Update on Apomorphine for the Rapid Treatment of Hypomobility (“Off”) Episodes in Parkinson's Disease


School of Pharmacy, University of Missouri, 2411 Holmes Street, Kansas City, MO 64108; e-mail: oberingc@umkc.edu.


As Parkinson's disease progresses, fluctuations between akinesia, or hypomobility (“off” times), and mobility (“on” times) increase in frequency despite optimized pharmacotherapy. Motor fluctuations include predictable shortening of therapeutic effects, nocturnal or early morning akinesia, random hypomobility, and delayed mobility (variable responses to individual doses of drugs). Current oral antiparkinson drugs are inadequate for rapid and consistent relief of symptoms during hypomobility. Apomorphine, an injectable dopamine agonist recently introduced in the United States, is indicated for the management of hypomobility associated with advanced Parkinson's disease. Subcutaneous apomorphine is effective for rapid and consistent rescue from hypomobility, with a magnitude of motor improvement similar to that of levodopa. The effect begins within 20 minutes after dosing and lasts approximately 100 minutes. Therapeutic rescue doses are 2–6 mg, and patients typically require approximately three rescue doses/day. Apomorphine is associated with a clinically significant potential to cause nausea and orthostatic hypotension. These potential effects can be managed with antiemetic prophylaxis and appropriate determination of the therapeutic rescue dose.