Managing OFF Episodes in Parkinson’s Disease - Episode 4

Comparing Sublingual and Subcutaneous Apomorphine

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Mindy K. Bixby, DO and Laxman Bahroo, DO compare subcutaneous and sublingual apomorphine hydrochloride and discuss important factors to consider when selecting a formulation.

Laxman Bahroo, DO: If you look at it, we have 2 different formulations of apomorphine: the subcutaneous version and the sublingual version. Keep in mind, the 2 studies are different populations, and it’s difficult to compare. It’s important to compare the 2 to see if we can put the 2 medications side by side and differentiate them. I will tell you that the efficacy, in terms of the apomorphine subcutaneous, is providing a much more robust reduction. I tend to look at OFF episodes not just as OFF episodes but as rescue episodes. Rescue means that it can take you from a full OFF to a full on. In there, the apomorphine subcutaneous can take you from a full OFF to a full on. Whereas, if you look at the sublingual formulation, it may not be able to do as much of it.

Yes, it provides an onset there for 15 minutes and a full on in 30 minutes going up to 90 minutes. But its reduction of the UPDRS [Unified Parkinson’s Disease Rating System] in terms of disability is not as robust as the apomorphine subcutaneous formulation. Overall, that’s important for us to be aware of depending on the adverse effects, regarding the efficacy. Regarding the adverse effects, some are common, as Dr Bixby and I both mentioned. Specifically, there’s nausea, and potentially orthostasis. But their unique adverse effects are because of the delivery system of each issue. It’s important to be aware of even if they don’t see it upfront in the initiation phase. In time you may be able to see some sublingual adverse effects, oral ulcerations, erythema, and irritation of the tongue. It’s important. Dr Bixby, how does this impact your practice? We have 2 different apomorphine formulations. How do you choose? 

Mindy K. Bixby, DO: That’s a great question. It depends on personal choice of patients. Every case will be different. As we all know about Parkinson disease and symptoms, they have advantages regarding how they have caregivers who can help them, like their family. For some, there are opportunities for these patients to ask, “Are we having total OFFs when we have OFFs?” Or are they just having a little OFF episode before the next dose? We decide, “Maybe both of them are gonna be great.” But it’s a robust, “I’m turning OFF, and I am living on to move.” Then you may want to consider the injectable form because that we know it’s much more of a robust improvement of their motor symptoms. Based on that, we look at and talk to patients, and we tell them the 2 options. You tell them the efficacy, and you tell them about the rapid onset and what’s gonna happen to them. Sometimes, they try 1 and then they don’t like it and they try another. Overall, it just depends. Everybody is different. You deliver the opportunity to have them educated with the choices that we feel are the best for them based on what their symptoms are showing and what they need. 

We can make it more of a partnership by understanding what would work for you and how you feel. Are you feeling comfortable with an injection compared with under the tongue? Even the adverse effects of 1 or another. Overall, educating, educating, educating, and having an opportunity to help them based on how they’re feeling and how much OFF time they’re having and the severity of the OFF time. It’s an individual choice, and every person who walks in my clinic office is gonna be different based on what they’re feeling and how they’re experiencing things. 

Laxman Bahroo, DO: I completely agree. It’s important to have that dialogue with your patients: “What type of OFFs are you experiencing?” The more severe OFFs, the more disabling OFFs, are something we should consider the sublingual [apomorphine] for as an alternative. But the subcutaneous [apomorphine] may be the front-runner. Patients may want to try 1 that’s not the injectable first, realize that, and then move to the other 1. Maybe 1 can serve as a gateway to the other. If patients think we have multiple options, they will try 1.

As providers, it gives us the option to discuss it. Many times, I will discuss the 3 options. I’ll lay out briefly the pros and cons of each 1 and have the patients decide what works for them. Then I will give them guidelines of something that might be beneficial for them and something that may or may not work. That’s truly a collaborative decision-making, in which patients feel empowered. At the same time, compliance is better when patients are empowered. 

Mindy K. Bixby, DO: Absolutely.

Laxman Bahroo, DO: Thank you for watching this Neurology Live® Peers & Perspectives®. If you enjoyed the content, please subscribe to the e-newsletters to receive upcoming programs and other great content in your in-box.

Transcript Edited for Clarity