Practical Considerations in the Management of OFF-Episodes in Parkinson Disease - Episode 9
Laxman Bahroo, DO, and Sanjay Iyer, MD, discuss the efficacy and tolerability of subcutaneous and sublingual apomorphine and comment on patient selection for each formulation
Laxman Bahroo, DO: Dr Iyer, what do you think about the efficacy and the adverse effect profiles from the subcutaneous and sublingual? What are your thoughts between the 2?
Sanjay Iyer, MD: With the subcutaneous, because obviously you get very rapid absorption of it, that’s where more of the hypotension comes into play. I tend to see it more in my patients who are already exhibiting orthostatic hypotension. Those are the folks to watch out for. I have very few patients who have normal blood pressures and don’t experience any drops, who have problems with the subcutaneous. With the sublingual, the oral issues, oral ulcerations, the irritation, that’s just a big area where again, a third of the patients in the clinical trials are having issues. And that’s probably right, if not even underestimated. I asked my PA [physician assistant] who was saying, “Well, I’d always want to take the sublingual. I wouldn’t want to do a shot.” I said, “Well, get one of those Listerine PocketPaks.” And I said, “Stick it to the bottom of your tongue. Lift your tongue up. Stick it to the bottom of it. Now, hold it there for 3 minutes and tell me how comfortable it is.” And after about a minute and a half, her eyes are watering. It’s difficult. It’s not easy to do. It can be irritating, painful, and it’s just not comfortable.
Laxman Bahroo, DO: Now here’s an interesting thing. I completely agree in the way you’re describing and I think it’s important to discuss this with patients in terms of what sounds easy upfront may not be as easy as you think it is. How do you initiate your patients on the apomorphine sublingual vs subcutaneous? Do you do it differently or do you initiate them both the same way?
Sanjay Iyer, MD: A little bit differently. With the subcutaneous, the company has a nurse that will go out to the home and will do the education and will do the titration there in the home. And I tend to let them do that. Especially since I asked the patients to skip their levodopa in the morning that day. They’re really in a deep OFF. I want to see what dose it takes to give them the full ON. And often coming into the office is difficult when they’re OFF. I prefer to do it that way. With the sublingual, we’ll either do it in the office or do a virtual visit with them and say, “OK, well, just put it under your tongue and see how you do and do it that way.” I don’t necessarily need the nursing tool, if you will, for the sublingual.
Laxman Bahroo, DO: Right. I agree. I do the same thing in our office. We will only ask patients for the sublingual to come in. If they’re interested in coming in, we simply ask them. We’re happy to do it virtually. Our nurse practitioner will do it as a virtual visit with the understanding that they have a blood pressure cuff at home so they can check blood pressure, or either they can check it, or a caregiver can check it. And if somebody can check it, we can check blood pressures at baseline, sitting, standing 20 minutes, 40 minutes, and so on, and also be able to monitor the response. We want them in a space where we can see them moving back and forth. We can get a quick assessment of what they’re like at the end of a dose and so on and so forth. Now, the convenience of that vs the education from a nursing team, for the subcutaneous, we usually have the nursing team do it from the team that does the teaching for this. And that’s very important to have the nursing team because the injectable requires more teaching. And you’re absolutely right, in some sense that their patients are OFF. And we used to titrate these patients—initiate these patients and even titrate them in the office. And there were some hardships with the patients, but we would…they would soldier in, come in. And what finally put an end into that was the pandemic. When the pandemic came in, we exclusively moved those individuals to titrate at home. And if there was a little bit of hand-holding or apprehension, we would often tell them, “Look, we want to be able to have this done at home. And if you need me at that point, at 12:00 or 1:00, I’ll jump in on a phone conversation or telephone visit with the circle of care nurse, with you, your caregiver, and just tidy up a few things. Or we can always do the visit the day after or a few days later.” It allowed us the combination of virtuals to be able to do all these initiations.
Transcript Edited for Clarity