title: Effective delivery of apomorphine in the management of Parkinson disease: practical considerations for clinicians and Parkinson nurses.
abstract: 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.
authors.affiliation: *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.
authors.forename: Roongroj
authors.initials: R
authors.lastname: Bhidayasiri
authors.forename: K Ray
authors.initials: KR
authors.lastname: Chaudhuri
authors.forename: Peter
authors.initials: P
authors.lastname: LeWitt
authors.forename: Anne
authors.initials: A
authors.lastname: Martin
authors.forename: Kamolwan
authors.initials: K
authors.lastname: Boonpang
authors.forename: Teus
authors.initials: T
authors.lastname: van Laar
mesh_terms: D000978:Antiparkinson Agents / Q000008:administration & dosage / Q000493:pharmacokinetics; D001058:Apomorphine / Q000008:administration & dosage* / Q000009:adverse effects / Q000493:pharmacokinetics* / Q000627:therapeutic use; D018491:Dopamine Agonists / Q000008:administration & dosage / Q000493:pharmacokinetics; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D006801:Humans; D007279:Injections, Subcutaneous / Q000379:methods; D010300:Parkinson Disease / Q000188:drug therapy*; D017410:Practice Guidelines as Topic
chemical_list: D000978:Antiparkinson Agents; D018491:Dopamine Agonists; D001058:Apomorphine