About to start Mestinon, does it shorten the life span of Botox?

Question

Hi! I usually get Botox a few times a year but am about to start on Mestinon for a health condition. Is it contraindicated for Botox and/or does it shorten the life span of the Botox? Thanks in advance!

Anna Chacon, MD, FAAD · Answer

This is a very reasonable question, and I’m glad you’re asking before starting the medication.

Mestinon (pyridostigmine) is not generally considered an absolute contraindication to cosmetic Botox (botulinum toxin) injections, but the situation is a little more nuanced because the two medications affect opposite sides of the neuromuscular junction.

Botox works by blocking the release of acetylcholine from nerve endings, which temporarily relaxes the muscle.
Mestinon works by inhibiting the breakdown of acetylcholine, increasing the amount available at the neuromuscular junction.

Because of that, some people wonder whether Mestinon will “cancel out” Botox.

The reassuring news

For most patients taking Mestinon for conditions such as myasthenia gravis, dysautonomia, or other neuromuscular disorders, there is no strong evidence that it significantly shortens the lifespan of cosmetic Botox. Many patients on pyridostigmine still receive botulinum toxin treatments successfully.

The more important consideration is why you are taking Mestinon

If you are starting Mestinon for myasthenia gravis or another neuromuscular transmission disorder, that is the key issue. In those conditions, botulinum toxin can sometimes cause:

more pronounced muscle weakness than expected,
drooping of nearby muscles,
or systemic weakness in rare cases, particularly if large doses are used.

For that reason, the prescribing physician and the injector should both be aware of the underlying diagnosis.

Could it make Botox wear off faster?

In theory, increasing acetylcholine availability could slightly reduce the apparent effect of Botox, but in clinical practice this effect is usually minimal or not noticeable. The duration of Botox is influenced much more by:

the dose used,
the muscles treated,
your individual metabolism and muscle strength,
and how frequently you’ve had treatments.

So I would not expect Mestinon to suddenly make your Botox last only a few weeks.

What I would watch for

If you proceed with Botox after starting Mestinon, I would be more attentive to:

excessive eyelid drooping (ptosis),
difficulty smiling or chewing,
unusual facial weakness,
or weakness that feels different from your underlying condition.

These are uncommon, but they are more relevant than concerns about the Botox simply wearing off too quickly.

My overall take
Mestinon is not generally a reason to permanently stop cosmetic Botox.
It does not reliably shorten the lifespan of Botox in a clinically significant way for most patients.
The underlying condition being treated with Mestinon is the more important factor, especially if it involves myasthenia gravis or another neuromuscular disorder.

If I were counseling a patient in your situation, I would usually recommend starting Mestinon first, seeing how you tolerate it, and making sure the Botox injector knows the exact diagnosis and dosage of pyridostigmine before your next treatment session. That allows the injector to use conservative dosing and careful muscle selection, which is generally the safest approach.

Kenneth D. Steinsapir, MD · Answer

Myasthenia gravis is an autoimmune disease that attacks the connection between nerves and muscles. It causes muscle weakness. This is precisely the location that botulinum toxin works on to weaken muscle. For this reason, botulinum toxin (BOTOX) is contraindicated in patients with Myasthenia gravis. Don't have cosmetic botulinum treatment if you have Myasthenia gravis. Simple.

About to start Mestinon, does it shorten the life span of Botox?

Answers (2)

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