The clinical utility of long-term oral levodopa therapy in Parkinson disease (PD) is often limited by the emergence of motor complications. Over time, many patients with PD experience regular and/or unpredictable “off” periods, despite taking optimized oral medication regimens, with a major negative impact on their ability to undertake routine activities of daily living and consequently on their overall quality of life. One established approach for treating patients experiencing off periods and controlling motor fluctuations refractory to conventional oral drug therapy is the subcutaneous administration of the dopaminergic agonist apomorphine. This article outlines how the pharmacokinetic properties of apomorphine underpin its efficacy for the treatment of PD and provides practical guidance for the 3 main approaches in which it is used: subcutaneous intermittent apomorphine injection as a “rescue” therapy for off states, subcutaneous continuous apomorphine infusion for PD patients with intractable motor fluctuations as an alternative to other dopaminergic treatment, and in the apomorphine response (or challenge) test for assessment of dopamine-induced motor response in patients thought to have PD, or in establishing the optimal tolerated dose of apomorphine in patients already known to have PD. Also discussed is the management of potential adverse events with subcutaneous administration of apomorphine, the majority of which are mild and easily managed in practice. The importance of a multidisciplinary PD team in the optimal management of PD patients is now recognized, in particular the role of the specialist PD nurse.
*Chulalongkorn Center of Excellence on Parkinson's Disease and Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand; †Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA; ‡National Parkinson Foundation Centre of Excellence, King's College Hospital, Denmark Hill Campus, London, United Kingdom; §Wayne State University School of Medicine, Parkinson's Disease and Movement Disorders Program, Henry Ford West Bloomfield Hospital, West Bloomfield, MI; ║King's College Hospital, Denmark Hill Campus, London, United Kingdom; ¶Chulalongkorn Center of Excellence on Parkinson's Disease and Related Disorders, Bangkok, Thailand; and #Department of Neurology, Movement Disorder Center, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
Address correspondence and reprint requests to Roongroj Bhidayasiri, FRCP, MD, Chulalongkorn Center of Excellence on Parkinson's Disease and Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society,1873 Rama 4 Road Bangkok 10330, Thailand; E-mail: firstname.lastname@example.org
Conflicts of Interest and Source of Funding: R.B. is a consultant for Ipsen Pharmaceuticals. He has received honoraria from Boehringer-Ingelheim, GlaxoSmithKline, Abbott, Novartis, Roche, and Lundbeck Pharmaceuticals. He is supported by the research unit grant of Chulalongkorn University, Bangkok, Thailand. K.R.C. has received funding from Parkinson's UK, National Institute for Health Research, and European Commission and educational grants from UCB, Britannia Pharmaceuticals Ltd, AbbVie, and Medtronic, and in the last 3 years, K.R.C. has received honoraria from UCB, AbbVie, Britannia Pharmaceuticals Ltd, US WorldMeds, Mundipharma, Medtronic, Napp, and Otsuka Pharmaceuticals and acted as a consultant for UCB, AbbVie, Britannia Pharmaceuticals Ltd, Medtronic, and Mundipharma. P.L., A.M., and K.B. have no disclosures to report. T.V.L. is the recipient of lecture fees from Britannia Pharmaceuticals Ltd and Medtronic, and is a member of the Advisory Boards for AbbVie and Britannia Pharmaceuticals Ltd.