New trends in advanced parkinson disease stage therapy.

The aim of the study was to point out the contribution of new invasive therapeutic procedures in the treatment of advanced stages of Parkinson's disease (PD) in comparison with classical oral pharmacotherapy. Data originated from a group of 43 patients with PD, 39% (17) with classic treatment, 23% (10) with intestinal gel of methyl ester levodopa (Duodopa), 19% (8) of patients were using subcutaneous delivery of apomorphine (APO) and the same quantity of patients had undergone deep brain stimulation (DBS). Majority of patients had advanced stages of PD, stage 4, by standards of Hoehn and Yahr scale (Hoehn and Yahr, 1967). Research observed improvement in majority of patients with novel treatments. A positive effect was also noted in the reduced need for oral therapy, where there was a significant decrease in all new therapies. Benefits were observed in the amount of antiparkinsonic drugs taken per os, where we observed reduction in all new therapies. A positive effect of the new therapeutic approaches in reducing "off" periods in patients has also been noted. In the case of Duodopa and DBS, the "off" period was shortened up to 50% and in the apomorphine pump up to 40%. Patients also reported reduction of some symptoms like rigidity, tremor and bradykinesis while dyskinesis still remains suba challenge. On the basis of the obtained results, it can be concluded that new therapeutic procedures for PCh will make it possible to manage symptoms typical of advanced stages of the disease, which without these procedures would lead to disability, which is the main reason for their indication. However, in early stages, well responding patients or in slow progressing disease oral antiparkinsonics are remaining as golden standard of treatment. This is not just due to good response but also because these classic drug formulations are significantly less expensive. In Slovakia, novel treatments are accessible through healthcare insurance only after secondary revision by insurance company doctors.

[The homecare provider, a little-known player in the care of Parkinson's patients]. / Le prestataire de santé à domicile, un acteur méconnu dans la prise en charge du patient parkinsonien.

Setting up a device-based treatment for a Parkinson's patient at home is a complex affair. The homecare nurse, an expert in this pathology, coordinates the various professionals working with the patient, and is the privileged contact for the prescribing doctor. Thanks to his or her wide range of skills, he or she can provide invaluable assistance to ensure that the patient's care goes smoothly.

Continuous subcutaneous apomorphine monotherapy in Parkinson's disease.

INTRODUCTION AND OBJECTIVE: Continuous subcutaneous apomorphine (APO) treatment is one of the 3 therapeutic options for advanced Parkinson's disease (PD), in addition to deep brain stimulation (DBS) and intrajejunal levodopa. Data from previously performed studies show that few PD patients can achieve APO infusion as monotherapy. The current pilot study presents the authors' experience in achieving APO monotherapy. MATERIAL AND METHODS: During the last 2 years, 9 patients with APO were treated in the Department of Neurology of the Medical University of Lublin; each patient was offered a 5-day duration APO treatment as monotherapy. The main indication for the APO therapy was advanced PD with motor fluctuations and the patient's non-agreement for DBS therapy. Mean age of treated patients - 65.11 years, mean disease duration - 7.67 years, mean Hoehn-Yahr - 2.67, mean L-dopa equivalent before APO treatment - 1751.11 mg, mean daily dose of apomorphine as monotherapy - 106.11 ± 14.09 mg. RESULTS: All treated patients managed to achieve APO monotherapy. A statistically significant reduction was found in the duration of the 'off' states in the observed PD patients on APO monotherapy (p<0.05). No significant improvement was observed in the III motor score of the UPDRS on APO treatment, compared to optimized oral therapy used before APO treatment. CONCLUSIONS: APO monotherapy can be achieved in advanced PD, and seems to be a good therapeutic option for this group of patients, especially in that it allows a significant reduction in the off-time which significantly simplifies the drug regime. Nevertheless, hospital admission with experienced neurologist supervision is recommended when establishing a PD patient's APO monotherapy.

Apomorphine pump in advanced Parkinson's disease: Effects on motor and nonmotor symptoms with brain metabolism correlations.

