Practical considerations in the use of apomorphine injectable

Abstract

This manuscript provides a practical summary of guidelines for institution of apomorphine subcutaneous injectable therapy, including patient education, pre-treatment issues, dosage titration and side-effect care. The timing of each injection is crucial if an impending "off" period is to be averted. Patients need to be aware of symptoms of an approaching "off" period, and the injection should be administered at the onset or ideally, in anticipation of an "off" episode. Patients being considered for apomorphine treatment should undergo pre-treatment assessment and optimization of ongoing oral therapy prior to initiation. Education and counseling regarding the benefits of apomorphine can often alleviate this. In addition, and where available, it is beneficial to provide the patient and caregiver(s) with additional written information and videos provided by the manufacturer demonstrating the operation of the pump or pen injection systems. Once a patient has been assessed as being a suitable candidate for apomorphine, an apomorphine challenge is performed to determine responsiveness and guide appropriate dosing, establish an individual dose, and to observe for side effects, such as nausea, postural hypotension, excessive somnolence, or dyskinesia. Three days prior to the challenge, domperidone 20 mg tid or trimethobenzamide (Tigan) 300 mg tid is recommended. Potential side effects include yawning, dopaminergic side effects, such as dyskinesias, nausea, orthostatic hypotension, confusion, hallucinations, somnolence and rarely, hypersexuality or other behavioral disturbances, and skin nodule formation.

Dopamine Receptor Agonists for the Treatment of Early or Advanced Parkinsonʼs Disease

“…Changing the site of injection every day and careful local hygiene reduce the incidence and severity of such a reaction. [219,220] Application-site reactions were cited as the most common adverse reaction to transdermal rotigotine in RCTs. [85,87,115,116] The majority of these events were rated as mild to moderate and appeared to be dose related.…”

Role of Apomorphine in the Treatment of Parkinson’s Disease

“…Trials have also been conducted using the anti-emetic trimethobenzamide, which works directly on the chemoreceptor trigger zone in the periphery. This drug is largely an anti-histamine with low affinities for dopamine receptors thus producing antiemetic effects without antidopaminergic properties [26]. The majority of the therapeutic trials conducted in the late 1980s and 1990s consistently demonstrated a reduction in the number of daily 'off' periods [4,25,[27][28][29][30][31].…”

Treatment Strategies in Early and Advanced Parkinson Disease

“…45 A Coombs test should be performed beforehand to exclude circulating antibodies against erythrocytes. One of the main side effects is skin reactions, located at the injection side, resulting in the formation of small nodules.…”