections per muscle
Note:
Gastrocnemius	6 to 9 Units/kg the listed individual doses to be injected in the muscles can be used within the range mentioned without exceeding 15 Units/kg total dose for unilateral injection or 30 Units/kg for bilateral injections or 1000 Units whichever is lower.	Up to 4
Soleus	4 to 6 Units/kg	Up to 2
Total	10 to 15 Units/kg divided across both muscles	Up to 6

Figure 4: Muscles for Injection for Lower Limb Spasticity in Pediatric Patients



Figure 4 (Dysport 04)

Although actual location of the injection sites can be determined by palpation, the use of injection guiding technique, e.g. electromyography or electrical stimulation, is recommended to target the injection sites.

Repeat DYSPORT® treatment should be administered when the effect of a previous injection has diminished but no sooner than 12 weeks after the previous injection. A majority of patients in the clinical studies were retreated between 16-22 weeks, however; some had a longer duration of response. The degree and pattern of muscle spasticity and overall clinical benefit at the time of re-injection may necessitate alterations in the dose of DYSPORT® and muscles to be injected.

The safety and effectiveness of DYSPORT^® injected into proximal muscles of the lower limb for the treatment of spasticity in pediatric patients has not been established.

Lower Limb Spasticity in Pediatric Patients less than 2 years of age

The safety and effectiveness of DYSPORT^® in the treatment of lower limb spasticity in pediatric patients of less than 2 years of age has not been evaluated.

Treatment of Upper Limb Spasticity in Pediatric Patients

The safety and effectiveness of DYSPORT^® in the treatment of upper limb spasticity in pediatric patients has not been demonstrated [see Warnings and Precautions (5.2)].

Instructions for Preparation and Administration for the Treatment of Lower Limb Spasticity in Pediatric Patients 2 years and older

DYSPORT^® is supplied as single-use 300Unit or 500Unit vials. Only use sterile preservative-free 0.9% Sodium Chloride Injection, USP for reconstitution of DYSPORT^®. Each 500 Unit vial of DYSPORT^® is to be reconstituted with 2.5 mL of preservative-free 0.9% Sodium Chloride Injection, USP prior to injection. Each 300 Unit vial of DYSPORT^® is to be reconstituted with 1.5 mL of preservative-free 0.9% Sodium Chloride Injection, USP prior to injection. The concentration of the resulting solution will be 20 Units per 0.1 mL. Further dilution with preservative-free 0.9% Sodium Chloride Injection, USP, may be required to achieve the final volume for injection. No more than 0.5 mL of DYSPORT^® should be administered in any single injection site.

To calculate the total units of DYSPORT^® required for treatment of one leg, select the dose of DYSPORT^® in Units/kg/leg and the body weight (kg) of the patient (see Table 4). Using an appropriately sized sterile syringe (e.g., 3 mL syringe), needle and aseptic technique, draw up 2.5 mL of preservative-free 0.9% Sodium Chloride Injection, USP. Insert the needle into the DYSPORT^® 500 Unit vial. The partial vacuum will begin to pull the saline into the vial. Any remaining required saline should be expressed into the vial manually. Do not use the vial if no vacuum is observed. Swirl gently to dissolve. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration. Reconstituted DYSPORT^® should be a clear, colorless solution, free of particulate matter; otherwise it should not be injected.

Draw the required patient dose of DYSPORT^® into a sterile syringe and dilute with additional preservative-free 0.9% Sodium Chloride Injection, USP, if required, to achieve the final volume for injection. Expel any air bubbles in the syringe barrel. Remove the needle used to reconstitute the product and attach an appropriately sized new sterile needle.

Use immediately after reconstitution in the syringe.

Discard the vial and needle in accordance with local regulations.

Cervical Dystonia

The data described below reflect exposure to DYSPORT^® in 446 cervical dystonia patients in 7 studies. Of these, two studies were randomized, double-blind, single treatment, placebo-controlled studies with subsequent optional open-label treatment in which dose optimization (250 to 1000 Units per treatment) over the course of 5 treatment cycles was allowed.

The population was almost entirely Caucasian (99%) with a median age of 51 years (range 18–82 years). Most patients (87%) were less than 65 years of age; 58.4% were women.

Common Adverse Reactions

The most commonly reported adverse reactions (occurring in 5% or more of patients who received 500 Units of DYSPORT^® in the placebo-controlled clinical trials) in cervical dystonia patients were: muscular weakness, dysphagia, dry mouth, injection site discomfort, fatigue, headache, musculoskeletal pain, dysphonia, injection site pain and eye disorders (consisting of blurred vision, diplopia, and reduced visual acuity and accommodation). Other than injection site reactions, most adverse reactions became noticeable about one week after treatment and lasted several weeks.

The rates of adverse reactions were higher in the combined controlled and open-label experience than in the placebo-controlled trials.

During the clinical studies, two patients (<1%) experienced adverse reactions leading to withdrawal. One patient experienced disturbance in attention, eyelid disorder, feeling abnormal and headache, and one patient experienced dysphagia.

Table 5 compares the incidence of the most frequent adverse reactions from a single treatment cycle of 500 Units of DYSPORT^® compared to placebo [see Clinical Studies (14.1)].

Table 5: Most Common Adverse Reactions (≥5%) and Greater than Placebo in the Pooled, Double-blind, Placebo-Controlled Phase of Clinical Trials in Patients with Cervical Dystonia

Adverse Reactions	DYSPORT® 500 Units (N=173)	Placebo (N=182)
	%	%
Any Adverse Reaction	61	51
General disorders and administration site conditions	30	23
Injection site discomfort	13	8
Fatigue	12	10
Injection site pain	5	4
Musculoskeletal and connective tissue disorders	30	18
Muscular weakness	16	4
Musculoskeletal pain	7	3
Gastrointestinal disorders	28	15
Dysphagia	15	4
Dry mouth	13	7
Nervous system disorders	16	13
Headache	11	9
Infections and infestations	13	9
Respiratory, thoracic and mediastinal disorders	12	8
Dysphonia	6	2
Eye Disorders The following preferred terms were reported: vision blurred, diplopia, visual acuity reduced, eye pain, eyelid disorder, accommodation disorder, dry eye, eye pruritus.	7	2

Dose-response relationships for common adverse reactions in a randomized multiple fixed-dose study in which the total dose was divided between two muscles (the sternocleidomastoid and splenius capitis) are shown in Table 6.

Table 6: Common Adverse Reactions by Dose in Fixed-dose Study in Patients with Cervical Dystonia

Adverse Reactions	DYSPORT® Dose
	Placebo	250 Units	500 Units	1000 Units
Any Adverse Event	30%	37%	65%	83%
Dysphagia	5%	21%	29%	39%
Dry Mouth	10%	21%	18%	39%
Muscular Weakness	0%	11%	12%	56%
Injection Site Discomfort	10%	5%	18%	22%
Dysphonia	0%	0%	18%	28%
Facial Paresis	0%	5%	0%	11%
Eye Disorders The following preferred terms were reported: vision blurred, diplopia, visual acuity reduced, eye pain, eyelid disorder, accommodation disorder, dry eye, eye pruritus.	0%	0%	6%	17%

Injection Site Reactions

Injection site discomfort and injection site pain were common adverse reactions following DYSPORT^® administration.

