Makindo Medical Notes

PD specialist use only: Apomorphine therapy requires specialist supervision and is generally reserved for patients with advanced Parkinson’s disease experiencing frequent and disabling “off” episodes despite optimised oral therapy.

📖 About

• Used in advanced Parkinson’s disease to rapidly reverse “off” episodes (motor fluctuations).
• Not an opioid — despite its name, it has no activity at opioid receptors.
• Always check the BNF link here for up-to-date prescribing information.

⚙️ Properties

• Non-selective dopamine receptor agonist with high affinity for D₂-like receptors in the striatum (caudate and putamen).
• Structurally a morphine derivative, but with no opioid pharmacology.
• Administered by subcutaneous injection or continuous infusion for rapid effect.

💊 Indications & Dosing – Apomorphine (verify with BNF/datasheet)

• 🧠 Advanced Parkinson’s disease with motor fluctuations
  • Test dose: 1 mg SC at first sign of “off” episode → if tolerated, increase to 2 mg after 30 min.
  • Titrate at ≥40 min intervals to find threshold dose.
  • Typical range: 3–30 mg/day in divided SC injections (max 10 mg per injection).
  • Continuous SC infusion: For patients needing >10 injections/day; usual max ~100 mg/day.

⚠️ Cautions and Contraindications

• Contraindications: Severe dementia or psychosis, respiratory depression, severe hepatic impairment, children.
• Caution: Hypotension, cardiac disease, elderly frailty, or impulse-control disorders.
• Must not be given without antiemetic cover (usually domperidone started 2–3 days before initiation to prevent nausea/vomiting).

❗ Side Effects

• Very common: Nausea, vomiting (without domperidone cover), somnolence, yawning.
• Neuropsychiatric: Hallucinations, confusion, impulse-control disorders (gambling, hypersexuality).
• Neurological: Dyskinesias may be exacerbated (especially with levodopa co-therapy).
• Cardiovascular: Hypotension, syncope, QT prolongation.
• Local: Injection site nodules, pain, erythema.

🧪 Monitoring

• Baseline: BP (sitting and standing), ECG, U&E, LFTs.
• Monitor for: neuropsychiatric symptoms, dyskinesias, hypotension, impulse-control disorders.
• Review antiemetic use — domperidone is usually tapered once tolerance develops.

📚 References

• BNF: Apomorphine
• NICE NG71: Parkinson’s Disease in Adults