Chapter 6: Practical aspects of administration of onabotulinumtoxinA

Candidates for onabotulinumtoxinA are generally patients with overactive bladder (OAB) or neurogenic detrusor overactivity (NDO) whose disease is inadequately controlled with behavioral therapy and oral medication. All patients must be willing and able to perform clean intermittent catheterization (CIC). Before the decision to administer onabotulinumtoxinA is made, the clinician should provide counseling to the patient regarding the agent's indications, proposed benefits, risks, and mode of administration. The patient should be aware that onabotulinumtoxinA takes effect after approximately 1-2 weeks and usually lasts for 4-10 months, after which repeat injections will be necessary to maintain effect. Patient preparation may include pre-treatment antibiotics and withdrawal of antiplatelet therapy or anticoagulants. Preparation of the product involves reconstitution in sterile saline and dilution according to the planned dose. Local anesthesia (e.g., bladder instillation of lidocaine) is usually administered, although general anesthesia may be used in certain cases. The injections are performed using a flexible or rigid cystoscope, and the procedure takes approximately 15 min. The initial follow-up visit occurs within 7-14 days, when evidence of adverse effects, including urinary retention, can be evaluated. Repeat injections can be scheduled as needed, but not sooner than 3 months. Currently, the total dose of onabotulinumtoxinA should not exceed 360 U in a 3-month period for all indications, including those outside the urinary tract (i.e., cosmetic, ophthalmologic, etc.). Overall, onabotulinumtoxinA is effective, generally well tolerated, safe, and is relatively simple to provide.