Less Common Adverse Reactions

The following adverse reactions were reported less frequently (<5%).

Breathing Difficulty

Breathing difficulties were reported by approximately 3% of patients following DYSPORT^® administration and in 1% of placebo patients in clinical trials during the double-blind phase. These consisted mainly of dyspnea. The median time to onset from last dose of DYSPORT^® was approximately one week, and the median duration was approximately three weeks.

Other adverse reactions with incidences of less than 5% in the DYSPORT^® 500 Units group in the double-blind phase of clinical trials included dizziness in 3.5% of DYSPORT^®-treated patients and 1% of placebo-treated patients, and muscle atrophy in 1% of DYSPORT^®-treated patients and in none of the placebo-treated patients.

Laboratory Findings

Patients treated with DYSPORT^® exhibited a small increase from baseline (0.23 mol/L) in mean blood glucose relative to placebo-treated patients. This was not clinically significant among patients in the development program but could be a factor in patients whose diabetes is difficult to control.

Electrocardiographic Findings

ECG measurements were only recorded in a limited number of patients in an open-label study without a placebo or active control. This study showed a statistically significant reduction in heart rate compared to baseline, averaging about three beats per minute, observed thirty minutes after injection.

Glabellar Lines

In placebo-controlled clinical trials of DYSPORT^®, the most common adverse reactions (≥2%) following injection of DYSPORT^® were nasopharyngitis, headache, injection site pain, injection site reaction, upper respiratory tract infection, eyelid edema, eyelid ptosis, sinusitis, nausea, and blood present in urine.

Table 7 reflects exposure to DYSPORT^® in 398 patients 19 to 75 years of age who were evaluated in the randomized, placebo-controlled clinical studies that assessed the use of DYSPORT^® for the temporary improvement in the appearance of glabellar lines [see Clinical Studies (14)]. Adverse reactions of any cause occurred in 48% of the DYSPORT^®-treated patients and 33% of the placebo-treated patients.

Table 7: Most Common Adverse Reactions with > 1% Incidence in Pooled, Placebo-Controlled Trials for Glabellar Lines

Adverse Reactions by Body System	DYSPORT® (N=398) % Patients who received treatment with placebo and DYSPORT® are counted in both treatment columns.	Placebo (N=496) %
Any Adverse Reaction	48	33
Eye Disorders
Eyelid Edema	2	0
Eyelid Ptosis	2	<1
Gastrointestinal Disorders
Nausea	2	1
General Disorders and Administration Site Conditions
Injection Site Pain	3	2
Injection Site Reaction	3	<1
Infections and Infestations
Nasopharyngitis	10	4
Upper Respiratory Tract Infection	3	2
Sinusitis	2	1
Investigations
Blood Present in Urine	2	<1
Nervous System Disorders
Headache	9	5

In the overall safety database, where some patients received up to twelve treatments with DYSPORT^®, adverse reactions were reported for 57% (1425/2491) of patients. The most frequently reported of these adverse reactions were headache, nasopharyngitis, injection site pain, sinusitis, URI, injection site bruising, and injection site reaction (numbness, discomfort, erythema, tenderness, tingling, itching, stinging, warmth, irritation, tightness, swelling).

Adverse reactions that occurred after repeated injections in 2–3% of the population included bronchitis, influenza, pharyngolaryngeal pain, cough, contact dermatitis, injection site swelling, and injection site discomfort.

The incidence of eyelid ptosis did not increase in the long-term safety studies with multiple re-treatments at intervals ≥ three months. The majority of the reports of eyelid ptosis were mild to moderate in severity and resolved over several weeks [see Dosage and Administration (2.3)].

Spasticity in Adults

Injection Site Reactions

Injection site reactions (e.g., pain, bruising, haemorrhage, erythema/haematoma etc.) have occurred following administration of DYSPORT^® in adults treated for spasticity.

Upper Limb Spasticity in Adults

Table 8 lists the most frequently reported adverse reactions (≥2%) in any DYSPORT^® dose group and more frequent than placebo in double-blind studies evaluating the treatment of upper limb spasticity in adults with DYSPORT^®.

Table 8: Most Common Adverse Reactions Observed in at Least 2% of Patients Treated in Pooled, Double-Blind Trials of Adult Patients with Upper Limb Spasticity Reported More Frequently than with Placebo

Adverse Reactions	DYSPORT®		Placebo
	500 Units (N=197) %	1000 Units (N=194) %	(N=279) %
Infections and infestations
Nasopharyngitis	4	1	1
Urinary tract infection	3	1	2
Influenza	1	2	1
Infection	1	2	1
Musculoskeletal and connective tissue disorders
Muscular weakness	2	4	1
Pain in extremity	0	2	1
Musculoskeletal pain	3	2	2
Back pain	1	2	1
Nervous system disorders
Headache	1	2	1
Dizziness	3	1	1
Convulsion	2	2	1
Syncope	1	2	0
Hypoaesthesia	0	2	<1
Partial seizures	0	2	0
General disorders and administration site conditions
Fatigue	2	2	0
Asthenia	2	1	<1
Injury, poisoning and procedural complications
Fall	2	3	2
Injury	2	2	1
Contusion	1	2	<1
Gastrointestinal disorders
Diarrhea	1	2	<1
Nausea	2	1	1
Constipation	0	2	1
Investigation
Blood triglycerides increased	2	1	0
Respiratory, thoracic and mediastinal disorders
Cough	1	2	1
Vascular disorders
Hypertension	1	2	<1
Psychiatric disorders
Depression	2	3	1

Less Common Adverse Reactions

In a pooled analysis of clinical studies, adverse reactions with an incidence of less than 2% reported in DYSPORT^® treatment groups included dysphagia 0.5%, gait disturbance 0.5%, hypertonia 0.5%, and sensation of heaviness 0.3%.

Lower Limb Spasticity in Adults

The data described below reflect exposure to DYSPORT^® in 255 adult patient with lower limb spasticity. Of this population, 89% were Caucasian, 66% male, and the median age was 55 years (range 23–77 years). Table 9 lists the adverse reactions that occurred in ≥2% of patients in any DYSPORT^® dose group and more frequent than placebo in the double blind study evaluating the treatment of lower limb spasticity in adults. The most common of these adverse reactions (≥5%) in any DYSPORT^® dose group were falls, muscular weakness, and pain in extremity.

