A delphi consensus statement about French practical management of continuous apomorphine infusion in patients with Parkinson's disease and motor fluctuations

Abstract

Background: There are currently no consensus guidelines on how to progressively optimize treatment when initiating continuous subcutaneous apomorphine infusion (CSAI) in patients with Parkinson's disease (PwPD).

Aims: To provide practical guidelines on CSAI initiation in PwPD with motor fluctuations, with a focus on the target dose of apomorphine over time and subsequent adjustment of oral treatment according to the patient's characteristics.

Methods: A panel of French neurologists with extensive experience in treating patients with advanced Parkinson's disease used a modified Delphi approach to generate a knowledge synthesis on CSAI initiation according to patient characteristics.

Results: We identified five profiles based on patient characteristics. The target dose of apomorphine over time and the subsequent adjustment of oral therapy were highly dependent on these profiles. The CSAI flow rate varied from a maximum of 3 mg/h for older or more sensitive patients to 6-10 mg/h for younger patients experiencing early fluctuations. In most cases, the preferred approach was to reduce both levodopa and dopamine agonists when increasing CSAI. For optimum efficacy, the total target dose of levodopa equivalent (calculated as the sum of the oral dose and the apomorphine dose) should be greater than or equal to the pre-initiation dose after initiation of CSAI, regardless of patient characteristics.

Conclusion: We provide patient-tailored recommendations with precise indications for the adjustment of apomorphine, oral therapy and levodopa equivalent dose over time during CSAI initiation, based on distinct patient profiles.

Keywords: Apomorphine infusion; Levodopa; Levodopa equivalent daily dose; Parkinson's disease; Treatment.