19 November 2018

Dupuytren’s contracture: when injections are better

Clinical Drugs Surgery

As surgeons become more comfortable treating Dupuytren’s contracture with injection rather than surgery, and demand from the general public grows, the manufacturer is hoping to boost awareness among referrers.

Approved in 2013, Xiaflex (collagenase Clostridium histolyticum) is the only non-surgical treatment for the condition given the green light by the TGA.

Patients are injected with the solution, containing enzymes that dissolve the collagen that causes contracture, causing it to weaken and allow it to be disrupted by manual manipulation in the days following the injection.

If the contracture doesn’t fully resolve, the injection can be repeated once or twice at four-week intervals.

Up to two affected sites in a hand can be injected at the same time, according to the manufacturers.

According to clinical trial data, around half of patients who have up to three injections improve to having no or a negligible contracture, compared with only around 6% of those in the placebo group.

Ms Diana Wei, registered pharmacist and Medical Services Associate at Actelion Pharmaceuticals, said that now they have a number of surgeons on board with the procedure, they are hoping to raise awareness of it among GPs and other referrers.

There are currently around 250 surgeons with the special training to do the injections, and GPs can find a local clinic using the website www.xiaflex.com.au

Canberra orthopaedic surgeon Dr Maurizio Damiani said he’s seen almost two dozen patients have the procedure.

“The results are generally quite good, they’re very similar to the results you get with surgical incision,” he said.

The main early difference he said he saw was around the six-week mark when they came back for review, where the skin on their palm almost looked normal.

Because those performing the procedure need to have special training, Dr Damiani and his colleague work with a radiologist who has been trained to perform the procedure and can do it under ultrasound guidance, which increases the safety of the procedure.

Dr Damiani said he would be more likely to opt for surgery in patients with greater joint involvement, to help minimise the risk of the inadvertent destruction of collagen in areas not involved in the contracture.

“[Xiaflex] does have a role and it does have a purpose, the only thing we don’t have is long-term results,” Dr Damiani said. Ongoing research would be needed to see whether the recurrence rate was the same as with surgery.

Cost would be another important factor for the patient, he said.

The drug is not currently PBS listed and many private health insurers do not cover it, so the patient may be looking at substantial out of pocket costs. Injections may cost around $1200 to $1800.

Patients may also need multiple injections.

“The flipside is that they don’t need to have an anaesthetic, they don’t need to go to hospital and they don’t have a scar.”

It is also indicated for Peyronie’s disease.