Table 9: Adverse Reactions Observed in at Least 2% of Patients Treated in the Double-Blind Trial of Adult Patients with Lower Limb Spasticity and Reported More Frequently than with Placebo

Adverse Reactions	Dysport 1000 U (N=127) %	Dysport 1500 U (N=128) %	Placebo (N=130) %
Musculoskeletal and connective tissue disorders
Muscular weakness	2	7	3
Pain in extremity	6	6	2
Arthralgia	4	2	1
Back pain	3	0	2
Injury, poisoning and procedural complications
Fall	9	6	3
Contusion	2	0	0
Wrist fracture	2	0	0
Nervous system disorders
Headache	0	3	1
Epilepsy/Convulsion/Partial seizure/Status Epilepticus	4	1	2
Infections and infestations
Upper respiratory tract infection	2	1	1
General disorders and administration site conditions
Fatigue	1	4	0
Asthenia	2	1	1
Influenza-like illness	2	0	0
Edema peripheral	2	0	0
Investigations
Alanine aminotransferase increased	2	0	1
Gastrointestinal disorders
Constipation	0	2	1
Dysphagia	2	1	1
Psychiatric disorders
Depression	2	3	0
Insomnia	0	2	0
Vascular disorders
Hypertension	2	1	1

In the efficacy and safety studies of DYSPORT^® for the treatment of lower limb spasticity in adults, muscular weakness was reported more frequently in women (10%) treated with 1500 units of DYSPORT^® compared to men (5%). Falls were reported more frequently in patients 65 years of age and over. [see Use in Specific Populations (8.5)]

Lower Limb Spasticity in Pediatric Patients

Table 10 reflects exposure to DYSPORT^® in 160 patients, 2 to 17 years of age, who were evaluated in the randomized, placebo-controlled clinical study that assessed the use of DYSPORT^® for the treatment of unilateral or bilateral lower limb spasticity in pediatric cerebral palsy patients [see Clinical Studies (14.4)]. The most commonly observed adverse reactions (≥10% of patients) are: upper respiratory tract infection, nasopharyngitis, influenza, pharyngitis, cough and pyrexia.

Table 10: Adverse Reactions Observed in ≥ 4% of Patients Treated in the Double-Blind Trial of Pediatric Patients with Lower Limb Spasticity and Reported More Frequently than with Placebo

Adverse Reactions		Unilateral		Bilateral
	Placebo	Dysport® 10 units/kg	Dysport® 15 units/kg	Dysport® 20 units/kg	Dysport® 30 units/kg
	(N=79) %	(N=43) %	(N=50) %	(N=37) %	(N=30) %
Infections and infestations
Nasopharyngitis	5	9	12	16	10
Upper respiratory tract infection	13	9	20	5	10
Influenza	8	0	10	14	3
Pharyngitis	8	5	0	11	3
Bronchitis	3	0	0	8	7
Rhinitis	4	5	0	3	3
Varicella	1	5	0	5	0
Ear infection	3	2	4	0	0
Respiratory tract infection viral	0	5	2	0	0
Gastroenteritis viral	0	2	4	0	0
Gastrointestinal disorders
Vomiting	5	0	6	8	3
Nausea	1	0	2	5	0
Respiratory, thoracic and mediastinal disorders
Cough	6	7	6	14	10
Oropharyngeal pain	0	2	4	0	0
General disorders and administration site conditions
Pyrexia	5	7	12	8	7
Musculoskeletal and connective tissue disorders
Pain in extremity	5	0	2	5	7
Muscular weakness	1	5	0	0	0
Nervous system disorders
Convulsion/Epilepsy	0	7	4	0	7

Cervical Dystonia

About 3% of subjects developed antibodies (binding or neutralizing) over time with DYSPORT^® treatment.

Glabellar Lines

Testing for antibodies to DYSPORT^® was performed for 1554 subjects who had up to nine cycles of treatment. Two subjects (0.13%) tested positive for binding antibodies at baseline. Three additional subjects tested positive for binding antibodies after receiving DYSPORT^® treatment. None of the subjects tested positive for neutralizing antibodies.

Spasticity in Adults

Upper Limb Spasticity

From 230 subjects treated with DYSPORT^® and tested for the presence of binding antibodies, 5 subjects were positive at baseline and 17 developed antibodies after treatment. Among those 17 subjects, 10 subjects developed neutralizing antibodies. An additional 51 subjects from a separate repeat-dose study were tested for the presence of neutralizing antibodies only. None of the subjects tested positive.

In total, from the 281 subjects treated in the long-term studies and tested for the presence of neutralizing antibodies, 3.6% developed neutralizing antibodies after treatment. In the presence of binding and neutralizing antibodies to DYSPORT^® some patients continue to experience clinical benefit.

Lower Limb Spasticity

From 367 subjects treated with DYSPORT^® and tested for the presence of binding antibodies, 4 subjects were positive at baseline and 2 developed binding antibodies after treatment. No subjects developed neutralizing antibodies. An additional 85 subjects from two separate studies were tested for the presence of neutralizing antibodies only. One subject tested positive for the presence of neutralizing antibodies.

In total, from the 452 subjects treated in with DYSPORT^® and tested for the presence of neutralizing antibodies, 0.2% developed neutralizing antibodies after treatment.

Lower Limb Spasticity in Pediatric Patients

From 226 subjects treated with DYSPORT^® and tested for the presence of binding antibodies, 5 subjects previously receiving botulinum toxins were positive at baseline and 9 patients developed binding antibodies after injections. Among those 9 subjects, 3 subjects developed neutralizing antibodies, while one subject developed neutralizing antibodies from the 5 subjects testing positive for binding antibodies at baseline who previously received botulinum toxin injections.

From a separate repeat-dose study, 203 subjects were tested for the presence of neutralizing antibodies. Two subjects were positive for neutralizing antibodies at baseline and 5 subjects developed neutralizing antibodies after treatments. In total, from the 429 patients tested for the presence of neutralizing antibodies, 2.1% developed neutralizing antibodies after treatment. In the presence of binding and neutralizing antibodies to DYSPORT^®, some patients continued to experience clinical benefit.

Risk Summary

There are no adequate and well-controlled clinical studies with DYSPORT^® in pregnant women.

DYSPORT^® should only be used during pregnancy if the potential benefit justifies the potential risk to the fetus.

DYSPORT^® produced embryo-fetal toxicity in relation to maternal toxicity when given to pregnant rats and rabbits at doses lower than or similar to the maximum recommended human dose (MRHD) of 1000 Units on a body weight (Units/kg) basis (see Data).

In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively. The background risk of major birth defects and miscarriage for the indicated populations is unknown.

Data

In a study in which pregnant rats received daily intramuscular injections of DYSPORT^® (2.2, 6.6, or 22 Units/kg on gestation days 6 through 17 or intermittently 44 Units/kg on gestation days 6 and 12 only) during organogenesis, increased early embryonic death was observed with both schedules at the highest tested doses (22 and 44 Units/kg), which were associated with maternal toxicity. The no-effect dose for embryo-fetal developmental toxicity was 2.2 Units/kg (less than the maximum recommended human dose [MRHD] on a body weight basis.

