Significantly lower antigenicity of incobotulinumtoxin than abo- or onabotulinumtoxin

Harald Hefter, Dietmar Rosenthal, Alexander Jansen, Raphaela Brauns, Beyza Ürer, Hans Bigalke, Hans-Peter Hartung, Sven G Meuth, John-Ih Lee, Philipp Albrecht, Sara Samadzadeh

Research output: Contribution to journalJournal articleResearchpeer-review


BACKGROUND: For many indications, BoNT/A is repetitively injected with the risk of developing neutralizing antibodies (NABs). Therefore, it is important to analyze whether there is a difference in antigenicity between the different licensed BoNT/A preparations.

METHODS: In this cross-sectional study, the prevalence of NABs was tested by means of the sensitive mouse hemidiaphragm assay (MHDA) in 645 patients. Patients were split into those having exclusively been treated with the complex protein-free incoBoNT/A preparation (CF-MON group) and those having started BoNT/A therapy with a complex protein-containing BoNT/A preparation (CC-I group). This CC-I group was split into those patients who remained either on abo- or onaBoNT/A (CC-MON group) and those who had been treated with at least two BoNT/A preparations (CC-SWI group). To balance treatment duration, only CC-MON patients who did not start their BoNT/A therapy more than 10 years before recruitment (CC-MON-10 group) were further analyzed. The log-rank test was used to compare the prevalence of NABs in the CF-MON and CC-MON-10 group.

RESULTS: In the CF-MON subgroup, no patient developed NABs. In the CC-I group, 84 patients were NAB-positive. NABs were found in 33.3% of those who switched preparations (CC-SWI) and in 5.9% of the CC-MON-10 group. Kaplan-Meier curves for remaining NAB-negative under continuous BoNT/A therapy were significantly different (p < 0.035) between the CF-MON and CC-MON-10 group.

CONCLUSION: Frequent injections of a complex protein-containing BoNT/A preparation are associated with significantly higher risks of developing NABs than injections with the same frequency using the complex protein-free incoBoNT/A preparation.

Original languageEnglish
JournalJournal of Neurology
Pages (from-to)788-796
Publication statusPublished - Feb 2023
Externally publishedYes

Bibliographical note

© 2022. The Author(s).


  • Neutralizing antibodies
  • Difference in antigenicity
  • Botulinum toxin type A preparations
  • IncobotulinumtoxinA
  • Complex proteins
  • Antibodies, Neutralizing
  • Neuromuscular Agents
  • Animals
  • Cross-Sectional Studies
  • Botulinum Toxins, Type A
  • Mice


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