Continuous Subcutaneous Infusion Delivery of Apomorphine in Parkinson's Disease: A Systematic Review

Abstract

BackgroundContinuous subcutaneous apomorphine infusion (CSAI) is one of the advanced therapies for Parkinson's disease (PD).MethodsA systematic review of all published articles in English on CSAI for PD till January 30, 2022 was conducted.ResultsA total of 82 articles met the search criteria. Publications included retrospective or prospective open‐label observational studies, with a limited number of randomized control trials (RCT). Publications were highly heterogeneous and focused on different aspects of CSAI and included clinical audits, effects on cognition/behavior, axial symptoms, nocturnal issues, adverse events/reasons for discontinuation and comparison with other continuous dopaminergic therapies. CSAI was used in patients who presented severe motor fluctuations not resolved by oral therapy, poor candidates for deep brain stimulation (DBS) due to cognitive/behavioral issues or in those with DBS weaning effect. Recent studies have also shown that CSAI was useful for nocturnal usage in advanced PD, in addition to daytime utilization. Adverse effects were common and include skin lesions, sedation and nausea. Pump management difficulties and patient decisions were common reasons for therapy dropout, predominantly during the initial stages of the CSAI.ConclusionThere is consistent agreement on the benefits of CSAI in reducing OFF periods and improving ON periods without troublesome dyskinesia and specific motor and non‐motor symptoms. Although there is a paucity of RCTs, current data from almost 30 years of use suggests CSAI to be beneficial in advanced cases of PD.

How to Use the New European Academy of Neurology/Movement Disorder Society European Section Guideline for Invasive Therapies in Parkinson's Disease

“…Multiple open‐label studies confirm the efficacy of CAI in the reduction of daily off‐time. 40 , 41 , 42 , 43 Despite several retrospective large case series, detailed long‐term effects are understudied and have been reviewed recently 43 ; however, retrospective data confirm a sustained reduction in motor fluctuations for at least 2 years. 44 …”

“…Multiple open-label studies confirm the efficacy of CAI in the reduction of daily off-time. [40][41][42][43] Despite several retrospective large case series, detailed long-term effects are understudied and have been reviewed recently 43 ; however, retrospective data confirm a sustained reduction in motor fluctuations for at least 2 years. 44 Although effectiveness and safety of unilateral radiofrequency pallidotomy could be shown in EBM reviews for fluctuating PD patients, the GL recommends this only if other treatment options are not available.…”

Advanced therapies in Parkinson’s disease: an individualized approach to their indication

“…Particularly, sleep quality has shown enhancement in multiple studies, attributed partly to a positive influence on concomitant Restless Legs Syndrome. Furthermore, a positive impact on apathy and depression has been documented, along with a reduction in nocturia (Todorova and Chaudhuri 2013;Meira et al 2021;Kukkle et al 2023).…”

Personality and quality-of-life improvement after apomorphine infusion in Parkinson’s disease

“… 7 Finally, recent reviews confirmed all these results: improvement in OFF-time duration and in various non-motor symptoms (including neuropsychiatric disorders) following CSAI, as well as its safety and efficacy in people with advanced Parkinson’s disease. 9 , 10 …”