In a study in which pregnant rabbits received daily intramuscular injections of DYSPORT^® (0.3, 3.3, or 6.7 Units/kg) on gestation days 6 through 19 or intermittently (13.3 Units/kg on gestation days 6 and 13 only) during organogenesis, no embryofetal data were available at the highest dose administered daily (6.7 Units/kg) because of premature death in all does at that dose. At the lower daily doses or with intermittent dosing, no adverse developmental effects were observed. All doses for which data were available are less than the MRHD on a body weight basis.

In a study in which pregnant rats received 6 weekly intramuscular injections of DYSPORT^® (4.4, 11.1, 22.2, or 44 Units/kg) beginning on day 6 of gestation and continuing through parturition to weaning, an increase in stillbirths was observed at the highest dose tested, which was maternally toxic. The no-effect dose for pre- and post-natal developmental toxicity was 22.2 Units/kg (similar to the MRHD).

Risk Summary

There are no data on the presence of DYSPORT^® in human or animal milk, the effects on the breastfed infant, or the effects on milk production.

The developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for DYSPORT^® and any potential adverse effects on the breastfed infant from DYSPORT^® or from the underlying maternal condition.

Infertility

In rats, DYSPORT^® produced adverse effects on mating behavior and fertility [see Nonclinical Toxicology (13.1)].

Cervical Dystonia

Safety and effectiveness in pediatric patients have not been established [see Warnings and Precautions (5.2)].

Glabellar Lines

DYSPORT^® is not recommended for use in pediatric patients less than 18 years of age.

Upper Limb Spasticity

Safety and effectiveness in pediatric patients have not been established [see Warnings and Precautions (5.2)].

Lower Limb Spasticity in Pediatric Patients

The safety and effectiveness of DYSPORT^® injected into proximal muscles of the lower limb for the treatment of spasticity in pediatric patients has not been established [see Warnings and Precautions (5.2) and Adverse Reactions (6.1)].

Safety and effectiveness in pediatric patients with lower limb spasticity below 2 years of age have not been evaluated [see Warnings and Precautions (5.2)].

Juvenile Animal Data

In a study in which juvenile rats received a single intramuscular injection of DYSPORT^® (1, 3, or 10 Units/animal) on postnatal day 21, decreased growth and bone length (injected and contralateral limbs), delayed sexual maturation, and decreased fertility were observed at the highest dose tested, which was associated with excessive toxicity during the first week after dosing.

In a study in which juvenile rats received weekly intramuscular injections of DYSPORT^® (0.1, 0.3, or 1.0 Units/animal) from postnatal day 21 to 13 weeks of age, decreases in bone mineral content in the injected limb, associated with atrophy of injected and adjacent muscles, were observed at the highest dose tested. No adverse effects were observed on neurobehavioral development. However, dose levels were not adjusted for growth of the pups. On a body weight basis, the doses at the end of the dosing period were approximately 15% of those at initiation of dosing. Therefore, the effects of DYSPORT^® throughout postnatal development were not adequately evaluated.

Cervical Dystonia

There were insufficient numbers of patients aged 65 years and over in the clinical studies to determine whether they respond differently than younger patients. In general, elderly patients should be observed to evaluate their tolerability of DYSPORT^®, due to the greater frequency of concomitant disease and other drug therapy [see Dosage and Administration (2.1)].

Glabellar Lines

Of the total number of subjects in the placebo-controlled clinical studies of DYSPORT^®, 8 (1%) were 65 years and over. Efficacy was not observed in subjects aged 65 years and over [see Clinical Studies (14.2)]. For the entire safety database of geriatric subjects, although there was no increase in the incidence of eyelid ptosis, geriatric subjects did have an increase in the number of ocular adverse reactions compared to younger subjects (11% vs. 5%) [see Dosage and Administration (2.2)].

Adult Spasticity

Upper Limb Spasticity

Of the total number of subjects in placebo-controlled clinical studies of DYSPORT^®, 30 percent were aged 65 years and over, while 8 percent were aged 75 years and over. No overall differences in safety or effectiveness were observed between these subjects and younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out.

Lower Limb Spasticity

Of the total number of subjects in placebo controlled clinical studies of DYSPORT^®, 18% (n = 115) were 65 and over, while 3% (n = 20) were 75 and over. Subjects aged 65 years and over who were treated with DYSPORT^® reported a greater percentage of adverse reactions as compared to younger subjects (46% versus 39%). Fall and asthenia were observed with greater frequency in older subjects, as compared to those younger (10% versus 6% and 4% versus 2%, respectively).

Carcinogenesis

Studies to evaluate the carcinogenic potential of DYSPORT^® have not been conducted.

Mutagenesis

Genotoxicity studies have not been conducted for DYSPORT^®.

Impairment of Fertility

In a fertility and early embryonic development study in rats in which either males (2.9, 7.2, 14.5 or 29 Units/kg) or females (7.4, 19.7, 39.4 or 78.8 Units/kg) received weekly intramuscular injections prior to and after mating, dose-related increases in pre-implantation loss and reduced numbers of corpora lutea were noted in treated females. Failure to mate was observed in males that received the high dose. The no-effect dose for effects on fertility was 7.4 Units/kg in females and 14.5 Units/kg in males (approximately one-half and equal to, respectively, the maximum recommended human dose of 1000 Units on a body weight basis).

Study GL-1

Study GL-1 was a single-dose, double-blind, multi-center, randomized, placebo-controlled study in which 158 previously untreated subjects received either placebo or 50 Units of DYSPORT^®, administered in five aliquots of 10 Units (see Figure 1). Subjects were followed for 180 days. The mean age was 43 years; most of the subjects were women (85%), and predominantly Caucasian (49%) or Hispanic (47%). At Day 30, 55% of DYSPORT^®-treated subjects achieved treatment success: a composite 2 grade improvement of glabellar line severity at maximum frown (Table 13).

In study GL-1, the reduction of glabellar line severity at maximum frown was greater at Day 30 in the DYSPORT^® group compared to the placebo group as assessed by both Investigators and subjects (Table 14).

