Cutaneous side effects of infused apomorphine: The patient and carer experience

Abstract

Subcutaneously infused apomorphine, used in the treatment of Parkinson's disease, is associated with the development of hard nodules at the infusion site. They may interfere with drug absorption and make it difficult to find a suitable infusion site. Relatively little is known about aetiological factors for nodule development, or which treatments are most effective. A case series assessment was used to investigate nodule formation, effects and management in 24 individuals receiving apomorphine by infusion. Demographics and clinical information, opinions of patients and carers, and physical and sonographic assessment data were obtained. Difficulty finding infusion sites was the most commonly reported problem caused by nodules. Tissue changes varied considerably, and included nodule formation, dermal thickening and diffuse oedema. No single factor was found to substantially influence severity, but poor hygiene and needle-changing technique appeared to exacerbate the problem. A variety of treatments were employed and therapeutic ultrasound was reported to be particularly beneficial. Tissue evaluation by visual inspection, palpation and sonography may be feasible tools for the assessment of condition severity and treatment effectiveness.

Apomorphine formulation may influence subcutaneous complications from continuous subcutaneous apomorphine infusion in Parkinson’s disease

“…There was a decrease in the number (but not size) of nodules from baseline to switch, which could suggest a regression-tothe-mean effect. However, the numbers (5)(6)(7)(8)(9)(10)(11)(12)(13)(14) and sizes (8-36 mm) of nodules at baseline cover fairly large ranges and do not represent a particular subgroup, apart from the fact that their nodules were considered problematic. Furthermore, there was a continuous decrease in both numbers and size over the subsequent timepoints, which is in contrast to previous observations on untreated or sham ultrasound treated CSAI-associated nodules [14].…”

“…Although it is relatively uncommon that s.c. nodules lead to discontinuation of therapy, they can be troublesome and associated with itching or soreness, and sometimes pain, skin discolouration and scarring; in severe cases, ulceration and necrosis may also occur [4,8]. Furthermore, nodules may lead to suboptimal s.c. apomorphine uptake with reduced clinical benefit [8,9]. Attention to skin hygiene, rotation of infusion sites, massage and ultrasound at infusion sites are recommended to reduce s.c. nodules [8,[10][11][12][13][14], but does not eliminate the problem.…”

“…Furthermore, nodules may lead to suboptimal s.c. apomorphine uptake with reduced clinical benefit [8,9]. Attention to skin hygiene, rotation of infusion sites, massage and ultrasound at infusion sites are recommended to reduce s.c. nodules [8,[10][11][12][13][14], but does not eliminate the problem.…”

“…Although it is relatively uncommon that s.c. nodules lead to discontinuation of therapy, they can be troublesome and associated with itching or soreness, and sometimes pain, skin discolouration and scarring; in severe cases, ulceration and necrosis may also occur [ 4 , 8 ]. Furthermore, nodules may lead to suboptimal s.c. apomorphine uptake with reduced clinical benefit [ 8 , 9 ].…”

Cutaneous adverse drug reaction after continuous subcutaneous apomorphine infusion

“…1 Adverse events to APO are usually mild and mostly neuropsychiatric and cutaneous. 3 A few cases with delayed reactions at the injection site [4][5][6] and immediate type 1 hypersensitivity reaction have been described. 7 In a retrospective analysis, 8 skin rash was reported in 3.5% of APO users, generally within the first 2 weeks, as in our patient, but there was no specific clinicopathological characterization of these reactions nor confirmation of their culprit.…”