The role of subcutaneous infusion of apomorphine in Parkinson’s disease

Abstract

Continuous subcutaneous apomorphine infusion therapy (CSAI) has proved to be effective in advanced Parkinson’s Disease patients with motor fluctuations not controlled by oral or transdermal medication. In this clinical setting it competes directly with intrajejunal levodopa and deep brain stimulation (DBS), however randomised controlled comparative studies are lacking. The advantages of CSAI is that it is the least invasive of these three therapeutic options, is reversible, practical to use and has shown significant efficacy for the management of both peak-effect dyskinesias and off-period nonmotor-symptoms. Contraindications to the use of CSAI are severe dementia or neuropsychiatric symptoms and severe biphasic dyskinesias, however unlike DBS, advanced age is not a contraindication. This review summarises the evidence regarding efficacy, safety and tolerability of CSAI, provides guidance on the selection of suitable patients and gives practical instructions on how to initiate CSAI and manage possible adverse events.

Keywords::

• apomorphine
• dyskinesias
• levodopa-induced fluctuations
• Parkinson’s disease
• subcutaneous infusion

Financial & competing interests disclosure

Karoline Wenzel has received honoraria from Abbvie Pharmaceuticals and Brittania Pharmaceuticals for participation in advisory boards and giving lectures. There are no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. Carl-Nikolaus Homann has no financial or competing interests. Giovanni Fabbrini has received honoraria from Lundbeck for giving lectures. Carlo Colosimo has received honoraria from UCB, Merz and Ipsen for participation in advisory boards and giving lectures. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Continuous subcutaneous apomorphine infusion therapy (CSAI) is an effective treatment option for advanced Parkinson’s disease patients with motor fluctuations that cannot be controlled by conventional oral or transdermal medication.

• CSAI may also improve dyskinesias and nonmotor symptoms.

• CSAI treatment should be initiated in an experienced center or by a specialist neurologist with experience in treating patients with advanced Parkinson’s disease.

• By using CSAI, complex conventional oral or transdermal treatment regimens can be simplified thereby improving patient adherence.

• The treatment can be initiated during in-patient hospitalization or in a day hospital setting.

• Patient’s and caregiver’s education and support in handling the device have to be provided, ideally by a specialist nurse.

• Of the three device-aided methods, CSAI, levodopa/carbidopa intrajejunal gel infusion and deep brain stimulation, CSAI is the least invasive. Furthermore, it is completely reversible and requires less additional logistic amenities including neurosurgical or gastroenterological support.

• No randomized, controlled comparative studies with levodopa/carbidopa intrajejunal gel or deep brain stimulation are available; therefore, the decision on which therapy is best for the individual patient should be made based on the available evidence for each method, physician experience and patient preference.

• Further randomized controlled studies to evaluate efficacy and safety of CSAI are warranted.