Objective: To compare dosing, duration of action, and patient-reported outcomes across inco-, abo- and ona- BoNT (botulinum toxin) in cervical dystonia (CD), hemifacial spasm (HFS), blepharospasm and spasticity in a real-world setting.

Background: The three licensed botulinum toxin type A (BoNT-A) formulations – inco, abo and ona – differ in formulation, unit standardisation and labelled potency. Large-scale, real-world, head-to-head comparisons across multiple indications incorporating patient-reported outcomes (PROMs) remain scarce.

Method: Retrospective analysis of a prospectively maintained database comprising 23,078 injection cycles between 29/1/2018 and 8/4/2025. Data was collected using a LIVEchart and retained in an electronic database.

Outcome measures included units given, time to onset, time since working well, weeks of good effect (WGE), and a 7-point PROM scale ranging from major benefit to major deterioration. Statistical analysis of WGE, PROMs and dose ratios has been performed.

Results: WGE was comparable across formulations: inco 10.71 weeks (10.55–10.97), abo 11.29 weeks (10.70–11.89), ona 11.32 weeks (10.5–12.14). There were no statistically significant pairwise differences across all or any indications (all p>0.05).

Mean doses per cycle across all indications were: inco 164.5 U, abo 525.2 U, ona 231.2 U. The real-world abo:inco dose ratio was 3.19:1 across all indications, ranging from 3.22:1 (HFS) to 4.72:1 (spasticity). The real-world ona:inco dose ratio was 1.40:1 across all indications, ranging from 1.09:1 (CD/HFS) to 1.26:1 (spasticity).

PROMs were consistently high across all formulations: any benefit was reported in 95.6% (inco), 95.9% (abo) and 96.7% (ona) of cycles; major or moderate benefit was recorded in 87.9%, 89.0% and 91.1% respectively. These findings were consistent across individual indications.

Conclusion: This large real-world dataset demonstrates equivalent efficacy across the three BoNT-A formulations as measured by patient-reported outcomes and duration of action.

Real-world dose ratios support, but do not uniformly replicate, conventional conversion ratios, particularly for spasticity where the abo:inco ratio was 1:4.7.

These findings support a clinician-led, patient-centred approach to toxin selection based on indication, dosing practicality and individual response, rather than assumed formulation non-equivalence.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/are-all-toxins-created-equal-real-world-analysis-of-abo-inco-and-ona-bont-a-from-prospective-livechart-over-7-years/