A 10 year retrospective audit of long-term apomorphine use in Parkinson's disease.

OBJECTIVES: Apomorphine is a potent dopamine agonist useful in the treatment of Parkinson's disease patients with disabling motor fluctuations and 'off' periods, not responding to oral medication. It can also be of benefit in reducing dyskinesia by providing more constant dopaminergic stimulation and permitting lower levodopa dosage. However, there is a paucity of information on long-term benefits of apomorphine, including no large-scale phase III trial. We have examined our experience of apomorphine over the last 10 years, to assess indications, pattern of use, efficacy, and side effect profile. METHODS: All patients requiring apomorphine were identified through the Parkinson's disease Nurse Specialist's records. An audit form was produced so that the same information was gathered from all case-notes. RESULTS: There were 107 patients (61 males and 46 females). Mean age of disease onset was 50.9 years, SD+/-9.3 (range 29-78). The mean duration of disease at start of apomorphine treatment was 10 years (SD+/-4.8, range 2-29). The most common indications for apomorphine were severe unpredictable 'off' periods (75.7 %), motor fluctuations (18.7 %) and dyskinesia (5.6 %). Most patients (63.6 %) used both intermittent subcutaneous injections and infusion via pump; 25.2% were on intermittent injection, and 11.2 % infusion alone. Mean dose per injection was 3.7 mg. Mean infusion dose 69.8 mg, running over a mean of 13.5 hours. The mean duration of intermittent apomorphine use was 48.2 months. The mean duration of infusion was 25.1 months. Complications included skin problems in 16 patients, 2 had symptomatic hypotension, 2 worsening confusion, 1 new confusion and 5 new hallucinations (after sometime on apomorphine). Sixteen patients have stopped using apomorphine completely. Thirteen have stopped the pump, but continue on intermittent injections. CONCLUSION: Subcutaneous apomorphine is easy for patients to use, is well tolerated and has a low incidence of side effects, especially confusion.

Modafinil for Parkinson's disease fatigue.

Fatigue is common in Parkinson's disease (PD), occurring in up to 42% of patients (2). There is no recognized treatment. This is a study of modafinil for Parkinson's disease related fatigue. Ethical approval was given. Patients with idiopathic PD were recruited from a Movement Disorders clinic. Those with depression, dementia, and other causes for fatigue were excluded. Patients were assessed using the Fatigue Severity Scale (FSS), Hospital Anxiety and Depression Scale (HADS), self-rating of improvement, Epworth Sleepiness Scale (ESS), and UPDRS. Modafinil was titrated up over 4 weeks to maximum of 400 mg/day. There followed a 5 week maintenance phase before reassessment. Thirteen patients participated. No significant change was seen in any safety measure. The FSS did not change significantly, however those on modafinil rated an improvement in their fatigue compared to placebo. The Modafinil group had a statistically significant improvement on ESS (p < 0.05). This is a small study of modafinil in selected PD patients. There is a suggestion of improvement on the global clinical impression scale for fatigue, but no significant change on FSS. A larger study is needed to further evaluate this drug in PD fatigue. This study highlights the problems with recruitment when trialing treatments of non-motor symptoms in PD. A significant improvement in EDS was seen.