Ramon L. Rodriguez, MD, Neurologist and Movement Disorders Specialist and Medical Director, Neurology One
Sponsored by Sunovion Pharmaceuticals Inc.
The chronic and progressive nature of Parkinson’s disease (PD) can be challenging as we work to manage the condition and identify an appropriate balance of treatments for patients.
Carbidopa/levodopa has long been the gold standard for the treatment of PD. Carbidopa/levodopa is usually the first prescription we, as healthcare providers, recommend when a patient is diagnosed with PD and requires symptomatic benefit. Additional therapies, including but not limited to, MAO-B or COMT inhibitors and dopamine agonists may be added to a patient’s treatment plan as needed to help manage progressive PD symptoms.
Unfortunately, as the condition progresses, an individual’s response to carbidopa/levodopa may become erratic and less consistent, leading to the re-emergence or worsening of PD symptoms otherwise controlled with carbidopa/levodopa—also known as OFF episodes.
OFF Episodes are Common and Disruptive
Over time, the therapeutic window narrows and an individual’s response to carbidopa/levodopa becomes progressively less consistent. After five years of treatment with levodopa, as many as 50% of people with PD experience OFF episodes; this percentage increases to 70% of people after nine years of taking oral carbidopa/levodopa.1,2
Characterized in part by motor symptoms like tremor, rigidity, bradykinesia, or other symptoms, OFF episodes can present in the morning upon awakening, and may happen multiple times throughout the day.3
These OFF episodes can be disruptive for patients and their care partners. During an OFF episode, doing activities like getting out of bed or up from a chair, walking unassisted, buttoning a shirt, or eating may be nearly impossible for a patient to accomplish on their own. Despite the addition of daily adjunctive treatments to help address OFF episodes, people can still spend hours each day navigating these challenges while trying to maintain their routines.
Sublingual Therapy Alleviates OFF Episodes as They Occur
With an evolving treatment landscape, there are on-demand options to treat OFF episodes as they occur, including a novel sublingual therapy. KYNMOBI® (apomorphine HCl) sublingual film is approved by the U.S. Food and Drug Administration (FDA) for the acute, intermittent treatment of OFF episodes associated with PD. This film formulation of apomorphine dissolves under the tongue to treat OFF episodes on-demand. The discreet delivery method allows for the absorption of apomorphine through the oral mucosa.
In clinical trials, treatment with KYNMOBI resulted in statistically significant improvement in motor symptoms associated with OFF episodes at 30 minutes after dosing, compared to placebo. Improved scores in motor symptoms were seen as early as 15 minutes post-administration and persisted up to 90 minutes. A recently shared pooled analysis of the pivotal and ongoing long-term safety study (open-label dose titration phases) of KYNMOBI compared motor improvement after treatment with KYNMOBI vs. levodopa and the mean motor response with KYNMOBI was shown to be approximately two times higher at 15 minutes post-dose and remained higher at 30 minutes post-dose.4
For these reasons, I consider KYNMOBI an important therapeutic option. My patients appreciate having an on-demand solution to treat OFF episodes as they occur that they can easily carry with them. It affords them greater control of their PD symptoms throughout the day and helps them to navigate their lives more easily between carbidopa/levodopa doses.
Facilitating Productive Conversations About OFF Episodes with Patients and Care Partners
Patients and care partners might notice that, over time, the response to oral carbidopa/levodopa has become less consistent. Some people may not recognize the patterns in these changes or know how to articulate the experience, and others may also adapt their activities and routines to accommodate their OFF episodes.
As healthcare providers, we can help patients and their care partners identify the patterns in OFF episodes and work with them to proactively address the challenges they face as their disease progresses.
Probing deeper about bothersome symptoms and encouraging people to monitor the times of day they experience more PD symptoms as well as tracking challenges in navigating activities are important areas of discussion for our patients and their care partners.
To learn more about PD OFF episodes and the potential for treatment with KYNMOBI, visit KYNMOBIHCP.com. Please see below for Important Safety Information.
IMPORTANT SAFETY INFORMATION AND INDICATION FOR KYNMOBI (apomorphine hydrochloride) SUBLINGUAL FILM
Contraindications: KYNMOBI is contraindicated in patients:
- Using concomitant drugs of the 5HT3 antagonist class, including antiemetics (e.g., ondansetron, granisetron, dolasetron, palonosetron) and alosetron. There have been reports of profound hypotension and loss of consciousness when subcutaneous apomorphine was administered with ondansetron.