Table 14: GL-1: Investigator's and Subject's Assessment of Glabellar Line Severity at Maximum Frown Using a 4-point Scale (% and Number of Subjects with Severity of None or Mild)

	Investigator's Assessment		Subject's Assessment
Day	DYSPORT® N=105	Placebo N=53	DYSPORT® N=105	Placebo N=53
14	90% 95	17% 9	77% 81	9% 5
30	88% 92	4% 2	74% 78	9% 5
60	64% 67	2% 1	60% 63	6% 3
90	43% 45	6% 3	36% 38	6% 3
120	23% 24	4% 2	19% 20	6% 3
150	9% 9	2% 1	8% 8	4% 2
180	6% 6	0% 0	7% 7	8% 4

Study GL-2

Study GL-2 was a repeat-dose, double-blind, multi-center, placebo-controlled, randomized study. The study was initiated with two or three open-label treatment cycles of 50 Units of DYSPORT^® administered in five aliquots of 10 Units DYSPORT^® (see Figure 1). After the open-label treatments, subjects were randomized to receive either placebo or 50 Units of DYSPORT^®. Subjects could have received up to four treatments through the course of the study. Efficacy was assessed in the final randomized treatment cycle. The study enrolled 311 subjects into the first treatment cycle and 142 subjects were randomized into the final treatment cycle. Overall, the mean age was 47 years; most of the subjects were women (86%) and predominantly Caucasian (80%).

At Day 30, 52% of DYSPORT^®-treated subjects achieved treatment success: a composite 2 grade improvement of glabellar line severity at maximum frown (seeTable 13 ).

The proportion of responders in the final treatment cycle was comparable to the proportion of responders in all prior treatment cycles.

After the final repeat treatment with DYSPORT^®, the reduction of glabellar line severity at maximum frown was greater at Day 30 in the DYSPORT^® group compared to the placebo group as assessed by both Investigators and subjects (Table 15).

Table 15: GL-2: Investigator's and Subject's Assessments of Glabellar Line Severity at Maximum Frown Using a 4-point Scale (% and Number of Subjects with Severity of None or Mild)

	Investigator's Assessment		Subject's Assessment
Day	DYSPORT® N=71	Placebo N=71	DYSPORT® N=71	Placebo N=71
30	85% 60	4% 3	79% 56	1% 1

Study GL-3

Study GL-3 was a single-dose, double-blind, multi-center, randomized, placebo-controlled study in which 300 previously untreated subjects received either placebo or 50 Units of DYSPORT^®, administered in five aliquots of 10 Units (see Figure 1). Subjects were followed for 150 days. The mean age was 44 years; most of the subjects were women (87%), and predominantly Caucasian (75%) or Hispanic (18%).

At Day 30, 60% of DYSPORT^®-treated subjects achieved treatment success: a composite 2 grade improvement of glabellar line severity at maximum frown (see Table 16).

In study GL-3, the reduction of glabellar line severity at maximum frown was greater at Day 30 in the DYSPORT^® group compared to the placebo group as assessed by both Investigators and subjects (see Table 16).

Table 16. GL-3: Investigator's and Subject's Assessment of Glabellar Line Severity at Maximum Frown Using a 4-point Scale (% and Number of Subjects with Severity of None or Mild)

	Investigator's Assessment		Subject's Assessment
Day	DYSPORT® N=200	Placebo N=100	DYSPORT® N=200	Placebo N=100
14	83% 166	5% 5	83% 165	2% 2
30	86% 171	0% 0	82% 163	2% 2
60	75% 150	1% 1	65% 130	4% 4
90	51% 102	1% 1	46% 91	2% 2
120	29% 58	1% 1	31% 61	3% 3
150	16% 32	1% 1	16% 31	3% 3

Geriatric Subjects

In GL1, GL2, and GL3, there were 8 subjects aged 65 and older who were randomized to DYSPORT^® 50 Units in 5 equal aliquots of 10 Units (4) or placebo (4). None of the geriatric DYSPORT^® subjects were a treatment success at maximum frown at Day 30.

Upper Limb Spasticity

The efficacy and safety of DYSPORT^® for the treatment of upper limb spasticity in adult patients was evaluated in a randomized, multi-center, double-blind, placebo-controlled study that included 238 patients (159 DYSPORT^® and 79 placebo) with upper limb spasticity (Modified Ashworth Scale (MAS) score ≥2 in the primary targeted muscle group for toxin naive patients or MAS score ≥3 in the primary targeted muscle group for toxin non-naive patients at least 4 months after the last botulinum toxin injection, of any serotype) who were at least 6 months post-stroke or post-traumatic brain injury.

DYSPORT^® 500 Units (N=80), DYSPORT^® 1000 Units (N=79), or placebo (N=79) was injected intramuscularly into the affected upper limb muscles. After injection of the primary targeted muscle groups (PTMG), the remainder of the dose was injected into at least two additional upper limb muscles determined by the patient's individual presentation. Table 17 provides the mean and range of DYSPORT^® doses injected and the number of injections into specific muscles of the upper limb.

Table 17: DYSPORT^® Dose Injected and Number of Injections per Muscle in Adult Patients with Upper Limb Spasticity

Muscle	DYSPORT® Treatment Group	Number of Patients	Mean DYSPORT® Units Injected (Min, Max)	Number Of Injection Sites Median, [Q1 ; Q3]
Flexor digitorum profundus (FDP) PTMG	500 U	54	93.5 Units (50 to 100)	1, [1 ; 2]
	1000 U	65	195.5 Units (100 to 300)	2, [1 ; 2]
Flexor digitorum superficialis (FDS)	500 U	63	95.4 Units (50 to 100)	2, [1 ; 2]
	1000 U	73	196.8 Units (100 to 300)	2, [1 ; 2]
Flexor carpi radialis (FCR)	500 U	57	92.2 Units (25 to 100)	1, [1 ; 2]
	1000 U	57	178.1 Units (80 to 300)	1, [1 ; 2]
Flexor carpi ulnaris (FCU)	500 U	47	89.9 Units (25 to 180)	1, [1 ; 2]
	1000 U	49	171.2 Units (80 to 200)	1, [1 ; 2]
Brachialis	500 U	60	148.5 Units (50 to 200)	2, [1 ; 2]
	1000 U	43	321.4 Units (100 to 400)	2, [2 ; 2]
Brachioradialis	500 U	42	88.3 Units (50 to 200)	1, [1 ; 2]
	1000 U	28	172.1 Units (50 to 200)	1, [1 ; 2]
Biceps Brachii (BB)	500 U	28	106.4 Units (50 to 200)	2, [1 ; 2]
	1000 U	19	207.4 Units (100 to 400)	2, [1 ; 2]
Pronator Teres	500 U	14	81.8 Units (45 to 200)	1, [1 ; 1]
	1000 U	30	157.3 Units (80 to 200)	1, [1 ; 1]

The co-primary efficacy variables were muscle tone assessed by the MAS at the primary targeted muscle group at week 4 and the Physician Global Assessment (PGA) at week 4 (Table 18).

