Absolute contraindications to botulinum toxin injection include infection at the site of injection or known hypersensitivity to any component of the product.
AbobotulinumtoxinA should not be given to patients with allergies to cow’s milk protein; this limitation does not apply to onabotulinumtoxinA, incobotulinumtoxinA, or rimabotulinumtoxinB.
Relative contraindications to treatment include neuromuscular disorders that could amplify the effect of the toxin, such as:
- myasthenia gravis,
- Eaton-Lambert syndrome,
- myopathies, or
- amyotrophic lateral sclerosis.
Caution should also be exercised in patients taking drugs that can interfere with neuromuscular transmission (eg, aminoglycosides, cholinesterase inhibitors, quinidine, magnesium sulfate, succinylcholine, and curare-type nondepolarizing blockers).
OnabotulinumtoxinA, abobotulinumtoxinA, incobotulinumtoxinA, and rimabotulinumtoxinB are pregnancy class C agents, and injection generally should be avoided in pregnant women.
The risks of maternal-infant transmission of botulinum toxin in lactating women are unknown; thus, we avoid their use in this population.