Dishing on a New Neuromodulator

Successfully incorporating the newest neuromodulator into your practice requires dosing conservatively, pricing wisely, and not overselling the product’s longevity, experts told Modern Aesthetics® magazine.

Last September, the FDA approved Daxxify (daxibotulinumtoxinA-lanm, Revance). “It’s the first real game-changer that we’ve had in toxins for over 30 years,” said Wm. Philip Werschler, MD, a dermatologist in private practice in Spokane, Washington.

Previously, Dr. Werschler explained, developers would “play around” with dilution, dosing, and needle techniques. He said the only difference between previously available neuromodulators was the manufacturing process. “The active ingredient (botulinum toxin type A) has always been the same,” he remarked. “Now, we have something different that seems to last longer. In the data that’s been released, 50% of patients had lasting effect at 6 months, which means that 50% of patients had an effect at more than 6 months.”¹

Dr. Werschler stated that daxibotulinumtoxinA’s novel peptide stabilizer makes the molecule slightly stickier than previously approved neuromodulators. “It hangs out at the motor endplate longer before the active part of the toxin is absorbed,” he said. According to Dr. Werschler, although daxibotulinumtoxinA is better engineered than existing neuromodulators, once its heavy-chain carrier is absorbed, it consists of the same light-chain molecule, and the same Hall Clostridium strain, as the other type A neuromodulators.

To integrate daxibotulinumtoxinA into your practice, experts offered four tips.

NO. 1: DON’T OVERSTATE DURATION

With any aesthetic product, said Dr. Werschler, “when you get into claims of duration, it’s a slippery slope. Be careful not to overpromise.” When discussing daxibotulinumtoxinA with patients, he plans to stick with clinical trial data showing that it lasts longer than Botox Cosmetic (onabotulinumtoxinA, Allergan Aesthetics, an AbbVie company), Xeomin (incobotulinumtoxinA, Merz), Jeuveau (prabotulinumtoxinA-xvfs, Evolus), or Dysport (abobotulinumtoxinA, Galderma). “Approximately half of patients still had a nice effect at 24 weeks,” he stated. Dr. Werschler said he will tell patients he wishes the same results for them (Figure). He has seen practitioners claim that results last up to a year. “That’s a huge mistake,” he said, “because now you’re overpromising and underdelivering.”

Figure. A 45-year-old woman before and at various time points after daxibotulinumtoxinA-lanm injection (top). A 56-year-old woman before and at various time points after daxibotulinumtoxinA-lanm injection (bottom).

NO. 2: USE LABELED DOSING

Maximizing daxibotulinumtoxinA duration depends on dosing, Dr. Werschler said. Labeled glabellar doses for this product and onabotulinumtoxinA are 40 units and 20 units, respectively. Already, he said, some dermatologists are providing 20 units of daxibotulinumtoxinA at the same price as onabotulinumtoxinA or slightly higher. “If people are paying for Daxxify, and all they’re reading about is how much longer it lasts, then they’re getting treated with a suboptimal dose, 24 weeks’ duration is going to be elusive,” he said. “I hope that people don’t try to substitute, say, Botox dosing with Daxxify, because then they are essentially undertreating.” The resulting intensity and duration of effect will be underwhelming, he commented.

NO. 3: PRICE APPROPRIATELY

Dr. Werschler’s average neuromodulator patient comes in three times yearly. If he can get them an extra 4 to 8 weeks of efficacy with daxibotulinumtoxinA, he reasoned, then they need visit only twice yearly. “That’s probably where it’s going to fall,” he remarked. However, he said, patients accustomed to spending $500 for onabotulinumtoxinA treatment three times yearly may balk at spending $900 to $1,000 for a new product in the same category. Moreover, with two yearly daxibotulinumtoxinA visits, patients’ $1,500 annual toxin expenditures would increase to $2,000. To address patients’ cost concerns, he emphasized that daxibotulinumtoxinA requires one fewer appointment per year, which saves patients time, pain, bruising risk, and needle sticks.

According to proprietary Revance research, patients are willing to spend at least 50% more for a neurotoxin that delivers a 6-month median duration.^2-5 Dr. Werschler commented that most dermatologists he knows are charging a 50% to 100% premium for daxibotulinumtoxinA.

Theoretically, said Amy Forman Taub, MD, daxibotulinumtoxinA’s increased duration should translate into a higher price. “What complicates the equation is that it takes twice the units to accomplish 50% more duration,” she said. Dr. Taub is the founder of Advanced Dermatology and skinfo.com skincare boutique, a cofounder of SkinQRI, and an assistant professor of dermatology at Northwestern University Feinberg School of Medicine.

