8/7/2019 Adults Past Dosing

http://slidepdf.com/reader/full/adults-past-dosing 1/2

E D I T I O N 3 . 0

L O W E R L I M B S

U P P E R L I M B S

Management of Spasticity withBotulinum Toxin Type A (botox ® )

suggested adult botox ® dosing

© WE MOVE™| REVISED AUGUST 2005 | EDITION 3.0

SUGGESTED ADULT BOTOX DOSING CONTINUED ON REVERSE SIDE

Clinical Pattern Potential Muscles Involved

Avg. Starting

Dose/Units

BOTOX® Dose

Units/Visit

Number of

Injection Sites

† For localization of psoas, fluoroscopy/ultrasound is recommended

Adducted/Internally pectoralis complex 100 50 – 200 2 – 4Rotated Shoulder latissimus dorsi 100 50 – 200 2 – 4

teres major 50 25 – 100 1 – 2subscapularis 75 50 – 100 1 – 2

Flexed Elbow brachioradialis 60 25 – 100 1 – 3biceps 80 75 – 200 2 – 4brachialis 50 40 – 150 1 – 2

Pronated Forearm pronator quadratus 25 10 – 50 1pronator teres 40 – 50 25 – 75 1 – 2

Flexed Wrist flexor carpi radialis 50 25 – 100 1 – 2flexor carpi ulnaris 40 20 – 100 1 – 2

Thumb-in-Palm flexor pollicis longus 20 10 – 50 1adductor pollicis 10 5 – 30 1flexor pollicis brevis/opponens 10 5 – 30 1

Clenched Fist flexor digitorum superficialis (per fascicle) 20 20 – 50 1flexor digitorum profundus (per fascicle) 20 20 – 50 1

Intrinsic Plus Hand lumbricales/interossei (per lumbrical) 10 5 – 15 1

Flexed Hip iliopsoas † 100 50 – 200 2psoas 100 50 – 200 2rectus femoris 100 75 – 200 2 – 4

Flexed Knee medial hamstrings 100 50 – 200 2 – 3gastrocnemius (as knee flexor) 125 50 – 150 2 – 4lateral hamstrings 100 75 – 200 2 – 3

Adducted Thighs adductor longus/brevis/magnus 200/leg 75 – 300 6/leg

Stiff (Extended) Knee quadriceps mechanism 100 50 – 300 6

Equinovarus Foot gastrocnemius medial/lateral 100 50 – 250 2 – 4soleus 100 50 – 200 2 – 4tibialis posterior 75 50 – 150 1 – 3tibialis anterior 50 50 – 150 1 – 3flexor digitorum longus 75 50 – 100 1 – 3flexor digitorum brevis 25 20 – 40 1flexor hallucis longus 50 25 – 75 1 – 2

Striatal Toe extensor hallucis longus 50 20 – 100 1 – 2

8/7/2019 Adults Past Dosing

http://slidepdf.com/reader/full/adults-past-dosing 2/2

CLINICAL SITUATION DOSE PER MUSCLEADecrease in DoseMay be Indicated if:

An Increase in DoseMay be Indicated if:

dose modifiers

The suggested doses in this table represent updates to the original dosing recommendations. These were based on the consensus opinion of the Spasticity Study Group.For further discussion, see Mayer NH, Simpson DM, editors. Spasticity: Etiology, Evaluation, Management, and the Role of Botulinum Toxin Type A.New York: we move , 2002

Before prescribing any pharmacologic agent, review the complete prescribing information, including indications, contraindications, warnings, precautions, and adverse events.

H E A D A N D N E C K

Potential Muscles InvolvedAvg. StartingDose/Units

BOTOX® DoseUnits/Visit

Number of Injection Sites

sternocleidomastoid ( scm )† † 40 25 – 75** 1 – 3scalenus complex 30 15 – 50 1 – 3

splenius capitis 50 30 – 150 1 – 3semispinalis capitis 60 50 – 150 1 – 3longissimus capitis 60 50 – 150 1 – 3trapezius 50 50 – 150 1 – 3levator scapulae 60 25 – 100 1 – 3

masseter 40/side 20 – 60/side 2/side

temporalis 20/side 20 – 40/side 1 – 2/side

†† The dose should be reduced by 50% if bothscm muscles are injected.

**Neck weakness may be a risk from injection of neck extensors at the upper end of the dose range

key points

dosing guidelines for adults

suggested adult botox ® dosing (continued)

Meaningful assessment of treatment outcome depends on careful definition of objectivesbeforehand

Patients may benefit from anxiolytics and/or topical anesthetics before injection

Most patients begin to feel a therapeutic effect within 24 – 72 hours after injection, withthe peak effect occurring at approximately 1 – 4 weeks

Concurrent therapies may improve likelihood of reaching treatment objectives

Reassessment at 3 – 6 weeks is recommended to evaluate patient response

The decision to re-treat is not a forgone conclusion and should be revisited after eachtherapy session

Total maximum body dose per visit =

400–600 Units, except in select situations

Maximum volume per site = 0.5 – 1.0

mL, except in select situationsReinjection v 3 months, except inselect situations

Dosing tables are web viewableand downloadable at

www.mdvu.org

Patient weight Low High

Likely duration of therapy Chronic Acute

Muscle bulk Very small Very large

Number of muscles being injected simultaneously Many Few

Ashworth score Low Very high

Underlying voluntary control Good Poor

Concern that treatment may result in excess weakness High Low

Results of previous therapy Too much weakness Inadequate response

© WE MOVE™| REVISED AUGUST 2005 | EDITION 3.0