Enzyme (collagenase) injection to treat Dupuytren's contracture

This is the most recent addition to Dupuytren's therapies. Dupuytren's contracture is characterized by excessive collagen deposition which appears as cords causing an extension deficit, i.e. a bent finger. These finger cords causing metacarpophalangeal and/or proximal interphalangeal joint contracture (contracture at the base or middle joint of a finger) are targeted by a non-operative method injecting an enzyme (Clostridial collagenase, brand names: Xiaflex or, in Europe, Xiapex). This enzyme weakens the cord which then, in a next step, can be pulled and mechanically broken. Bent fingers thus become straight and functional again. One of the early studies proposes enzyme injection as a safe and effective method of treating as an alternative to surgical fasciectomy: "In fact some of our patients who have had fasciectomy on one hand but have been treated in our trials for the contralateral hand have commented in glowing terms that the less invasive injection treatment was far superior to their surgical experience. … To date our recurrence rates are low in the clinical trials described and are < 5% at 4 years from our first open-label clinical trial using 10,000 U of collagenase. There have been no disease extensions to other fingers." Link: abstract_enzyme_article, full text see literature.

There is already good and longer term evidence of the therapy's effectiveness. Phase 3 of clinical trials has been completed and Xiaflex has been approved by the US FDA in February 2010 for treating Dupuytren's contracture and by the EU in February 2011.

Patients' experience

If you are interested in experience of patients with collagenase injections please visit our web page "Personal experiences" and in our forum e.g. the threads "Auxilium AA4500 Phase 3 Clinical Trial Experience" and "Just had Xiaflex ". You can find many more reports by seraching our forum for Xiaflex. For a while collagenase had been provided under the brand name AA4500. The current brand name used by its manufacturer Auxilium is Xiaflex and, in Europe, Xiapex.

 

Video of collagenase treatment

Below are several YouToube links from a patient, Samantha Hoffman, who documented various phases prior, during, and after her collagenase treatment. It does not show much of the procedure itself but shows results and related feelings.

prior to treatment
  

after the injection

before breaking the cords

after the manipulation

the day after

four days after

after_2nd_injection

10_months_later

A more advertizing video, also showing Drs. Maria Badalamente and Lawrence Hurst, the inventors of the collagenase treatment, is on

http://video.aol.de/video-detail/frozen-finger-fix/446064678

 

Collagenase and NA - what is the difference?

The treatment of Dupuytren's contracture with collagenase injection is similar to needle aponeurotomy (also called NA or percutaneous needle fasciotomy, abbreviated as PNF). Both treatments address already bent fingers and both start with weakening the contracting cord. NA does this by stitching a thin needle repeatedly into the cord and thus weaking it mechanically. Collagenase does this weakening by injecting a small amount of collagenase, which locally weakens/dissolves a part of the cord. After this weaking step both therapies stretch the finger mechanically until the weakened cord actually snaps and the finger becomes straight again. The difference between collagenase and NA is essentially the way by which the cord is weakened before it is broken mechanically. Injection of collagenase is therefore sometimes also described as enzyme fasciotomy. A difference between both methods may be the time period until the disease returns. For the time being long term studies with good statistics comparing both methods are required to judge this potential difference.

See also the round table discussion on "New treatments for Dupuytren contracture"

led by D. Kay Kirkpatrick, MD discussion. A tabular comparison for patients is provided by Herbert Gates Xiaflex _NA. An indirect comparison between collagenase and NA is included in the last paragraph of van Rijssen et al. "Five-Year Results of a Randomized Clinical Trial on Treatment in Dupuytren’s Disease: Percutaneous Needle Fasciotomy versus Limited Fasciectomy" Plastic Reconstr Surg 129 (2012) p 469–477. abstract The authors suspect a higher recurrence rate after collagenase than after NA or fasciectomy but that's no final proof, just an indication at best. Detailed studies are still required and have been started in several countries.

In Februrary 2012 the German Institute for Quality and Efficiency in Health Care (IQWiG) reviewed collagenase injection and stated that so far no advantage of collagenase has been proven relative to PNF (NA) or classical hand surgery summary and MNT. Consequently the current vendor Pfizer withdrew Xiaflex from the German market in May 2012. Pfizer will terminate marketing of Xiapex in all of Europe in April 2013 but probably another marketing company will step in PhilBJ.

A tabular comparison of both techniques is provided on hand_center.

 

Collagenase for Ledderhose disease and Peyronie's disease

Collagenase is not yet tested for treatment of Ledderhose disease, maybe due to smaller market opportunities or maybe due to dominating nodules rather than cords. A thread in our forum reports on an off-label use of Xiaflex for Ledderhose "Xiaflex". - Collagenase has been proposed as therapy for Peyronie's disease, Phase III trials have been completed and Auxilium has applied for approval by the FDA link.

 

Page last modified: 10/25/2013

 


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