Charging 50% more for daxibotulinumtoxinA than for other toxins would create a price increase of 300% for patients, said Dr. Taub. In the glabella, for instance, 20 units of onabotulinumtoxinA at $15 apiece equals $300 versus $900 ($22.50 times 40 units) for daxibotulinumtoxinA. Alternatively, Dr. Taub added, pricing each 2 units of daxibotulinumtoxinA at 1.5 times the amount of onabotulinumtoxinA results in patient prices of $450 versus $300, respectively.

“I started thinking I would just charge the same as the other toxins per unit because the price will wind up doubling,” she said. Using labeled doses and charging $15 per unit, daxibotulinumtoxinA costs patients $600 ($15 times 40) versus $300 for onabotulinumtoxinA, as described earlier. “You are making double the money,” she said. “Plus, the net is more since unit-for-unit daxibotulinumtoxinA costs less than Botox.”

Many physicians worry that, with daxibotulinumtoxinA, they will see their patients less often, Dr. Taub noted. “But in our office, people come two to two-and-a-half times per year on average,” she said. “We are very busy at the office, gratefully, and so the ability to make twice what we would for a given slot (due to increasing the dosage) is an increase in ROI [return on investment]. It also opens another slot for someone else, so it is a win-win.” Seeing patients fewer times could make them more likely to bring up other treatments, for instance, topping off their filler at the same time as their toxin, she noted

NO. 4: EMBRACE SECOND-GENERATION TOXIN THERAPY

The array of FDA-approved neuromodulators is expected to grow. The next game-changer, said Dr. Werschler, will be short-acting toxins. For example, BoNTE (botulinum toxin type E, AbbVie), currently in phase 3 trials, takes effect within 24 hours or less but wears off in 14 to 30 days.⁶ Additional toxins under development include relabotulinumtoxinA (Galderma) and Letybo (letibotulinumtoxinA, Hugel Aesthetics).^7-9 With an amended Biologics License Application under FDA review, Hugel anticipates launching letibotulinumtoxinA in 2023, according to the company’s website.

With several new neuromodulators on the horizon, Dr. Werschler predicted that, within a few years, patients wanting toxin treatment will have a full menu of options, as they do in fillers, and injectors may use different toxin types for different areas and purposes. “It’s an exciting time,” he said. “We’re beginning to customize toxin therapy beyond the well-established changes in dosing and dilution.”

Dr. Taub has been an investigator and consultant for Allergan and an investigator for Revance.

Dr. Werschler has been a consultant, investigator, and trainer for Merz Aesthetics; a consultant and trainer for Allergan; and an investigator for Revance and Galderma.

1. Carruthers JD, Fagien S, Joseph JH, et al. DaxibotulinumtoxinA for injection for the treatment of glabellar lines: results from each of two multicenter, randomized, double-blind, placebo-controlled, phase 3 studies (SAKURA 1 and SAKURA 2). Plast Reconstr Surg. 2020;145(1):45-58. doi:10.1097/PRS.0000000000006327

2. Revance. Data on File. DAXI Consumer WTP Survey. Kx Advisors. July 2021.

3. Revance. Data on File. Sizing the Market Opportunity for DAXI Consumers. Kx Advisors. March 2020.

4. Revance. Data on File. Bringing DAXI to Market. IDEO. October 2019.

5. Revance. Data on File. Practice Economics Study. Insight Strategy Advisors. August 2017.

6. Yoelin SG, Dhawan SS, Vitarella D, Ahmad W, Hasan F, Abushakra S. Safety and efficacy of EB-001, a novel type E botulinum toxin, in subjects with glabellar frown lines: results of a phase 2, randomized, placebo-controlled, ascending-dose study. Plast Reconstr Surg. 2018;142(6):847e-855e. doi:10.1097/PRS.0000000000005029

7. Shridharani S, et al. Treatment of moderate-to-severe glabellar lines with relabotulinumtoxinA: reliable combinations that always deliver. Oral presentation at: Vegas Cosmetic Surgery & Aesthetic Dermatology; June 10, 2022; Las Vegas, NV.

8. Ibrahim SF, Ablon G, Bank D, et al. Treatment of lateral canthal lines with relabotulinumtoxinA, an investigational liquid botulinum toxin: clinical efficacy and safety results from the READY-2 phase III trial. Oral presentation at: Vegas Cosmetic Surgery & Aesthetic Dermatology; June 10, 2022; Las Vegas, NV.

9. Mueller DS, Prinz V, Adelglass J, et al. Efficacy and safety of letibotulinumtoxin A in the treatment of glabellar lines: a randomized, double-blind, multicenter, placebo-controlled phase 3 study. Aesthet Surg J. 2022;42(6):677-688. doi:10.1093/asj/sjac019