Xiaflex and Dupuytren Treatment
Xiaflex treats Dupuytren contracture by dissolving cords
Xiaflex is the brand name of the enzyme collagenase, produced by Auxilium Pharmaceuticals, Inc., that originates from clostridium histolyticum, the same bacterium that causes gas gangrene. Actually, Xiaflex is a combination of two separate enzymes, called Aux-I and Aux-II that work together to break up the peptide bonds of the collagen protein. In early 2010 the FDA approved Xiaflex for treatment of Dupuytren contracture when a palpable cord is present; Xiaflex was not approved for Dupuytren treatment when only nodules or lumps on palms are found.
Dupuytren’s contracture is a slowly progressive condition that affects five times the number of men than women, affecting the deep soft tissue of the palm of the hand, called the palmar fascia. The problem is characterized by excessive collagen deposition in the palmar fascia that leads to finger contracture caused by a nodule that can develop a rope-like cord. As Dupuytrens disease progresses, the cord can slowly cause the affected finger(s) to go into flexion contracture toward the palm of the hand. With one or more fingers locked in a flexed contracture and unable to be straightened or extended, the individual with Dupuytren has significant problems with simple daily activities such as dressing, washing, toileting, and handling objects.
Xiaflex and Dupuytren treatment compared with surgery
The decision to use a surgical treatment for Dupuytren’s contracture depends on multiple factors:
1. Stage and severity of the current condition
2. History of prior hand surgery
3. Status of the skin of the palm
5. General health status
7. Presence of complicating factors, such as the presence of bony deformity from joint disease or the like.
Surgery for Dupuytren’s contracture is typically considered a reasonable option only when the finger contracture causes a distortion of at least 30º of finger flexion.
Dupuytren surgical and drug options include:
1. Fasciotomy – surgery in which only the offending cords are cut, without removal of any diseased fascia. Needle aponeurotomy is a less invasive form of fasciotomy; it is a blind procedure in which the surgeon attempts to weaken the cords by tearing, puncturing and otherwise dividing the cords via a needle tip inserted through the skin, instead of a scalpel.
2. Fasciectomy – surgery in which diseased, contracted and thickened tissue is cut and removed from the palm and fingers through incisions in the palm and affected finger(s).
a. Partial fasciectomy – in which only mature and clearly deformed tissue is removed; it is often used in moderate to severe cases where 1 or 2 fingers are involved.
b. Complete or radical fasciectomy – in which all bands of thickened and abnormal tissue that reduces joint movement and hand function are completely removed, sometimes requiring skin grafting if insufficient healthy skin is available due to the amount of tissue removed or when prior Dupuytren surgery has reduced the amount of available healthy tissue.
3. Amputation of the affected finger(s) – surgery performed when hand pain and deformity is present to such a degree of impairment because past multiple Dupuytren surgeries have created so much scar tissue and removed so much tissue that no further surgery is possible.
4. Xiaflex for Dupuytren treatment – used when cords, not nodules, are present. Enables treatment to be done sooner when the MCP (metacarpophalangeal) or the PIP (proximal interphalangeal) joints are at 20º of finger flexion. Thus, Xiaflex can be used 10º sooner into the finger flexion progression than surgery.
Xiaflex treatment of a Dupuytren cord requires a doctor to make multiple injections of Xiaflex into the palm of the hand into the Dupuytren’s cord at various points. Twenty four hours later the patient returns to the office for the doctor to forcefully break the cords that were enzymatically weakened the day before, by taking the fingers into extension
Xiaflex is injected into only one cord per treatment series, using a small quantity of Xiaflex solution that is divided between three injection sites selected by the treating doctor. If a first Xiaflex injection does not achieve the desired results then the procedure is repeated again one month later. A patient can only receive three series of Xiaflex treatments per Dupuytren cord.
In 70% of Xiaflex treatments the patient must return one month later for a second series of Xiaflex injections into the same finger cord to complete the procedure because of sufficient cord disruption did not occur at the first procedure.
Reasons to avoid Xiaflex as a Dupuytren treatment
Incorrectly performed injections of Xiaflex may cause damage of the local tendons, blood vessels, joints and nerves. A mistake of injecting the Xiaflex by even 1mm can have terrible consequences in which permanent loss of finger movement or permanent injury to blood vessels and nerves can occur. That is why the FDA requires that Xiaflex injections should be performed by a doctor who has been specially trained to make these collagenase injections. However, this training consists of an online video that contains 20 minutes of training.
Each patient undergoing these injections must know that the recurrence rate of Dupuytren contracture after Xiaflex treatment is for 19.3% recurrence after two years. This is a lower recurrence rate compared to fasciectomy (34% recurrence) and needle aponeurotomy (85%,recurrence), but still recurrence of the problem. At this time no one knows if this recurrence rate increases with each subsequent series of injections, or if the degree of Dupuytren thickening worsens each time recurrence occurs.. Also, at this time, no one knows if the long term effects of repeated injections of Xiaflex on healthy tendons, ligaments, arteries, veins and blood vessels.
To avoid the possible side effects and adverse reactions of Xiaflex for Dupuytren treatment, it is worthwhile to consider first using more conservative Alternative Medicine methods before more radical methods like surgery or Xiaflex injections .