Table 18: Primary Endpoints (PTMG MAS and PGA) and MAS by Muscle Group at Week 4 in Adult Patients with Upper Limb Spasticity

	Placebo (N=79)	DYSPORT®
		(500 units) (N=80)	(1000 units) (N=79)
LS= Least Square;
LS Mean Change from Baseline in PTMG Muscle Tone on the MAS	-0.3	-1.2 p≤0.05	-1.4
LS Mean PGA of Response to Treatment	0.7	1.4	1.8
LS Mean Change from Baseline in Wrist Flexor Muscle Tone on the MAS	-0.3 (n=54)	-1.4 (n=57)	-1.6 (n=58)
LS Mean Change from Baseline in Finger Flexor Muscle Tone on the MAS	-0.3 (n=70)	-0.9 (n=66)	-1.2 (n=73)
LS Mean Change from Baseline in Elbow Flexor Muscle Tone on the MAS	-0.3 (n=56)	-1.0 (n=61)	-1.2 (n=48)

Lower Limb Spasticity

The efficacy of DYSPORT^® for the treatment of lower limb spasticity was evaluated in a randomized, multi-center, double-blind, placebo-controlled study that included 381 patients (253 DYSPORT^® and128 placebo). Patients had lower limb spasticity (Modified Ashworth Scale (MAS) score ≥2 in the affected ankle joint for toxin naive patients, or MAS score ≥3 in the affected ankle joint for toxin non-naive patients) and were at least 6 months post-stroke or post-traumatic brain injury.

Table 19 provides the median DYSPORT^® doses injected and the number of injections into specific muscles of the lower limb as reported in the double-blind study. In the study, the gastrocnemius and soleus muscles, and at least one additional lower limb muscle were injected, according to the clinical presentation.

Table 19: DYSPORT^® Dose Injected and Number of Injections per Muscle in the Lower Limb - Median for the 1000 Unit and 1500 Unit Dose Groups

Injected Muscle	DYSPORT® Units Injected	Number Of Injection Sites
Gastrocnemius
Lateral	100 Units to 150 Units	1
Medial	100 Units to 150 Units	1
Soleus	333 Units to 500 Units	3
Tibialis posterior	200 Units to 300 Units	2
Flexor digitorum longus	133 Units to 200 Units	1 to 2
Flexor hallucis longus	67 Units to 200 Units	1

The primary efficacy variable was muscle tone assessed by the MAS at the ankle joint at week 4. The first secondary endpoint was the Physician Global Assessment (ranges from –4 = markedly worse to +4= markedly improved) at week 4 (Table 20).

Table 20: Primary Endpoint Change in MAS and the First Secondary Endpoint PGA at Week 4 in Adult Patients with Lower Limb Spasticity

LS Mean Change from Baseline on the Modified Ashworth Scale	Dysport 1000 Units	Dysport 1500 Units	Placebo
	(N = 125)	(N = 128 )	(N = 128)
Week 4	-0.6	-0.8 P<0.05	-0.5
LS Mean Physician Global Assessment ScoreInvestigator
Week 4	0.9	0.9	0.7

Cervical Dystonia, Spasticity in Adults, and Lower Limb Spasticity in Pediatric Patients

•  500 Unit Vial
  •  Each vial contains 500 Units of freeze-dried abobotulinumtoxinA.
  •  Box containing 1 vial—NDC 15054-0500-1
  •  Box containing 2 vials—NDC 15054-0500-2
  •  300 Unit Vial
    •  Each vial contains 300 Units of freeze-dried abobotulinumtoxinA.
    •  Box containing 1 vial—NDC 15054-0530-6

    Glabellar Lines

    •  Each vial contains 300 Units of freeze-dried abobotulinumtoxinA.
    •  Box containing 1 vial— NDC 0299-5962-30

The dose of DYSPORT^® for the treatment of glabellar lines is a total of 50 Units given intramuscularly in five equal aliquots of 10 Units each to achieve clinical effect (see Figure 1).

Dosing in initial and subsequent treatment sessions should be tailored to the individual based on the size, number and location of muscles involved, severity of spasticity, the presence of local muscle weakness, the patient's response to previous treatment, and/or adverse event history with botulinum toxins.

No more than 1 mL should generally be administered at any single injection site. The maximum recommended total dose (upper and lower limb combined) of DYSPORT® for the treatment of spasticity in adults is 1500 Units.

Although actual location of the injection sites can be determined by palpation, the use of injection guiding technique e.g., electromyography, electrical stimulation is recommended to target the injection sites.

For injection: 300 Units or 500 Units of lyophilized powder in a single-use vial for reconstitution with preservative-free 0.9% Sodium Chloride Injection, USP.

DYSPORT^® is contraindicated in patients with:

• Known hypersensitivity to any botulinum toxin preparation or to any of the components in the formulation [see Description (11)]. Hypersensitivity reactions have been reported, including anaphylaxis [see Adverse Reactions (6.2)]. This product may contain trace amounts of cow's milk protein. Patients known to be allergic to cow's milk protein should not be treated with DYSPORT^®.
• Infection at the proposed injection site(s).

The potency Units of DYSPORT^® are specific to the preparation and assay method utilized. They are not interchangeable with other preparations of botulinum toxin products and, therefore, units of biological activity of DYSPORT^® cannot be compared to or converted into units of any other botulinum toxin products assessed with any other specific assay method [see Description (11)].

Post-marketing safety data from DYSPORT^® and other approved botulinum toxins suggest that botulinum toxin effects may, in some cases, be observed beyond the site of local injection. The symptoms are consistent with the mechanism of action of botulinum toxin and may include asthenia, generalized muscle weakness, diplopia, blurred vision, ptosis, dysphagia, dysphonia, dysarthria, urinary incontinence and breathing difficulties. These symptoms have been reported hours to weeks after injection. Swallowing and breathing difficulties can be life-threatening and there have been reports of death related to spread of toxin effects. The risk of symptoms is probably greatest in children treated for spasticity but symptoms can also occur in adults treated for spasticity and other conditions, particularly in those patients who have underlying conditions that would predispose them to these symptoms. In unapproved uses, including upper limb spasticity in children and approved indications, symptoms consistent with spread of toxin effect have been reported at doses comparable to or lower than the maximum recommended total dose [see Use in Specific Populations (8.4)].

Treatment with DYSPORT^® and other botulinum toxin products can result in swallowing or breathing difficulties. Patients with pre-existing swallowing or breathing difficulties may be more susceptible to these complications. In most cases, this is a consequence of weakening of muscles in the area of injection that are involved in breathing or swallowing. When distant effects occur, additional respiratory muscles may be involved [see Warnings and Precautions (5.2)].

Deaths as a complication of severe dysphagia have been reported after treatment with botulinum toxin. Dysphagia may persist for several weeks, and require use of a feeding tube to maintain adequate nutrition and hydration. Aspiration may result from severe dysphagia and is a particular risk when treating patients in whom swallowing or respiratory function is already compromised.

Treatment of cervical dystonia with botulinum toxins may weaken neck muscles that serve as accessory muscles of ventilation. This may result in a critical loss of breathing capacity in patients with respiratory disorders who may have become dependent upon these accessory muscles. There have been post-marketing reports of serious breathing difficulties, including respiratory failure.

