Optimal Management of OFF Episodes in Parkinson's Disease - Episode 5

Apomorphine Subcutaneous Injection: Circle of Care Program for Off-Episodes in Parkinson Disease

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Daniel E. Kremens, MD, JD: We’ve talked about some of the advantages and great results we’ve had with this drug [apomorphine hydrochloride], but it’s not for everybody. There are disadvantages. I know many of my patients are reluctant to use needles. There is also a societal stigma that surrounds needle use as well, and I find that to be a challenge for a lot of patients. It’s not necessarily the physical use of the needle. Although a patient who is very, very off might have some physical challenges, more often patients are just afraid of needles or there’s a stigma.

Rajeev Kumar, MD: I agree with that. It’s interesting. I call that needlephobia. It’s very interesting. When I’ve talked to many neurologists and patients, if the concept of using a needle is approached in the correct way, then it’s amazing how accepting the vast majority of patients are of using a needle to get back on again—when it improves quality of life. It’s a very easy thing to administer, and it’s not so scary once you’ve tried it. It’s more anxiety of impression. It’s more the thinking about it than the actual doing of it that is scary. We’ve done a small survey in a large group of patients, not yet published, and found 80% to 90% of patients who have troublesome off-episodes are ready to inject themselves if you discuss it with them. My experience with asking general neurologists is there’s a fear, greater than that, of their patients not being accepting of it. It’s important, as you put it, to ask the question and have the discussion in a tempered way. If you do so, I would submit to you, the vast majority of patients who have troublesome off-episodes will say, “Yes, if you can tell me when I inject myself, it’s not a big deal. You can teach me or my caregiver how to do it in 15 or 20 minutes, and I can get back on reliably. Then I’d be willing to have that insurance policy and inject myself to get going when I need it rather than being stuck.” The vast majority of patients would be willing to do so.

Daniel E. Kremens, MD, JD: One other nice thing is there’s a program. I’m not sure how much you use it, but I use it a lot. The company that makes Apokyn [apomorphine hydrochloride] provides a program called Circle of Care in which nurses go out and help patients deal with needle problems if [there are] any. They teach them how to inject and can help with initiation of the drug. Initiation of the drug needs to be done under medical supervision, and this is for any apomorphine product. I’ve used the Circle of Care program a lot to help with any concerns patients have regarding the needle.

Rajeev Kumar, MD: I agree with you totally. Let’s review that program a little, the adverse effects one should think about, and the process of titration. In addition to beginning Tigan [trimethobenzamide] before administering the titration, the patient should be seen in the practically defined off-state, typically after levodopa withdrawal overnight. Different doses of Apokyn [apomorphine hydrochloride] should be administered roughly 90 to 120 minutes apart. The patient should be examined serially. Examine for drops in blood pressure, because orthostatic hypotension can occur as well as nausea. Also, sleepiness and yawning are not uncommon when Apokyn [apomorphine hydrochloride] is first administered and can sometimes be an ongoing problem. Those are perhaps the most troublesome adverse effects when titrating.

Most patients need between 2 and 8 mg of Apokyn [apomorphine hydrochloride] injection per dose. Then the dose can be customized based on the response during the titration. Typically, we begin at 2 mg and go to 4, then 6, and then 8 mg, depending on the size of the patient. You can adjust this based on the body mass of the patient during the titration. Once the appropriate dose is discovered, the patient can begin to use that [apomorphine hydrochloride] on an ongoing basis. Apokyn [apomorphine hydrochloride] can be used, if necessary, many times a day. Although if a patient is using Apokyn [apomorphine hydrochloride] many times a day, that’s usually a good indicator to the neurologist who’s treating them that some adjustment in their baseline medication or treatment should be implemented. That way they can prevent off-episodes in addition to using Apokyn [apomorphine hydrochloride] to get them back on when needed.

I agree, the Circle of Care nurse program is very helpful. I unfortunately and fortunately have a lot of experience with that program. One of my nurses who worked with me for more than a decade, and who I trained, is the company’s head trainer for the western United States. This nurse teaches all the other nurses how to titrate Apokyn [apomorphine hydrochloride] and how to manage patients on Apokyn [apomorphine hydrochloride]. I do use it. It’s very helpful, and it’s nice that I can call my old nurse when I have a patient and say, “Please take care of this patient. This is what I want you to do. Just call me on my cell if there’s a problem.” It gives me a lot of reassurance.

Daniel E. Kremens, MD, JD: That’s fantastic.