hi all

a search of the pd list archives returns over 200 references to apomorphine
[the first of these look quite informative]
at:
<http://james.parkinsons.org.uk/>

a search at google.com returned this article as google's first choice:

EPDA Drug Information - Apomorphine (Britaject)
<http://www.shef.ac.uk/misc/groups/epda/drug4.htm>

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EUROPEAN PARKINSON'S DISEASE ASSOCIATION

Drug Information

Apomorphine (Britaject)

Apomorphine is a dopamine agonist drug, used to treat Parkinson's disease,=
 which is given by injection, unlike other dopamine agonists which are given=
 in tablet form.

Parkinson's Disease

Parkinson's is caused by a shortage of a chemical messenger (dopamine) in=
 the part of the brain which controls movement. This results in stiffness in=
 the muscles, slowness, difficulty when starting movements, and in some=
 people tremor.

The basal ganglia behave rather like to floppy disk of a computer where=
 programs of movements are stored and adjusted. Dopamine working in balance=
 with another chemical messenger, acetylcholine, is responsible for the=
 feedback mechanism that enables these programs of movement to be put into=
 action. The symptoms of Parkinson's do not appear until about 80% of the=
 dopamine has been lost, and the level of dopamine will continue to fall=
 slowly over many years. However each person is very different and the rate=
 and progression will vary enormously from one person to another.

Drug Therapy

Although at present there is no cure, several different drug treatments are=
 available to help control the symptoms of Parkinson's. The main aim of drug=
 therapy in the treatment of Parkinson's is to restore dopaminergic=
 function. This can be achieved by increasing the level of dopamine=
 (levodopa drugs), or by using drugs which mimic the effects of dopamine=
 (dopamine agonists).

Unfortunately the long term treatment of Parkinson's disease with levodopa=
 is often complicated by the development of fluctuating motor response in=
 relation to drug doses. These fluctuations, which are often called=
 wearing-off or the on-off syndrome generally occur after about 5-10 years=
 of levodopa treatment. Some people have likened the "on/off" syndrome to=
 the idea of a light being switched on or off - "off" when there is no=
 response to the drugs and "on" when the drugs are effective. Dopamine=
 agonists can be used in combination with levodopa to reduce these=
 fluctuations.

Dopamine agonists

Dopamine agonists work by stimulating the parts of the brain where dopamine=
 works, and unlike levodopa (the main drug used to treat Parkinson's), do=
 not require conversion by the brain cells first. They have a longer=
 duration of action that levodopa and may suit patients better than=
 levodopa. Dopamine agonists may be taken alone but are usually used in=
 conjunction with levodopa to "smooth out" control of symptoms in people=
 whose response to treatment is beginning to fluctuate. These include=
 bromocriptine (Parlodel), lisuride (Revanil), pergolide (Celance),=
 ropinirole (ReQuip), and cabergoline (Cabaser).

Apomorphine (Britaject)

Apomorphine (trade name Britaject) is a dopamine agonist manufactured by=
 Britannia Pharmaceuticals. It is usually prescribed to provide additional=
 or alternative benefit for those people who have had Parkinson's disease=
 for some time - who are finding that their drugs are less effective, and=
 who are experiencing "wearing-off" or sudden and unpredictable "on-off"=
 fluctuations.

The people who seem to benefit most are those who have bad "off" periods,=
 but who are reasonably well when "on". It does not help everyone, but it is=
 now often tried with people who have "off" periods of half an hour or more=
 and who have not improved after adjustments to their ordinary medication.=
 As apomorphine currently has to be given by injection, the person with=
 Parkinson's and their carer have to be able to cope with this and to learn=
 how to do it. This sometimes involves staying in hospital for a few days,=
 although an increasing number of potential users are now being assessed and=
 trained on a day care or domiciliary (home) care basis.

Advantages

The main advantage of apomorphine is that it can act as a "rescue treatment"=
 when tablets or capsules fail to take effect. For people who are assessed=
 as suitable, it will work within 5 to 15 minutes - much more quickly than=
 tablets or capsules. Because of this predictable response, it can sometimes=
 help people with Parkinson's to go on working for longer than would=
 otherwise be possible.

Disadvantages

The main disadvantage is that, at the moment, it can only be given by=
 injection. Other methods of delivery have been tried but have so far proved=
 less effective. This means that both the person with Parkinson's and their=
 main carer need to be willing and able to give the injections. The=
 technique and the confidence to use it can be taught, but there are people=
 who feel unable to face the prospect of having or giving regular=
 injections. It is important to involve the main carer (who may be a partner=
 or a close friend or relative) because there may be times when the person=
 with Parkinson's is too rigid or immobile to give the injection.