Patients treated with botulinum toxin may require immediate medical attention should they develop problems with swallowing, speech or respiratory disorders. These reactions can occur within hours to weeks after injection with botulinum toxin [see Warnings and Precautions (5.2), Adverse Reactions (6.1), Clinical Pharmacology (12.2)].

Caution should be exercised when administering DYSPORT^® to patients with surgical alterations to the facial anatomy, excessive weakness or atrophy in the target muscle(s), marked facial asymmetry, inflammation at the injection site(s), ptosis, excessive dermatochalasis, deep dermal scarring, thick sebaceous skin [see Dosage and Administration (2.3)] or the inability to substantially lessen glabellar lines by physically spreading them apart [see Clinical Studies (14.2)].

Do not exceed the recommended dosage and frequency of administration of DYSPORT^®. In clinical trials, subjects who received a higher dose of DYSPORT^® had an increased incidence of eyelid ptosis.

Individuals with peripheral motor neuropathic diseases, amyotrophic lateral sclerosis or neuromuscular junction disorders (e.g., myasthenia gravis or Lambert-Eaton syndrome) should be monitored particularly closely when given botulinum toxin. Patients with neuromuscular disorders may be at increased risk of clinically significant effects including severe dysphagia and respiratory compromise from typical doses of DYSPORT^® [see Adverse Reactions (6.1)].

This product contains albumin, a derivative of human blood. Based on effective donor screening and product manufacturing processes, it carries an extremely remote risk for transmission of viral diseases and variant Creutzfeldt-Jakob disease (vCJD). There is a theoretical risk for transmission of Creutzfeldt-Jakob disease (CJD), but if that risk actually exists, the risk of transmission would also be considered extremely remote. No cases of transmission of viral diseases, CJD, or vCJD have ever been identified for licensed albumin or albumin contained in other licensed products.

The possibility of an immune reaction when injected intradermally is unknown. The safety of DYSPORT^® for the treatment of hyperhidrosis has not been established. DYSPORT^® is approved only for intramuscular injection.

The following serious adverse reactions are discussed below and elsewhere in labeling:

• Distant Spread of Toxin Effect [see Boxed Warning]
• Lack of Interchangeability between Botulinum Toxin Products [see Warnings and Precautions (5.1)]
• Spread of Effects from Toxin [see Warnings and Precautions (5.2)]
• Dysphagia and Breathing Difficulties [see Warnings and Precautions (5.3)]
• Facial Anatomy in the Treatment of Glabellar Lines [see Warnings and Precautions (5.4)]
• Pre-existing Neuromuscular Disorders [see Warnings and Precautions (5.5)]
• Human Albumin and Transmission of Viral Diseases [see Warnings and Precautions (5.6)]
• Intradermal Immune Reaction [see Warnings and Precautions (5.7)]

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

Because adverse reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

The following adverse reactions have been identified during post-approval use of DYSPORT^®: vertigo, photophobia, influenza-like illness, amyotrophy, burning sensation, facial paresis, hypoesthesia, erythema, and excessive granulation tissue. Hypersensitivity reactions including anaphylaxis have been reported. Dry eye was observed at <1% during clinical trials and has been reported in post-marketing surveillance in the treatment of glabellar lines.

As with all therapeutic proteins, there is a potential for immunogenicity.

The incidence of antibody formation is highly dependent on the sensitivity and specificity of the assay. In addition, the observed incidence of antibody positivity in an assay may be influenced by several factors including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, comparison of the incidence of antibodies across products in this class may be misleading.

No formal drug interaction studies have been conducted with DYSPORT^®.

Patients treated concomitantly with botulinum toxins and aminoglycosides or other agents interfering with neuromuscular transmission (e.g., curare-like agents) should be observed closely because the effect of the botulinum toxin may be potentiated. Use of anticholinergic drugs after administration of DYSPORT^® may potentiate systemic anticholinergic effects such as blurred vision.

The effect of administering different botulinum neurotoxin products at the same time or within several months of each other is unknown. Excessive weakness may be exacerbated by another administration of botulinum toxin prior to the resolution of the effects of a previously administered botulinum toxin.

Excessive weakness may also be exaggerated by administration of a muscle relaxant before or after administration of DYSPORT^®.

Exploratory analyses in trials for glabellar lines in African-American subjects with Fitzpatrick skin types IV, V, or VI and in Hispanic subjects suggested that response rates at Day 30 were comparable to and no worse than the overall population.

Excessive doses of DYSPORT^® may be expected to produce neuromuscular weakness with a variety of symptoms. Respiratory support may be required where excessive doses cause paralysis of respiratory muscles. In the event of overdose, the patient should be medically monitored for symptoms of excessive muscle weakness or muscle paralysis [see Warnings and Precautions (5.2)]. Symptomatic treatment may be necessary.

Symptoms of overdose are likely not to be present immediately following injection. Should accidental injection or oral ingestion occur, the person should be medically supervised for several weeks for signs and symptoms of excessive muscle weakness or paralysis.

There is no significant information regarding overdose from clinical studies.

In the event of overdose, antitoxin raised against botulinum toxin is available from the Centers for Disease Control and Prevention (CDC) in Atlanta, GA. However, the antitoxin will not reverse any botulinum toxin-induced effects already apparent by the time of antitoxin administration. In the event of suspected or actual cases of botulinum toxin poisoning, please contact your local or state Health Department to process a request for antitoxin through the CDC. If you do not receive a response within 30 minutes, please contact the CDC directly at 770-488-7100. More information can be obtained at http://www.cdc.gov/ncidod/srp/drugs/drug-service.html.

Botulinum toxin type A, the active ingredient in DYSPORT^® (abobotulinumtoxinA), is a purified neurotoxin type A complex produced by fermentation of the bacterium Clostridium botulinum type A, Hall Strain. It is purified from the culture supernatant by a series of precipitation, dialysis, and chromatography steps. The neurotoxin complex is composed of the neurotoxin, hemagglutinin proteins and non-toxin non-hemagglutinin protein.

DYSPORT^® is supplied in a single-use, sterile vial for reconstitution intended for intramuscular injection. Each vial contains 300 Units or 500 Units of lyophilized abobotulinumtoxinA, human serum albumin (125 mcg) and lactose (2.5 mg). DYSPORT^® may contain trace amounts of cow's milk proteins [see Contraindications (4)].

One unit of DYSPORT^® corresponds to the calculated median lethal intraperitoneal dose (LD50) in mice. The method for performing the assay is specific to Ipsen's product DYSPORT^®. Due to differences in specific details such as vehicle, dilution scheme and laboratory protocols for various mouse LD50 assays, Units of biological activity of DYSPORT^® are not interchangeable with Units of any other botulinum toxin or any toxin assessed with any other specific assay method [see Dosage Forms and Strengths (3)].

