Collagenase clostridium histolyticum injections (hereafter referred to as “collagenase”)

A commercially available form of collagenase, called “Xiaflex”, was approved by Health Canada in 2012 for the treatment of adult patients with Dupuytren’s contracture where a palpable (readily evident by physical examination) cord can be identified.

What is collagenase?

Collagenase is a purified and commercially available form of an enzyme originally sourced from a type of bacteria called Clostridium histolyticum. This enzyme digests proteins called collagens within a Dupuytren’s contracture cord. As collagens lend contractile strength to the cord, collagenase (Xiaflex) injections can cause the contracture cord to weaken, stretch and break. Once the contracture cord is broken, patients are able to extend their fingers and/or palms more normally.

How is it administered?

The first visit will include injection of the medication into the cord. There is a follow-up visit 24 to 72 hours after the first injection, where the physician may try to extend the cord if it is still intact. A splint will be provided to maintain finger extension. A follow-up visit may be required after 30 days, where an additional injection may be given, with extension if the contracted cord persists.
Injections may be administered up to three times per cord at approximately four-week intervals if contracture persists.

Effectiveness of the treatment

Two randomized controlled trials have demonstrated that collagenase was effective for the treatment of Dupuytren’s contracture (after 30 days), with an acceptable safety profile, provided the treatment is administered by a health care professional with experience performing hand surgery and treating Dupuytren’s contracture.
Collagenase may be more effective for treating contractures in the palm and across the metacarpal phalangeal joint (MCP, the joint between a finger and the palm) than contractures of the proximal (PIP) or distal (DIP) interphalangeal joints (the joints in the fingers).
There is currently insufficient data on the long-term recurrence of DD and long-term adverse effects following injections. Disease recurrence rates after collagenase treatments are comparable to other minimally invasive treatment such as Needle aponeurotomy (NA), but are greater than those after fasciectomy.

Patient input information

Many patients consider collagenase to be a minimally invasive procedure and associated with a quick recovery. Several visits to the doctor are required for collagenase treatment, and only one finger is treated at a time. Collagenase treatment is limited to three injections per cord. By comparison, percutaneous fasciotomy and surgery can treat several fingers/joints in a single session.
The cost of the medication is assumed by the patient when the procedure takes place outside of a hospital facility.

Adverse effects and risks

Potentially adverse side effects include pain, swelling, swollen lymph nodes, allergic reactions, skin injury, hematoma (blood clot) formation, and tendon injury (tendon rupture in the worst cases).

Many of the adverse effects from collagenase injection are associated with inflammatory and immunological mechanisms.

Who should perform the injection?

Collagenase should be administered by a health care professional with experience performing hand surgery and treating Dupuytren’s contracture.