Published recently in European Neurological Review, the peer-reviewed journal from touchNEUROLOGY, Claudia Trenkwalder et al, reports on a symposium, chaired by Claudia Trenkwalder (Germany), covering the most practical and effective approaches to enhance the outcomes of Parkinson's disease (PD) patients across all disease stages. Despite taking multiple oral medications to control the symptoms of PD, many patients experience significant OFF time each day, with troublesome motor fluctuations and dyskinesias, that impact their quality of life. Stuart Isaacson (US) discussed how to optimise ON time in PD patients once fluctuations start. He highlighted the importance of considering non-oral routes of administration of PD medication to avoid gastrointestinal issues that are common in PD and can affect medication absorption.
He reviewed the results of the AM-IMPAKT (Apokyn for Motor IMProvement of morning AKinesia Trial) study, which demonstrated that delayed ON and dose failure due to poor absorption of oral levodopa can be rapidly and reliably overcome with subcutaneous apomorphine injection. Georg Ebersbach (Germany) considered the later stages of disease and the management of patients who require continuous dopaminergic stimulation. Using case study illustrations, he advised how to select the correct form of advanced therapy for patients, highlighting the importance of continuous review and monitoring to optimise their outcomes.
The full peer-reviewed, open-access article is available here: http://www.touchneurology.com/articles/enhancing-patient-outcomes-current-therapies-practical-approaches-treatment-optimisation
Disclosure: Claudia Trenkwalder has received personal fees for advisory boards from Mundipharma, UCB, Vifor Pharma, Britannia Pharmaceuticals, Novartis; payments for lectures from UCB, Astra Zeneca, Desitin, Mundipharma, Abbvie; royalties from Schattauer Verlag. Stuart H Isaacson has received honoraria for CME activities, research grants and/or consultant and promotional speaker fees from AbbVie, Acadia, Adamas, Addex, Allergan, Allon, AstraZeneca, Biotie, Britannia, Chelsea, Civitas, Eisai, GE, GSK, Impax, Ipsen, Kyowa, Lilly, Merck Schering-Plough, Medtronics, Merz, Michael J Fox Foundation, Novartis, Neurocrine, National Institutes of Health (NIH), Novartis, Orion, Parkinson Study Group, Phytopharm, Purdue, Roche, Santhera, Serono, Shire, Teva, UCB and US World Meds. Georg Ebersbach has received consultancies from AOK Nordost; honoraria for advisory boards from UCB Pharma, AbbVie Pharma, Grünenthal Pharma; speaker's honoraria from AbbVie Pharma, Britannia Pharma, Desitin Pharma, Grünenthal Pharma, Licher GmbH, Mundipharma, TEVA Pharma, UCB Pharma, Zambon Pharma; royalties from Kohlhammer Verlag. This article reports the proceedings of a sponsored satellite symposium held at the 20th International Congress of Parkinson's Disease and Movement Disorders, Berlin, Germany and, as such, has not been subject to this journal's usual peer-review process. A member of the editorial board reviewed the report before publication.
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Parkinson's disease is a disorder of the brain. A small part of the brain, called the substantia nigra, is mainly affected. This area of the brain sends messages down nerves to help control the muscles of your body. Messages are passed between brain cells, nerves and muscles by chemicals called neurotransmitters. Dopamine is the main neurotransmitter made by the brain cells in the substantia nigra.
If you have Parkinson's disease, some of the cells in the substantia nigra region of your brain will have become damaged. Over time, this happens to more and more cells. As cells are damaged, the amount of dopamine that is produced is reduced. A combination of the reduction of cells and a low level of dopamine in the cells in this part of the brain causes nerve messages to your muscles to become slowed and abnormal. This produces the typical symptoms of Parkinson's disease: tremor, stiffness and slow movement.
Apomorphine is a dopamine-receptor agonist. It is a medicine that acts on the same receptors (tiny areas in the brain) as dopamine. In effect, it acts like a substitute for dopamine. Some people who have Parkinson's disease in its later stages develop a condition where one minute they can move freely and the next minute they find it difficult. This is called an 'on-off effect. Apomorphine can help to reverse the 'off' episodes, but its effect only lasts for about an hour. As it needs to be given by an injection under the skin, frequent injections are needed. Because of this, it is sometimes given as a continuous infusion, using tubing with a needle at the end (called a cannula) that is inserted under the skin.
Your treatment with apomorphine will be supervised by a doctor who specialises in treating people with Parkinson's disease. The first few doses will be given while you are being looked after in hospital.
Before using apomorphine
Some medicines are not suitable for people with certain conditions, and sometimes a medicine may only be used if extra care is taken.
For these reasons, before you start using apomorphine it is important that your doctor knows:
- If during your 'on' times, you have times when you are unable to move (dystonias) or if you have involuntary movements (dyskinesias).
- If you have any problems with your breathing.
- If you have a heart condition or a blood vessel disorder.
