Australia is lagging behind the rest of the world when it comes to the use of botulinim toxin for post-stroke spasticity, new figures suggest.

The Drug Utilisation Sub-Committee (DUSC) of the Pharmaceutical Benefits Advisory Committee (PBAC) has noted that the use of botulinum toxin is low in the context of post-stroke spasticity.

It found 742 patients were treated with PBS-subsidised botulinum toxin for upper limb spasticity following a stroke, with 1,002 prescriptions dispensed in 2017.

However the use of botulinum toxin for other indications appeared to be in line with predictions. Overall, 13,116 patients were treated with botulinum toxin type A for spasticity or dystonia in 2017.

The majority of use was for spasmodic torticollis, blepharospasm and hemifacial spasm. Use for each of these indications has been growing, with a higher rate of growth evident for spasmodic torticollis in 2016 and 2017.

The number of patients with cerebral palsy receiving botulinum toxin for upper limb spasticity or foot deformity due to spasticity increased until 2015 and has now stabilised.

The Committee also noted that 20%-45% of patients, depending on the indication, only had one prescription supplied.

“This suggests that many patients who initiate botulinum toxin may not achieve functional improvement or dislike the injections and cease treatment,” it said.

Access to botulinum denied 

Rehabilitation physician Dr Ian Baguley, from the University of Sydney, told the limbic that access to botulinum toxin for post-stroke spasticity was sub-optimal.

He said there were some clinicians such as geriatricians who ‘historically don’t think about spasticity or inject’ and were not aware of what might be achieved.

And the ‘mish-mash of accidental systems’ for getting access to the treatment didn’t help.

“We’re trying to get people to have systems to recognise spasticity when it comes on because there are a group of people who will have spasticity at three months and it will disappear and people who don’t have it at three months then have it by six months. The current system seems to completely miss these people.”

Dr Baguley said Australia lagged behind international trends in the use of botulinum for spasticity.

For example, there was evidence that injecting as early as two weeks post-stroke – currently not covered by the Australian funding model – was better than waiting until patients were in distress and non-functional.

And there should also be PBS-reimbursed access to botulinum toxin beyond four cycles, he believed.

“I’ve just come back from a conference in Paris where the Australian experience is quite out of step with the rest of the world in that there are a proportion of people that you only need to inject once, twice or three times, but there is this other group that internationally, would be injected life-long or while ever they have issues.”

“We are the only country that has a limitation of four cycles and we are a laughing stock internationally.”

Dr Baguley coauthored a recent cost-effective analysis of extending access to botulinum toxin treatment in patients who were benefiting.

It found the incremental cost per QALY gained from botulinum toxin beyond the current restriction of four treatments was $59,911 – a figure he suggested was ‘sitting around the magic number’ for cost effectiveness from the government’s perspective.

“There is the sub-group of people who you severely disadvantage by removing their access.”

“Botulinum toxin works on the muscles that will not switch off and helps to reduce the impact of that, and for some people when you inject you can unmask muscle function that gets hidden away underneath the spasticity and allow them to get extra function back.”

He said the Rehabilitation Medicine Society of Australia and New Zealand currently had a submission pending with PBAC regarding improved access to botulinum toxin.

He added that some people did drop out of treatment, typically after a second treatment, if they did not perceive the benefits outweighed the discomfort of injections.

Other patients, despite counselling, had unrealistic expectations.

“I do get people with spasticity who are hoping that when you inject them the stroke will go away, and even though you say this will not happen, they still think that everything will go back to normal.”