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previews",[218,228,233,241],{"type":219,"data":220},"video",{"readDurationInSeconds":221,"video":222},323,{"platform":223,"name":212,"url":224,"size":225},"YouTube","https:\u002F\u002Fyoutu.be\u002FjK0WAPzEOLU",{"width":226,"height":227},200,113,{"type":229,"data":230},"free_text",{"readDurationInSeconds":231,"text":232},77.6,"\u003Cp dir=\"ltr\">\u003Cspan>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.\u003C\u002Fspan>\u003C\u002Fp>\u003Cp dir=\"ltr\">\u003Cspan>Rapid titration protocol for apomorphine pen: \u003C\u002Fspan>\u003C\u002Fp>\u003Cp dir=\"ltr\">\u003Cspan>The patient should come into the office in the OFF state.\u003C\u002Fspan>\u003C\u002Fp>\u003Col>\u003Cli dir=\"ltr\">\u003Cspan>Document blood pressure while seated.\u003C\u002Fspan>\u003C\u002Fli>\u003Cli dir=\"ltr\">\u003Cspan>Administer 1 mg apomorphine via pen injection.\u003C\u002Fspan>\u003C\u002Fli>\u003Cli dir=\"ltr\">\u003Cspan>Assess motor function and orthostatic blood pressure 10 minutes after the injection.\u003C\u002Fspan>\u003C\u002Fli>\u003Cli dir=\"ltr\">\u003Cspan>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.\u003C\u002Fspan>\u003C\u002Fli>\u003Cli dir=\"ltr\">\u003Cspan>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.\u003C\u002Fspan>\u003C\u002Fli>\u003Cli dir=\"ltr\">\u003Cspan>Calculate the final dose (covered in a later lesson via case example).\u003C\u002Fspan>\u003C\u002Fli>\u003C\u002Fol>\u003Cp> \u003C\u002Fp>\u003Cp dir=\"ltr\">\u003Cspan>For continuous subcutaneous apomorphine infusion (CSAI), there are three main phases of titration.\u003C\u002Fspan>\u003Cbr> \u003C\u002Fp>\u003Cp>\u003Cspan>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 \u002F 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.\u003C\u002Fspan>\u003C\u002Fp>\u003Cp> \u003C\u002Fp>\u003Cp>\u003Cspan>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 \u002F 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.\u003C\u002Fspan>\u003C\u002Fp>\u003Cp> \u003C\u002Fp>\u003Cp>\u003Cspan>Fine-tuning: Over the subsequent 3 months, fluctuations are minimized and the dosages and regimen are fine-tuned. \u003C\u002Fspan>\u003C\u002Fp>\u003Cp> \u003C\u002Fp>",{"type":234,"data":235},"cta",{"readDurationInSeconds":236,"text":237,"buttonText":238,"buttonUrl":239,"teachIllustration":240},4,"Start the first chapter of our Parkinson's Masterclass: Advanced Therapeutics course for free","Start chapter 1 now","https:\u002F\u002Fwww.medmastery.com\u002Fuser\u002Fregister?target=%2Fcourses%2Fparkinsons-masterclass-advanced-therapeutics","https:\u002F\u002Fmedmastery-backend-prod-kjbeds.s3.eu-west-1.amazonaws.com\u002Fmedia\u002Fimages\u002F9ab1a4dc-b2e8-4a53-86a4-1f1d531e4aee",{"type":229,"data":242},{"readDurationInSeconds":243,"text":244},13.333333333333334,"\u003Cp dir=\"ltr\">\u003Cspan>Explore cutting-edge Parkinson’s treatments, including device-assisted and lesioning therapies. 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Elevate your expertise in Parkinson's care today!",{"duration":279,"quizzes":280,"lessons":281},7176,6,36,{"id":283,"name":271,"image":284,"profession":285,"relativeUrl":288,"specializations":289},13652,"https:\u002F\u002Fmedmastery-backend-prod-kjbeds.s3.eu-west-1.amazonaws.com\u002Fmedia\u002Fimages\u002F9c43cf02-eef5-4b9f-95a2-065d9945a2de",{"name":286,"description":287},"Movement Disorder Specialist","Co-director of both the Parkinson’s Disease and Movement Disorders Division as well as the STIM (Surgical Therapies Improving Movement) program at the University of Michigan.","\u002Fteachers\u002Fkelvin-l-chou-md",[253],99,"2m",[293,320,339],{"id":294,"title":295,"text":296,"image":297,"author":305,"path":313,"readDuration":314,"readDurationFormatted":315,"internal":316},1351,"Starting statins as first-line therapy for hyperlipidemia","Starting statins: how to choose the right agent for your patient, match statin intensity to cardiovascular risk, and monitor effectively after initiation.",{"alt":298,"title":299,"size":300,"location":302},"Healthcare provider discussing starting statins with a patient and reviewing a medication bottle","",{"width":301,"height":301},660,{"bucket":303,"key":304},"public-drupal-medmastery-assets-production","\u002F2026-05\u002FC121(2)_magazine image.png",{"id":306,"title":307,"relativeURL":308,"image":309,"professionLong":310,"profession":311,"weight":236},1563,"Franz Wiesbauer, MD MPH","\u002Fteachers\u002Ffranz-wiesbauer-md-mph","https:\u002F\u002Fmedmastery-backend-prod-kjbeds.s3.eu-west-1.amazonaws.com\u002Fmedia\u002Fimages\u002F9c43cef0-41ee-4005-9e4a-d8711c816401","Franz is the founder and CEO of Medmastery. 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