Do Xiaflex injections really have a low Dupuytren recurrence rate?
What does “recurrence rate for Dupuytren contracture” mean?
Dupuytren contracture is famous for the fact that in about half of the cases the problem returns about five years after hand surgery. For some people the reappearance is as soon as one year after an invasive operation to remove the cords, nodules and contracted hand tissue. Many people are disheartened to learn that surgery and Xiaflex injections are not a final answer to their hand problem because of Dupuytren recurrence.
Consider a brief delay of Xiaflex injections to see if natural remedies might help
The Dupuytren Contracture Institute is not against Xiaflex injections or surgery for Dupuytren’s contracture. Since 2002 our position has always been to recommend surgical intervention in those cases that have not responded to an aggressively applied round of conservative Alternative Medicine therapy. If a brief therapeutic trial of natural Alternative Medicine treatment has limited results, we then advise to have an evaluation from two doctors who specialize in Dupuytren’s contracture for possible surgical or Xiaflex intervention.
However, there are those who approach the management of their Dupuytren contracture in the reverse order: They first have hand surgery for their Dupuytren’s problem and only after the problem recurs do they consider conservative treatment.
People from around the world report they rushed into having a hand operation, not knowing of the possible side effects and recurrence issues that develop after invading the area of Dupuytren’s disease. It is DCI‘s opinion that it is safe and reasonable to attempt to improve the body’s ability to heal and repair the problem of Dupuytrens contracture by aggressively using several conservative Alternative Medicine treatment measures for a short time. We strongly suggest that anyone with Dupuytren contracture works with what is known and what is available – even if it is not perfect – before submitting to potentially risky surgery. If DCI’s conservative concepts do not improve or eliminate the hand lump, Dupuytren’s surgery can always be done later.
How low is the Dupuytren recurrence rate after Xiaflex treatment?
Auxilium Pharmaceutical, manufacturer of Xiaflex collagenase injections, boasts that in a two-year study Xiaflex had a recurrence rate of 19.3 percent, a considerably lower rate of return than those who used surgical procedures to treat their hand problem.
The answer to the question “Is the Xiaflex recurrence rate for Dupuytren low?” is a qualified yes and no.
Yes, Xiaflex or collagenase treatment results in a considerably lower Dupuytren recurrence rate than hand surgery. However, this does not necessarily mean that the rate of recurrence is actually low; it only means the problem will come back slower than what happens after invasive hand surgery. The reality is that hand surgery has a tremendously high recurrence rate, so a non-surgical therapy option by comparison will look favorable.
Every child learns that pointing to someone who has done something worse than you does not diminish his crime. When you told your mother that the child next door stole 25 cents from his mother, you were trying to make yourself look pretty good for stealing only 10 cents from her purse. Your mother was not swayed by the faulty logic of a scared child. In the final analysis, even though the numbers were different, both children did something wrong.
And along a similar line of thought, 19.3% recurrence is still a high rate for Dupuytren contracture to come back after being subjected to an invasive medical procedure that carries risks, even though there are other treatment methods that have a considerably higher rate of recurrence.
Most surgeons will admit that any type of physical invasion into the palm (like with surgery or injections) seems to accelerate the progression of Dupuytren’s disease. Patients note that their previously slow progressing hand contracture not only recurred after surgery but worsened at a faster rate.
Perhaps a better question to ask is, “Would you want to undergo an invasive medical procedure like a Xiaflex injection series, knowing that 20 out of 100 people will have to do it again in two years?” The answer should take into account that more injections might not be as simple and uneventful as receiving the first Xiaflex injection.
Xiaflex has a short history of treatment of Dupuytren contracture
Since Xiaflex was given FDA approval for Dupuytren contracture treatment in early 2010, not enough time has lapsed and not enough patients have used this procedure for the FDA to know sure what will happen to those 19.3% of patients who have recurrence within two years after receiving a second – or third or fourth – injection series.
For example, recent research information released about Xiaflex at the three year follow-up shows that 34.8% of joints with initial clinical success experienced recurrence, considerably higher than the 19.3% recurrence rate reported at the two year mark. It is reasonable to speculate that the Xiaflex recurrence rate will continue to increase at the four and five year follow up marks, bringing Xiaflex recurrence much closer to the frequency of hand surgery.
There are two valid issues to consider about repeated injections with a new drug like Xiaflex:
- When Xiaflex is injected to dissolve the collage cord of Dupuytren’s contracture it carries the risk of physician error and unintended drug consequences, such as injection into a nerve or artery, accidental leakage causing destruction of tendons or muscles, or drug side effects.
- No one knows the long term consequences of multiple Xiaflex injections over time into the same area. After all, 70% of people who receive their first Xiaflex injections find that the Dupuytren cord does not break as it should; they must return one month later for another series of injections; if this does not work, they again must return in one month later. The manufacturer does not recommend that anyone receives more than three series of Xiaflex injections if it did not dissolve the cord by that time. In this way the manufacturer of Xiaflex is admitting there is a reasonable limit to how often and how much this drug can be used for the same cord.
Return of Dupuytren after hand surgery
There are two common types of Dupuytren hand surgery. The first is palmar fasciectomy (cutting the palm open to remove the deep connective tissue of the palm and collagen cords) with a 35% recurrence rate after two years. The other is needle aponeurotomy or palmar fasciotomy (inserting a needle into the palm and blindly slashing at the Dupuytren cords wit h the tip of that needle) with an 85% recurrence rate after two years.
By comparison, yes, the Xiaflex return rate of 19.3% recurrence at two years is lower than aggressive surgery. However, this recurrence rate for Xiaflex is said to be low only because the recurrence rates for the other types of surgery are so terribly high by comparison.
At the Dupuytren Contracture Institute we take the position that it is better to avoid the risk the hand problem will return after undergoing any kind of hand surgery by first attempting Alternative Medicine natural Dupuytren treatment.