Apomorphine also causes nausea and vomiting but this problem has been=
 largely overcome by giving another drug called domperidone (Motilium)=
 beforehand. Some people can even manage without domperidone after a few=
 months. Domperidone is a safe drug and although it makes the drug regime a=
 little more complicated, this is not really a disadvantage.

The site of the injections can become rather sore and irritated, especially=
 when a syringe driver is used. This problem can be reduced by diluting the=
 apomorphine with an equal amount of saline (a sterile salt solution).

Methods of Administering the Injections

Apomorphine can be injected in several different ways - by syringe driver,=
 syringe or a ready loaded disposable pen.

A syringe driver is a small, battery driven pump which can deliver a=
 continuous dose of medication through a needle which is inserted under the=
 skin (subcutaneously) in the lower abdomen (i.e. the area below the navel).=
 The medication, in this case apomorphine, is then absorbed into the blood=
 stream and goes from there to the brain. The dose can be adjusted to suit=
 the person with Parkinson's, and the pump itself is carried in their pocket=
 or in a small pouch. The position of the needle needs to be changed each=
 day to reduce the risk of the skin getting sore. A small number of people=
 use their syringe drivers continuously day and night. If this is essential,=
 the needle site must be changed every 12 hours.

Some people who are prescribed apomorphine need to use a syringe driver -=
 mainly those who have found that they need more than 10 injections a day.=
 Changing over to a syringe driver can greatly improve the quality of their=
 lives in such circumstances.

There are two alternatives to syringe drivers available at the moment. The=
 first is a syringe of the type that people with diabetes use to give=
 themselves their insulin. Most people who use apomorphine begin by using=
 this syringe and many find it quite simple and easy to use.

The disadvantage of a syringe is that it can only hold one dose. For this=
 and other reasons, some people prefer to use an injection pen, a special=
 type of multi-dose syringe. Until recently the only pen available was the=
 Hypoguard Penject which has to be loaded from the ampoules of apomorphine=
 issued at the pharmacist. This created a problem for some people,=
 especially those living alone or with carers who were unable to carry out=
 this task. Now Britannia Pharmaceuticals has produced a ready-loaded,=
 disposable Britaject Pen which overcomes this difficulty. It holds 30mg of=
 apomorphine and the individual dose (anything from 1 to 10 mg) is set by=
 turning the dial.

Both syringes and pens deposit apomorphine just under the skin and have the=
 advantage of not irritating it as much as a syringe driver. They do not,=
 give continuous medication, but apomorphine injections can be repeated=
 several times a day as necessary.

Apomorphine is usually prescribed by a specialist who will decide in=
 consultation with their hospital team which is the most appropriate system=
 for the person to use. No one delivery system is right for everyone - the=
 choice will depend on factors such as frequency of dose, manual dexterity,=
 lifestyle and availability of help.

Availability on the National Health Service

There is little problem with prescribing the syringes as they are also=
 widely used for diabetes. Hypoguard Penjects cannot be ordered on an=
 ordinary prescription form. Anyone who has problems in obtaining them=
 should contact the ward or clinic where they were assessed and trained and=
 ask for further advice. Britaject Pens can be prescribed but the needles=
 come separately and appropriate numbers should be provided by the=
 pharmacist who can obtain supplies directly from Britannia.

Syringe drivers are quite expensive and there are sometimes local problems=
 in obtaining them. Such problems are now easily resolved as Britannia=
 Pharmaceuticals has agreed to loan them free of charge. The fine infusion=
 lines used with syringe drivers have to be obtained through the District=
 Nursing Service.

Further Information

Each person with Parkinson's disease will have a different combination of=
 symptoms and will therefore react to medication in a different way. Your=
 doctor will be the best person to advise you on the appropriate treatment=
 for your condition and to give you further information on apomorphine.

Acknowledgement

This fact sheet has been adapted from information contained in "Parkinson's=
 at Your Fingertips" by Dr. Marie Oxtoby and Professor Adrian Williams,=
 published by Class Publishing.

Parkinson's Disease Society of the United Kingdom
215 Vauxhall Bridge Road,=20
London SW1V 1EJ=20
Tel: 0171 931 8080;=20
Fax: 0171 233 9226=20
Helpline: (Mondays - Fridays 10.00 am - 4.00 pm) 0171 388 5798=20
Registered Charity No: 258197=20
Date: 17th April 1997

Copyright =A9 EPDA, 1997, 1998=20
Last Updated 3rd June 1998
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janet paterson - 51 now /41 dx /37 onset - almonte/ontario/canada
http://www.newcountry.nu/pd/members/janet/index.htm
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