- With hypersensitivity/allergic reaction to apomorphine or to any of the ingredients of KYNMOBI. Angioedema or anaphylaxis may occur.
Warnings and Precautions:
- Nausea and Vomiting: KYNMOBI may cause nausea and vomiting when administered at recommended doses. Because of the high incidence of nausea and vomiting with KYNMOBI when administered at recommended doses, an antiemetic, e.g., trimethobenzamide 300 mg three times a day, is recommended beginning 3 days prior to the initial dose of KYNMOBI. Treatment with the antiemetic should only be continued as long as necessary to control nausea and vomiting, and generally no longer than two months after initiation of treatment with KYNMOBI. Concomitantly administered antiemetic drugs other than trimethobenzamide have not been studied. Antiemetics with anti-dopaminergic actions (e.g., haloperidol, chlorpromazine, promethazine, prochlorperazine, metoclopramide) have the potential to worsen symptoms in patients with PD and should be avoided.
- Falling Asleep During Activities of Daily Living and Somnolence: Patients treated with dopaminergic medications, including apomorphine, have reported falling asleep while engaged in activities of daily living, including the operation of motor vehicles, which sometimes has resulted in accidents. Patients may not perceive warning signs, such as excessive drowsiness, or they may report feeling alert immediately prior to the event.
Prescribers should reassess patients for drowsiness or sleepiness, especially since some of the events occur well after the start of treatment. Prescribers should also be aware that patients may not acknowledge drowsiness or sleepiness until directly questioned about drowsiness or sleepiness during specific activities.
Before initiating treatment with KYNMOBI, advise patients of the risk of drowsiness and ask them about factors that could increase the risk with KYNMOBI, such as concomitant sedating medications and the presence of sleep disorders.
- If a patient develops significant daytime sleepiness or falls asleep during activities that require active participation (e.g., conversations, eating, etc.), KYNMOBI should ordinarily be discontinued. If a decision is made to continue KYNMOBI, patients should be advised not to drive and to avoid other potentially dangerous activities. There is insufficient information to determine whether dose reduction will eliminate episodes of falling asleep while engaged in activities of daily living.
- Hypersensitivity: Oral soft tissue swelling (lips, tongue, gingiva, and mouth) was reported as an adverse reaction in patients treated with KYNMOBI. It is not known whether these events are related to apomorphine, sodium metabisulfite, or another KYNMOBI excipient. KYNMOBI rechallenge is not generally recommended after discontinuation as oral adverse reactions may recur and may be more severe than the initial reaction.
- Syncope/Hypotension/Orthostatic Hypotension: KYNMOBI may cause syncope, hypotension or orthostatic hypotension. Patients treated with KYNMOBI should receive an assessment for hypotension/orthostatic hypotension, especially if they have a history of hypotension or cardiovascular disease, or if they are currently using antihypertensive medication. Patients should be informed of this risk.
Hypotensive effects of KYNMOBI may be increased by the concomitant use of alcohol, antihypertensive medications, and vasodilators (especially nitrates). Patients should avoid alcohol when using KYNMOBI. Patients taking KYNMOBI should lie down before and after taking sublingual nitroglycerin. Monitor patients taking concomitant antihypertensive medications for hypotension and orthostatic hypotension.
- Oral Mucosal Irritation: KYNMOBI may cause oral irritation. Rechallenge is not generally recommended after discontinuation as oral adverse reactions may recur and be more severe than the initial reaction.
- Falls: Patients with PD are at risk of falling due to underlying postural instability, possible autonomic instability, and syncope caused by the blood pressure lowering effects of the drugs used to treat PD. KYNMOBI might increase the risk of falling by simultaneously lowering blood pressure and altering mobility.
- Hallucinations/Psychotic-Like Behavior: Patients with a major psychotic disorder should ordinarily not be treated with apomorphine because of the risk of exacerbating psychosis. In addition, certain medications used to treat psychosis may exacerbate the symptoms of PD and may decrease the effectiveness of KYNMOBI.
