Optimal Management of OFF Episodes in Parkinson's Disease - Episode 4

Apomorphine Subcutaneous Injection: Patient Selection for Off-Episodes in Parkinson Disease

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Rajeev Kumar, MD: In the 1990s, we were using Apokyn [apomorphine hydrochloride] a lot, and it was often an indicator. If a patient had to use Apokyn [apomorphine hydrochloride] a lot and was having a lot of off-episodes that were troublesome, that was an indicator that you should consider a device-aided therapy like deep-brain stimulation. Even now that is a reasonable indicator.

We still have patients who’ve had deep-brain stimulation, of course, and that was done effectively when off Apokyn [apomorphine hydrochloride]. Now that they’re out 10 years from deep-brain stimulation or 15 years out from deep-brain stimulation and having reemergence of more off-episodes, they’re using Apokyn [apomorphine hydrochloride] from time to time helpfully and effectively, even in combination with deep-brain stimulation. It is a nice drug, especially for patients who have morning akinesia or unpredictable off-episodes. Those are good areas to suggest that Apokyn [apomorphine hydrochloride] should be considered.

Daniel E. Kremens, MD, JD: When you think about different patients in your practices who’ve used Apokyn [apomorphine hydrochloride], I’ve had success with patients who are the very busy working person all the way to somebody you wouldn’t necessarily think was an Apokyn [apomorphine hydrochloride] patient. I had a gentleman with advanced Parkinson disease who also had a stroke. When he was in an off-state, he couldn’t feed himself. His caregivers were able to give him Apokyn [apomorphine hydrochloride] before meals, and it restored his dignity. He was able to feed himself. He didn’t need people to help him during that period. You wouldn’t think of this guy because he’s so advanced, but it made a real difference in his quality of life. It doesn’t just have to be the young, working patient who need Apokyn [apomorphine hydrochloride]. It really can work for a variety of Parkinson disease patients.

Rajeev Kumar, MD: It’s important to ask questions about impact on quality of life. I tremendously agree with you, and on the predictability, as you said. They need to give it before meals to make sure the patient is fully on so he can eat. Maybe chewing and even swallowing may have an improvement. It is extremely important, both for quality of life and for safety in that circumstance. It can even be, if you like, a little bit of an insurance policy. You have a family that goes with the patient out for dinner, and they don’t know if the patient is going to turn off in the middle of the meal. If dad turns off before we leave, we’re going to be stuck there for an hour or 2 at the end of the meal waiting for the next dose of levodopa to kick in. 

Just having the Apokyn [apomorphine hydrochloride] pen in their pocket, even if they don’t use it, is a tremendous relief and can improve ability to get out and be social, interact with others, and restore quality of life. Get to the ballgame. OK, it’s the seventh-inning stretch, but I can’t stand up. I’m going to inject myself with Apokyn [apomorphine hydrochloride] so I can leave here when the game is ending at the ninth inning. That’s a typical example of how that insurance policy helps. You can get going when you need to. If you don’t need it, great. Keep in pocket. I can get out of here without it. It’s great.