The subcutaneous apomorphine pen injection for intermittent administration and continuous subcutaneous apomorphine infusion (CSAI) require titration with medical supervision because of the risk of orthostatic hypotension and fainting. So let’s discuss how to titrate these devices.
Rapid titration protocol for apomorphine pen:
The patient should come into the office in the OFF state.
- Document blood pressure while seated.
- Administer 1 mg apomorphine via pen injection.
- Assess motor function and orthostatic blood pressure 10 minutes after the injection.
- Administer 1–3 mg apomorphine via pen injection. Give a lower dose if the patient is on < 600 mg of levodopa per day and a higher dose if the patient is on > 1200 mg per day.
- Assess motor function and orthostatic blood pressure 10 minutes after each injection. Stop when the patient is happy with their mobility or there is only mild dyskinesia.
- Calculate the final dose (covered in a later lesson via case example).
For continuous subcutaneous apomorphine infusion (CSAI), there are three main phases of titration.
Initiation: Lasts 3–4 days. During this phase, apomorphine is started slowly and gradually increased while tapering other medications including dopamine agonists, anticholinergics, amantadine, and COMT inhibitors. When initiating the pump, it’s recommended to start at a continuous infusion dose of 1 mg / h. For OFF periods, the bolus dose—which is generally ½ to ⅔ of the continuous dose—should be used and recorded so the pump settings can be adjusted.
Balancing: After the patient is off the first set of medications, levodopa is decreased, while continuing to increase apomorphine. The goal is to decrease levodopa by 50% and this typically takes 6–7 days. You can either decrease the dose of levodopa or the number of times that it is taken. Increase the apomorphine dose by 0.5 mg every 4 hours or by 1–1.5 mg every day up to the dose needed to control fluctuations. Most patients have an infusion dose of 4–7 mg / h during the day with lower doses needed overnight. At the end of the balancing period, patients should feel their medications working within 10 minutes of hooking up their pump.
Fine-tuning: Over the subsequent 3 months, fluctuations are minimized and the dosages and regimen are fine-tuned.
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