Apomorphine USA

♦ Initiation of apomorphine requires titration in the medical office, which can take up to 3-4 hr. Education and training are provided to the patient and the caregiver (109).

♦ More than one visit may be required for titration.

♦ The patient presents to the clinic in an 'off medication state, having discontinued PD medication by 10 pm the evening before the scheduled titration visit.

109 Apomorphine titration. A physician assistant educating a young Parkinson patient, who is experiencing motor fluctuations, on how to set up apomorphine injections. In the USA, apomorphine is available as a subcutaneous injection for PD patients experiencing wearing-off episodes, as a 'rescue' therapy In European countries, apomorphine is available as a continuous subcutaneous infusion.

109 Apomorphine titration. A physician assistant educating a young Parkinson patient, who is experiencing motor fluctuations, on how to set up apomorphine injections. In the USA, apomorphine is available as a subcutaneous injection for PD patients experiencing wearing-off episodes, as a 'rescue' therapy In European countries, apomorphine is available as a continuous subcutaneous infusion.

Apomorphine titration

FIRST TEST DOSE: 0.2 ML

SECOND TEST DOSE:0.4 ML Administer at next observed 'off' period, if necessary

THIRD TEST DOSE: 0.3 ML Administer during a separate 'off' period, if second test dose is not tolerated

• Ascertain that the patient is in the 'off' condition

• This dose is administered to the patient who tolerates the 0.2 mL test dose, but does not demonstrate a response. Do not administer sooner than 2 hrs following initial 0.2 mL test dose

• Dose of 0.3 mL should be administered to those who do not tolerate the 0.4 mL test dose. Do not administer sooner than 2 hours following the 0.4 mL test dose

• Obtain blood pressure (BP) in supine and standing positions prior to dosing.

• Obtain BP in supine and standing positions prior to dosing

• Obtain BP in supine and standing positions prior to dosing

• Patient or carer administers 0.2 mL test dose

• Patient or caregiver administers 0.4 mL test dose

• Patient or carer administers the 0.3 mL test dose

• Obtain BP in supine and standing positions at 20,40, and 60 minutes following dosing

• Obtain BP in supine and standing positions at 20, 40, and 60 minutes following dosing

• Obtain BP in supine and standing positions at 20, 40, and 60 minutes following dosing

• If the test dose is tolerated, and response is noted, the starting dose should be 0.2 mL, to be used as needed

• If the 0.4 mL test dose is tolerated, regardless of whether or not there is a response, the starting dose should be 0.3 mL, used as needed

• If the 0.3 mL test dose is tolerated, the starting dose should be 0.2 mL, used as needed

• As needed, this starting dose can be titrated upward at increments of 0.1 mL every few days.This can be done on an outpatient basis

• If needed, this dose can be increased in increments of 0.1 mL every few days.This can be done on an outpatient basis. Efficacy and tolerability will need to be assessed from time to time

• If needed, after a few days this dose can be increased to 0.3 mL.This can be done on an outpatient basis. Assess efficacy and tolerability from time to time.The dose in these patients generally should not be increased to 0.4 mL on an outpatient basis

• Those who develop clinically significant orthostatic hypotension with 0.2 mL test dose should not be considered candidates for treatment with apomorphine

Dose guidance: above volumes are based on the standard available strength in the USA, which is 10 mg/mL. For example, 0.2 mL equates to 2 mg apomorphine. Further dilution of the product (e.g. adding normal saline) or using alternative formulations available in other countries will affect volume and dose equivalences.

Dose guidance: above volumes are based on the standard available strength in the USA, which is 10 mg/mL. For example, 0.2 mL equates to 2 mg apomorphine. Further dilution of the product (e.g. adding normal saline) or using alternative formulations available in other countries will affect volume and dose equivalences.

110 Apomorphine dosage (USA).Titration of apomorphine to establish patient tolerance.

♦ Confirm the patient in is an 'off' episode.

♦ Evaluate test doses under monitored conditions to determine a dose (0.2 mL, 0.3 mL, or 0.4 mL) that the patient will tolerate (110).

♦ Blood pressure is checked before the dose, then 20, 40, and 60 minutes following the dose.

♦ Wait at least 2 hours between doses.

O If the patient does not tolerate it, stop.

O If the patient tolerates the dose at 0.2 mL and responds, send him/her home on 0.2 mL prn. If needed, the dose may be increased at home by 0.1 mL increments every few days, under the direction of the clinician.

♦ If the patient tolerates 0.2 mL, but does not respond, then give a test dose of 0.4 mL at the next observed 'off'.

O If the test dose of 0.4 mL is tolerated, send the patient home on a starting dose of 0.3 mL. If needed, dose may be increased at home in 0.1 mL increments every few days.

♦ If the patient does not tolerate 0.4 mL, give a

0.3 mL test dose during a separate, observed 'off' period. If this is tolerated, send patient home on 0.2 mL starting dose. If needed, the dose may be increased at home to 0.3 mL after a few days.

♦ The maximum recommended dose is 0.6 mL.

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