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Parkinson's disease - Management
How is apomorphine used in secondary care?
- Apomorphine is a potent dopamine agonist used as an adjuvant to levodopa.
- There are two distinct delivery methods for giving apomorphine: subcutaneous bolus doses or continuous infusion.
- Intermittent subcutaneous bolus doses are used as a rescue agent in advanced disease to treat severe 'off' episodes. They provide rapid reversal of 'off' periods (within a few minutes) but the effect only lasts for about 1 hour.
- A continuous subcutaneous infusion is used when people respond well to apomorphine injections but their control remains poor and they require frequent injections. The continuous subcutaneous infusion provides a constant therapeutic effect.
- The evidence base for the use of both intermittent injections and continuous infusions of apomorphine is relatively poor, but both techniques are licensed for use in England and Wales. The National Institute for Health and Clinical Excellence guideline development group considered these to be useful treatments for people with severe 'off' periods that are not responsive to changes in oral medication. However, as with other dopaminergic medication, there is a risk of triggering serious adverse effects such as confusion and hallucinations. In addition, the risk of injection-site reactions is considerable.
- Long-term continuous apomorphine infusions can dramatically reduce both 'off' periods and dyskinesia, and allow withdrawal of oral medication.
- Apomorphine should only be initiated by expert units that can provide home monitoring by a suitably trained healthcare professional, such as a Parkinson's disease nurse specialist.
[National Collaborating Centre for Chronic Conditions, 2006; ABPI Medicines Compendium, 2008b]
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