DYSPORT^® inhibits release of the neurotransmitter, acetylcholine, from peripheral cholinergic nerve endings. Toxin activity occurs in the following sequence: Toxin heavy chain mediated binding to specific surface receptors on nerve endings, internalization of the toxin by receptor mediated endocytosis, pH-induced translocation of the toxin light chain to the cell cytosol and cleavage of SNAP25 leading to intracellular blockage of neurotransmitter exocytosis into the neuromuscular junction. This accounts for the therapeutic utility of the toxin in diseases characterized by excessive efferent activity in motor nerves.

Recovery of transmission occurs gradually as the neuromuscular junction recovers from SNAP25 cleavage and as new nerve endings are formed.

The primary pharmacodynamic effect of DYSPORT^® is due to chemical denervation of the treated muscle resulting in a measurable decrease of the compound muscle action potential, causing a localized reduction of muscle activity.

Using currently available analytical technology, it is not possible to detect DYSPORT^® in the peripheral blood following intramuscular injection at the recommended doses.

The efficacy of DYSPORT^® was evaluated in two randomized, double-blind, placebo-controlled, single dose, parallel-group studies in treatment-naïve cervical dystonia patients. The principal analyses from these trials provide the primary demonstration of efficacy involving 252 patients (121 on DYSPORT^®, 131 on placebo) with 36% male and 64% female. Ninety-nine percent of the patients were Caucasian.

In both placebo-controlled studies (Study 1 and Study 2), a dose of 500 Units DYSPORT^® was given by intramuscular injection divided among two to four affected muscles. These studies were followed by long-term open-label extensions that allowed titration in 250 Unit steps to doses in a range of 250 to 1000 Units, after the initial dose of 500 Units. In the extension studies, re-treatment was determined by clinical need after a minimum of 12 weeks. The median time to re-treatment was 14 weeks and 18 weeks for the 75^th percentile.

The primary assessment of efficacy was based on the total Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) change from baseline at Week 4 for both studies. The scale evaluates the severity of dystonia, patient-perceived disability from dystonia, and pain. The adjusted mean change from baseline in the TWSTRS total score was statistically significantly greater for the DYSPORT^® group than the placebo group at Weeks 4 in both studies (see Table 11).

Analyses by gender, weight, geographic region, underlying pain, cervical dystonia severity at baseline and history of treatment with botulinum toxin did not show any meaningful differences between groups.

Table 12 indicates the average DYSPORT^® dose, and percentage of total dose, injected into specific muscles in the pivotal clinical trials.

Three double-blind, randomized, placebo-controlled, clinical studies evaluated the efficacy of DYSPORT^® for use in the temporary improvement of the appearance of moderate to severe glabellar lines. These three studies enrolled healthy adults (ages 19-75) with glabellar lines of at least moderate severity at maximum frown. Subjects were excluded if they had marked ptosis, deep dermal scarring, or a substantial inability to lessen glabellar lines, even by physically spreading them apart. The subjects in these studies received either DYSPORT^® or placebo. The total dose was delivered in equally divided aliquots to specified injection sites (see Figure 1).

Investigators and subjects assessed efficacy at maximum frown by using a 4-point scale (none, mild, moderate, severe).

Overall treatment success was defined as post-treatment glabellar line severity of none or mild with at least 2 grade improvement from Baseline for the combined investigator and subject assessments (composite assessment) on Day 30 (see Table 13). Additional endpoints for each of the studies were post-treatment glabellar line severity of none or mild with at least a 1 grade improvement from Baseline for the separate investigator and subject assessments on Day 30.

After completion of the randomized studies, subjects were offered participation in a two-year, open-label re-treatment study to assess the safety of multiple treatments.

Treatment with DYSPORT^® reduced the severity of glabellar lines for up to four months.

The efficacy of DYSPORT^® was evaluated in a double-blind, placebo-controlled multicenter study in patients 2 to 17 years of age treated for lower limb spasticity because of cerebral palsy causing dynamic equinus foot deformity. A total of 235 (158 DYSPORT^® and 77 Placebo) toxin naïve or non-naïve patients with a Modified Ashworth Score (MAS) of grade 2 or greater at the ankle plantar flexor were enrolled to receive DYSPORT^® 10 Units/kg/leg (n=79), DYSPORT^® 15 Units/kg/leg (n=79) or placebo (n=77) injected into the gastrocnemius and soleus muscles. Forty one percent of patients (n=66) were treated bilaterally and received a total lower limb DYSPORT^® dose of either 20 Units/kg (n=37) or 30 Units/kg (n=29). The primary efficacy endpoint was the mean change from baseline in MAS in ankle plantar flexor at Week 4; a co-primary endpoint was the mean Physician's Global Assessment (PGA) score at Week 4 (Table 21).

DYSPORT^® for Injection is supplied in a sterile, single-use, glass vial. Unopened vials of DYSPORT^® must be stored under refrigeration at 2°to 8°C (36°F to 46°F). Protect from light.

Do not use after the expiration date on the vial. All vials, including expired vials, or equipment used with DYSPORT^® should be disposed of carefully as is done with all medical waste.

DYSPORT^® contains a unique hologram on the carton. If you do not see the hologram, do not use the product. Instead contact 877-397-7671.

Advise the patient to read the FDA-approved patient labelling (Medication Guide).

Advise patients to inform their doctor or pharmacist if they develop any unusual symptoms (including difficulty with swallowing, speaking or breathing), or if any known symptom persists or worsens.

Inform patients that if loss of strength, muscle weakness, blurred vision or drooping eyelids occur, they should avoid driving a car or engaging in other potentially hazardous activities.

• People with certain breathing problems may need to use muscles in their neck to help them breathe. These patients may be at greater risk for serious breathing problems with DYSPORT®.
• Swallowing problems may last for several weeks. People who cannot swallow well may need a feeding tube to receive food and water. If swallowing problems are severe, food or liquids may go into your lungs. People who already have swallowing or breathing problems before receiving DYSPORT® have the highest risk of getting these problems.
2. Spread of toxin effects. In some cases, the effect of botulinum toxin may affect areas of the body away from the injection site and cause symptoms of a serious condition called botulism. The symptoms of botulism include:

• loss of strength and muscle weakness all over the body
• blurred vision and drooping eyelids
• trouble saying words clearly (dysarthria)
• trouble breathing

• double vision
• hoarseness or change or loss of voice (dysphonia)
• loss of bladder control
• trouble swallowing

Rx only
NDC Number: 15054-0500-1
1 Vial

abobotulinumtoxinA

Dysport^®

for Injection
For intramuscular use

500 units/vial

WARNING: Dosing units of botulinum toxins are not
interchangeable between commercial products.

Lift here

Principal Display Panel (500 Units Vial Carton)

Rx only
NDC Number: 15054-0530-6
1 Vial

abobotulinumtoxinA

Dysport^®

for Injection
For intramuscular use

300 units/vial

WARNING: Dosing units of botulinum toxins are not
interchangeable between commercial products.

Lift here

Principal Display Panel (300 Units Vial Carton)