INTRODUCTION: Patients with advanced Parkinson's disease (PD) and contraindications for subthalamic nucleus deep brain stimulation (DBS) could particularly benefit from subcutaneous infusion therapy with apomorphine. This original study was designed to evaluate the general efficacy of add-on apomorphine in motor and nonmotor symptoms in advanced PD, while characterizing the changes induced in brain glucose metabolism. The aim was to look at the underlying anatomical-functional pathways. METHODS: 12 patients with advanced PD were assessed before and after 6months of add-on apomorphine, using resting-state 18F-fluorodeoxyglucose positron emission tomography and exhaustive clinical assessments. RESULTS: After 6months of therapy, oral treatment was significantly reduced. Both motor and nonmotor scores improved, with a beneficial effect on executive functions, quality of life and apathy. Significant metabolic changes were observed, with overall increases in the right fusiform gyrus and hippocampus, alongside a decrease in the left middle frontal gyrus. Consistent correlations between significant changes in clinical scores and metabolism were established. CONCLUSION: Well tolerated, add-on apomorphine appears to be an interesting option for patients with fluctuations and contra-indications for DBS. Changes in brain metabolism, with beneficial effects on motor and nonmotor symptoms were observed after 6months. These preliminary results have to be confirmed by further studies.

Quality of life in Parkinson's disease improved by apomorphine pump: the OPTIPUMP cohort study.

To report on OPTIPUMP, a cohort study, investigating the impact in real-life clinical settings of continuous subcutaneous apomorphine infusion (CSAI) on the quality of life (HRQoL) of patients with Parkinson's disease. OPTIPUMP was a prospective, open-label, observational cohort study involving 30 investigational sites in France. CSAI was proposed as part of routine clinical care to patients aged ≥18 years, in absence of dementia, with a PD diagnosis and based on the presence of motor fluctuations not controlled by oral treatments. The impact of APO-pump on quality of life was evaluated as the difference in PDQ-39 scores between the initiation treatment and the follow-up visit after 6 months' treatment. All adverse events were recorded. Hyper- and hypodopaminergic behavioral tolerance was assessed on the Ardouin Scale of Behavior in Parkinson's Disease. Between September 2011 and January 2013, we enrolled 142 patients: 42 patients were withdrawn due to pump removal (33), death (4), lost of follow-up (4), no available data (1). 100 completed the study. At 6 months, their HRQoL had significantly improved (p = 0.011), as had their total UPDRS score (p < 0.001). Regarding the safety profile, Ardouin scale scores indicated that their hyperdopaminergic behaviors had not increased. CSAI had a favorable impact on HRQoL, with benefits outweighing risks. The analysis of the withdrawn patients highlights the heterogeneity of the use of the pump having an impact on its efficacy and tolerability.

Expert Consensus Group report on the use of apomorphine in the treatment of Parkinson's disease--Clinical practice recommendations.

Extensive published evidence supports the use of subcutaneously-administered apomorphine as an effective therapy for Parkinson's disease (PD) but to date no consensus recommendations have been available to guide healthcare professionals in the optimal application of apomorphine therapy in clinical practice. This document outlines best-practice recommendations for selecting appropriate candidates for apomorphine intermittent injection (the pen-injection formulation) or apomorphine continuous infusion (the pump formulation), for initiating patients onto therapy and for managing their ongoing treatment. Apomorphine is a suitable therapeutic option for PD patients who experience troublesome 'off' periods despite optimized treatment with oral PD medications. Due to its speed of onset, apomorphine injection is particularly suited to those patients requiring rapid, reliable relief of both unpredictable and predictable 'off' periods, those who require reliable and fast relief when anticipating an 'off', those with levodopa absorption or gastric emptying problems resulting in delayed or failed 'on', or for rapid relief of early morning dystonia or akinesia. Apomorphine infusion(1) is suited for patients whose 'off' periods can no longer be adequately controlled by standard oral PD treatment or for those in whom rescue doses of apomorphine injection are effective but either needed too frequently (more than 4-6 times per day), or are associated with increasing dyskinesia. In addition to treating motor fluctuations, there is evidence that apomorphine infusion may be effective for the management of specific non-motor symptoms of PD associated with 'off' periods. Apomorphine infusion is less invasive than other non-oral treatment options for advancing disease, intrajejunal levodopa infusion and deep-brain stimulation.