General considerations when starting apomorphine
PD
Table As with other device-aided therapies, a detailed discussion needs to take place with the patient and their family/carer(s) regarding the pros and cons of apomorphine infusion to determine whether it would fit their personal circumstances.In some countries, specially trained PD nurses (Bhidayasiri et al. Funding for apomorphine infusion varies across healthcare systems; centers need to ensure that funding or reimbursement approval is in place.It is advisable to establish local guidelines or standard operating procedures to ensure communication and coordinated action between patient, carers and healthcare professionals.An initial trial of subcutaneous apomorphine injection before starting infusion treatment is sometimes undertaken to confirm dopaminergic responsiveness and enable patients to experience the effects of the medication. This may also provide an estimate of the hourly dose needed. If a test dose is performed, motor function is assessed in an OFF state and is then followed by gradually increasing doses of apomorphine, until a clear switch to an ON state occurs. For dose finding, the prescribing information recommends intervals of 30–40 min between each apomorphine dose increase. A more rapid titration scheme has been proposed to avoid prolonged OFF states (Hagell and Odin Suggested stepwise initiation protocol for apomorphine infusionShould be administered according to local guidelines, if availableECG monitoring, for the QTc interval, is recommended prior to and during the initiation of domperidoneIt is recommended to commence the anti-emetic domperidone at least 2 days prior to initiating apomorphine, at a dose of 10 mg three times/dayDue to the risk of QTc prolongation, domperidone should be used at the lowest effective dose and for the shortest possible duration (see Starting dose: a starting dose of up to 1 mg/hour on day 1, with daily rate increases of 0.5–1 mg/hour, until the patient is stabilized on an effective, tolerated dose with individually adjusted concomitant oral medicationEach patient’s stable apomorphine dose will depend on individual efficacy and tolerabilityPatients treated with apomorphine continuous infusion can substantially reduce their concomitant oral PD medication, and in some cases discontinue them. This is a specific treatment goal in patients with troublesome dyskinesiasOnce a patient is established on apomorphine, the suggested procedure is to reduce oral PD medications in the following order: Dopamine agonists Monoamine oxidase type B (MAOB) inhibitors Catechol-O-methyl transferase (COMT) inhibitors Oral levodopa dose, then frequencyProvides flexibility to give additional medication if needed but without increasing the overall dose per hourFrequent use of the bolus dose function suggests that the hourly flow rate may need to be increased