VPA-induced coma with hyperammonemia and without evidence of hepatic failure should be considered in patients being treated with PHT or PB when VPA is administered concomitantly. This case report shows the importance of clinical monitoring and immediate drug discontinuation when drowsiness, gastrointestinal symptoms, or lethargy occur.

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Objective: To suggest that intranasal delivery may offer an effective alternative to subcutaneous injection of apomorphine. Methods: Four patients (3 men, 1 woman) with idiopathic Parkinson's disease, with disabling “on-off” fluctuations in motor performance, despite optimal adjustment in the levodopa regimen and use of dopamine agonists, were included in this study. Their mean age was 61.5 years (range 58–65) and the mean duration of the disease was 13.5 years (range 5–18). The mean duration of levodopa treatment was 12.2 years (range 5–16). Disabling fluctuations had been present in these patients for more than 1 year. The Hoehn and Yahr stage was III-IV during the off periods. All four patients had dyskinesia when receiving the peak dose. Levodopa and dopamine agonist medications were unchanged for 1 month before the study. All four patients had already received intermittent subcutaneous apomorphine injections for a mean of 12.25 months (range 7–16). Apomorphine solution 10 mg/mL was administered with the use of a metered-dose nebulizer that delivered 1 mg of solution with each puff. Results: All patients showed a clear clinical response, with a mean reduction in daily off period of 94.5% with respect to the basal off period. No loss of therapeutic effect or increase in dyskinesia was observed compared with subcutaneous apomorphine. The speed, quality, and duration of response were comparable with that found with injection of apomorphine. One patient showed a slight vestibulitis, but it did not interfere with the efficacy of apomorphine. Conclusions: Intranasal apomorphine is a comfortable and easy alternative to subcutaneous apomorphine in the treatment of off phases in patients with Parkinson's disease and severe refractory motor fluctuations.