- Impulse Control/Compulsive Behaviors: Case reports suggest that patients can experience intense urges to gamble, increased sexual urges, intense urges to spend money uncontrollably, and other intense urges and the inability to control these urges while taking one or more medications, including KYNMOBI, that increase central dopaminergic tone. In some cases, although not all, these urges were reported to have stopped when the dose was reduced, or the medication was discontinued. Because patients may not recognize these behaviors as abnormal, it is important for prescribers to specifically ask patients or their caregivers about the development of new or increased gambling urges, sexual urges, uncontrolled spending, binge eating or other urges while being treated with KYNMOBI. Physicians should consider dose reduction or stopping the medication if a patient develops such urges while taking KYNMOBI.
- Withdrawal-Emergent Hyperpyrexia and Confusion: A symptom complex resembling the neuroleptic malignant syndrome (characterized by elevated temperature, muscular rigidity, altered consciousness, elevated serum creatine kinase, and autonomic instability), with no other obvious etiology, has been reported in association with rapid dose reduction, withdrawal of, or changes in antiparkinsonian therapy.
- QTc Prolongation and Potential for Proarrhythmic Effects: QTc prolongation with KYNMOBI cannot be excluded.
Drugs that prolong the QTc interval have been associated with torsades de pointes and sudden death. The relationship of QTc prolongation to torsades de pointes is clearest for larger increases (20 msec and greater), but it is possible that smaller QTc prolongations may also increase risk, or increase it in susceptible individuals, such as those with hypokalemia, hypomagnesemia, bradycardia, concomitant use of other drugs that prolong the QTc interval, or genetic predisposition (e.g., congenital prolongation of the QT interval). Although torsades de pointes has not been observed in association with the use of KYNMOBI at recommended doses in clinical studies, experience is too limited to rule out an increased risk. Palpitations and syncope may signal the occurrence of an episode of torsades de pointes.
The risks and benefits of KYNMOBI treatment should be considered prior to initiating treatment with KYNMOBI in patients with risk factors for prolonged QTc.
- Fibrotic Complications: Cases of retroperitoneal fibrosis, pulmonary infiltrates, pleural effusion, pleural thickening, and cardiac valvulopathy have been reported in some patients treated with ergot-derived dopaminergic agents. While these complications may resolve when the drug is discontinued, complete resolution does not always occur. Although these adverse reactions are believed to be related to the ergoline structure of these dopamine agonists, whether other, nonergot derived dopamine agonists, such as KYNMOBI, can cause these reactions is unknown.
- Priapism: Apomorphine may cause prolonged painful erections in some patients. Severe priapism may require surgical intervention.
Most Common Adverse Reactions: Most common adverse reactions (incidence at least 10% in patients treated with KYNMOBI and with an incidence greater than placebo) were nausea, oral/pharyngeal soft tissue swelling, oral/pharyngeal soft tissue pain and paraesthesia, dizziness, and somnolence.
KYNMOBI (apomorphine hydrochloride) sublingual film is a non-ergoline dopamine agonist indicated for the acute, intermittent treatment of “off” episodes in patients with Parkinson’s disease.
You are encouraged to report negative side effects of prescription drugs to the FDA.
Visit www.fda.gov/medwatch or call 1-800-FDA-1088.
For more information, please see the KYNMOBI full Prescribing Information and Instructions for Use.
1. Thanvi BR, Lo TCN. Long-term motor complications of levodopa: clinical features, mechanisms, and management strategies. Postgrad Med J. 2004;80:452-458.
2. Ahlskog JE, Muenter MD. Frequency of levodopa-related dyskinesias and motor fluctuations as estimated from the cumulative literature. Mov Disord. 2001;16(3):448-458.
3. Hametner, E., K. Seppi, and W. Poewe. “The Clinical Spectrum of Levodopa-Induced Motor Complications.” Journal of Neurology 257, no. S2 (2010): 268–75. https://doi.org/10.1007/s00415-010-5719-9.
4. Hui, J., Fox, S., Neeson, W., Sciarappa, K., Pappert, E., Navia, B. (2021). Motor Responses to Apomorphine Sublingual Film Compared With Levodopa in Patients With Parkinson’s Disease and “OFF” Episodes. Presented at 73rd Annual Meeting of the American Academy of Neurology (AAN), April 2021.