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Apomorphine infusion could reduce periods of immobility in people with Parkinson’s disease

Study assessed use of infusion to reduce ‘off time’ in patients with persistent motor fluctuations

Study assessed the use of apomorphine to reduce ‘off time in patients with persistent motor fluctuations

Subcutaneous infusion of apomorphine. Picture: Science Photo Library

Motor symptoms of Parkinson’s disease can initially be well controlled with oral dopamine replacement. Unfortunately, most people will experience motor fluctuations with periods of immobility or ‘off time’ as the disease progresses. When these problems first emerge, they can be treated by shortening the interval between levodopa tablets, increasing the dose, adding medication to increase availability of dopamine, or by using dopamine agonists which work by making dopamine more effective.

However, over time motor fluctuations usually continue to worsen leading to troubling periods of immobility, and attempts to control fluctuations can lead to disabling dyskinesia with its involuntary and uncontrollable jerky movements. Difficult-to-control motor symptoms can be treated with deep brain stimulation, intestinal infusion of levodopa-carbidopa gel or with subcutaneous infusion of the dopamine agonist, apomorphine.

Continuous subcutaneous apomorphine infusion has been in use since 1993, but there is little research to support its use. This double-blind, randomised, controlled study of 107 people with persistent motor problems, despite optimal oral or transdermal treatment, provides much-needed evidence to support its use. Apomorphine infusion was shown to have clear benefits when compared with the placebo. This means it should be possible to reduce the dose of short-acting oral antiparkinson medications and so lessen side effects such as dyskinesia. No comparison has been made with levodopa-carbidopa gel, but that treatment is more invasive as it requires insertion of a gastric tube.

Implications for practice

Subcutaneous apomorphine infusion gives a meaningful reduction in off time in patients with persistent motor fluctuations and so has a clear place in the management of Parkinson’s disease.

Katzenschlager R, Poewe W, Rascol O et al (2018) Apomorphine subcutaneous infusion in patients with Parkinson’s disease with persistent motor fluctuations (TOLEDO): a multicentre, double-blind, randomised, placebo-controlled trial. The Lancet. Neurology. 17, 9, 749-759.

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