Establishing apomorphine treatment in Thailand: understanding the challenges and opportunities of Parkinson’s disease management in developing countries

ABSTRACT

Introduction

The increasing global burden of Parkinson’s disease (PD) poses a particular challenge for developing countries, such as Thailand, when delivering care to a geographically diverse populace with limited resources, often compounded by a lack of expertise in the use of certain PD medications, such as device-aided therapies (DAT).

Areas covered

A panel of local, regional, and international PD experts convened to review the unmet needs of PD in Thailand and share insights into effective delivery of DAT, focusing on experience with apomorphine infusion. Despite its proven efficacy and safety, implementation of apomorphine infusion as a new option was not straightforward. This has prompted a range of health-care professional and patient-focused initiatives, led by the Chulalongkorn Center of Excellence for Parkinson’s Disease and Related Disorders in Bangkok, to help establish a more coordinated approach to PD management throughout the country and ensure patients have access to suitable treatments.

Expert opinion

Overcoming the challenges of education, proficiency, resource capacity and standard of care for PD patients in developing countries requires a coordinated effort both nationally and beyond. The best practices identified in Thailand following the introduction of apomorphine infusion might be helpful for other countries when implementing similar programs.

KEYWORDS:

• Parkinson’s disease
• apomorphine infusion
• motor complications
• Thailand
• developing countries
• device-aided therapy
• Parkinson’s disease nurse specialists
• treatment accessibility
• specialist centers

Article highlights

• The increasing global burden of Parkinson’s disease (PD) represents a significant public health challenge, particularly for developing countries.

• Thailand is an example of a developing country with a diverse population distribution and limited health-care resources to manage this expanding PD population.

• With the projected increase in the number of PD cases, access to device-aided therapies (DAT) will be in greater demand; however, DAT are not available at all centers in Thailand and experience with them is often limited.

• A panel of PD experts convened to review the unmet needs of PD in Thailand and share insights into effective delivery of DAT, focusing on experience with the introduction of apomorphine infusion in Thailand since 2014.

• Led by the Chulalongkorn Centre of Excellence for Parkinson’s Disease and Related Disorders in Bangkok, a range of initiatives has now been established both for health-care professionals and patients to improve PD education and to gain experience with apomorphine infusion that can be used as a model for other countries.

• Adoption of apomorphine infusion in Thailand requires a pro-active approach to peer-to-peer education and patient engagement to ensure confident prescribing and persistence with treatment, however, access to therapy with an extremely diverse population will remain an ongoing challenge.

• ‘Team’ approach to PD care is the ideal scenario for implementing apomorphine infusion in a new environment but the feasibility of this will be dictated by local resources, so capacity building is something that needs to be addressed.

• Increased evidence regarding the efficacy, safety, and cost-effectiveness of apomorphine infusion in Thailand, and in different geographical regions, is of value to help demonstrate for which patients it is suitable and how treatment can be optimized in actual clinical practice, as opposed to a clinical trial setting.

Acknowledgments

Editorial assistance in the preparation of this manuscript was provided by Dr Karen Wolstencroft, supported by Britannia Pharmaceuticals Limited.

Declaration of interest

R Bhidayasiri has received consultancy and/or honoraria/lecture fees from Abbott, Boehringer-Ingelheim, Britannia, Ipsen, Novartis, Teva-Lundbeck, Takeda, and Otsuka pharmaceuticals; he has received research funding from the Newton Fund, the UK Government, Thailand Science, and Research Innovation Bureau, Thailand Research Fund, Crown Property Bureau, Chulalongkorn University, and the National Science and Technology Development Agency; he holds patents for laser-guided walking stick, portable tremor device, nocturnal monitoring, and electronic Parkinson’s disease symptom diary as well as copyright on dopamine lyrics and teaching video clips for common nocturnal and gastrointestinal symptoms for Parkinson’s disease.

R Chaudhuri has worked on advisory boards for AbbVie, UCB, Pfizer, Jazz Pharma, GKC, Bial, Cynapsus, Novartis, Lobsor, Stada, Medtronic, Zambon, Profile, Sunovion, Roche, Therevance, Scion. Honoraria for lectures: AbbVie, Britannia, UCB, Mundipharma, Zambon, Novartis, Boehringer Ingelheim, Neuroderm, Sunovion. Grants (Investigator Initiated): Britannia Pharmaceuticals, AbbVie, UCB, GKC, Bial, Academic grants: EU, IMI EU, Horizon 2020, Parkinson’s UK, NIHR, PDNMG, EU (Horizon 2020), Kirby Laing Foundation, NPF, MRC. P Lolekha has received honoraria/lecture fees from Abbott, Allergan, Berlin Pharm, BL Hua, Boehringer-Ingelheim, Eisai, GlaxoSmithKline, Novartis, and Siam Pharmaceutical; he has received research funding from Thammasat University. J Parsons is employed by Britannia Pharmaceuticals Ltd, UK. S Benedierks is employed by STADA Pharmaceuticals Australia Pty Ltd. A has received reimbursement of travel expenses to scientific meetings or honoraria for lecturing or consultancy from UCB, Seqirus, Theravance, Teva, Abbott, AbbVie, Stada, Allergan, Ipsen, and Merz. He holds shares in CSL Australia and Global Kinetics Corporation. T van Laar has received speaker fees from Britannia Pharmaceuticals and AbbVie. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or conflict with the subject matter or materials discussed in this manuscript apart from those disclosed.

Reviewer disclosures

A peer reviewer on this manuscript has acted on advisory boards for Britannia. They have also received honoraria from Medizin Akademie Organisationsteam (talk) and Britannia (talk and congress reports articles) as well as research grants from France Dévéloppement Electronique (FDE) and Association France Parkinson, Homeperf, LVL. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Additional information

Funding

This study is supported by Thailand Science Research and Innovation grant [RTA6280016], International Research Network grant [IRN59W0005] of the Thailand Research Fund, Chulalongkorn Academic Advancement Fund into Its 2nd Century Project of Chulalongkorn University [2300042200], and Centre of Excellence grant of Chulalongkorn University [GCE6100930004-1]. The expert panel meeting and apomorphine masterclass were co-sponsored by Britannia and Stada Thailand Pharmaceuticals Limited who had no influence on the contents.