- If you feel dizzy when you stand up, due to low blood pressure.
- If you have any problems with the way your kidneys work, or the way your liver works.
- If you have any mental health problems, such as psychosis or dementia.
- If you are pregnant or breast-feeding.
- If you are taking any other medicines. This includes any medicines you are taking which are available to buy without a prescription, such as herbal and complementary medicines.
- If you have ever had an allergic reaction to a medicine.
How to use apomorphine
- Always use apomorphine exactly as your doctor tells you to. It is only available as an injection.
- Treatment with apomorphine will be started while you are in hospital or in a specialist clinic. This is because you will need to be supervised closely at first. Your doctor or nurse will administer apomorphine for you to begin with. You will then be taught how to inject apomorphine yourself. It is injected under your skin on your lower abdomen or on the outer part of a thigh, as soon as you begin to feel an 'off' episode.
- Your doctor will tell you how much to use for each injection, and how often to give the injections. It is usual to use 3-30 mg daily, divided into several doses. The maximum dose per injection will be 10 mg, and the maximum dose in any 24-hour period will be 100 mg.
- Before you use an injection, check to make sure that the liquid is clear and doesn't contain any floating 'bits'. Do not use the injection if the solution is cloudy, contains particles or has turned a green colour.
Getting the most from your treatment
- Before you start this treatment, read the manufacturer's printed information leaflet from inside the pack. The manufacturer's leaflet will give you more information about apomorphine and a full list of the side-effects which you may experience from using it.
- Apomorphine can make you feel sick. Because of this, before you are given your first injection of apomorphine, you will be given at least two days' treatment with an anti-sickness medicine (usually domperidone). You should continue to take this during the first few weeks of your treatment with apomorphine. It may later be reduced or slowly withdrawn.
- Keep your regular appointments with your doctor so your progress can be monitored. You will need to have regular blood tests and other tests to check that you remain as healthy as possible. Also, apomorphine may cause your blood pressure to fall (particularly in the early days of your treatment) and your doctor will want to check for this.
- Occasionally, people using apomorphine have fallen asleep suddenly with little or no warning of feeling tired beforehand. Until you know how you react, take extra care if you drive or operate machinery. If you do find yourself falling asleep suddenly, you should see your doctor as soon as possible and avoid driving or using tools and machines in the meantime.
- Treatment with medicines like apomorphine can sometimes cause problems with impulsive types of behaviour. If you notice any changes in your behaviour, such as an increased desire to gamble, binge eat, spend excessively, or an increased sex drive, you must let your doctor know as soon as possible.
- Each time you collect a new prescription check to make sure you have been given the same injections as you have had before. APO-go® Pen injections are for injections which are given intermittently throughout the day, whereas APO-go® PFS injections are for when apomorphine is being given as a continuous infusion by a syringe driver.
- Stopping any treatment for Parkinson's disease suddenly can cause problems. Do not stop using this medicine without speaking to your doctor first.
- If you are having an operation or any other medical treatment, tell the person carrying out the treatment that you are using apomorphine.
Can apomorphine cause problems?
Along with their useful effects, most medicines can cause unwanted side-effects although not everyone experiences them. The table below contains some of the most common ones associated with apomorphine. You will find a full list in the manufacturer's information leaflet supplied with your medicine. The unwanted effects often improve as your body adjusts to the new medicine, but speak with your doctor or pharmacist if any of the following continue or become troublesome.
| Common apomorphine side-effects | What can I do if I experience this? |
| Feeling or being sick | Make sure that you take the anti-sickness medicine your doctor has prescribed for you. Speak with your doctor if this continues |
| Small lumps, tenderness and redness at the injection site | Use a different site of injection each time you use apomorphine. Ask your doctor or nurse for further advice |
| Feeling sleepy | This may occur at the start of your treatment but usually resolves after a few weeks. If you are affected, do not drive or use tools or machines. Speak with your doctor if this continues to be a problem |
| Feeling dizzy or light-headed | Stand up slowly and get your balance before you start to walk |
| Yawning, confusion, imagining things that are not real | If any of these become troublesome, speak with your doctor |
Important: speak with your doctor as soon as possible if you notice any of the following:
- Changes in your behaviour, such as a desire to gamble or an increased sex drive.
- Falling asleep suddenly. (It is important that you do not drive if this affects you.)
How to store apomorphine
- Keep all medicines out of the reach and sight of children.
- Store in a cool, dry place, away from direct heat and light.
Important information about all medicines
If you buy any medicines check with a pharmacist that they are safe to take with your other medicines.
Never take more than the prescribed dose. If you suspect that you or someone else might have taken an overdose of this medicine, go to the accident and emergency department of your local hospital. Take the container with you, even if it is empty.
This medicine is for you. Never give it to other people even if their condition appears to be the same as yours.
Do not keep out-of-date or unwanted medicines. Take them to your local pharmacy which will dispose of them for you.
If you have any questions about this medicine ask your pharmacist.
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