Objective: This is a poster presentation

Background: Continuous apomorphine therapy is a pump delivered infusion via subcutaneous injection for management of advanced therapy in Parkinson’s disease. The aim is to improve motor fluctuations and to reduce the numbers and severity of daily ‘off phases” (1). Subcutaneous nodules are a side effect of these infusions (2).Supportive evidence examined biopsies of these local inflammatory reactions which identified the nodules as panniculitis (3). Necrosis and subcutaneous abscesses can occur in the most severe cases of nodules (4).Good skin care routine, rotation of injection sites and massage  can help to reduce the incidence of skin nodule. The presence of nodules may interfere with absorption of the drug(5). There has been previous case studies where apomorphine at 2mg/hr, diluted with 1:2 sodium cholride has been trailed in an attempt to improve skin adverse events (6)

Method: Pt 1 received a established effective 5mg hourly infusion dose without dilution using apomorphine 100mg/20ml vials. Pt 2 received the same hourly dose of apomorphine, the infusion was constituted with 16mls of active ingredient and 4mls normal saline. The fluid rate measured by millilitres per hour is increased, whilst the milligrams of apomorphine delivered per hour is not altered. Observational data were collected over a 60 day period at baseline, at month 1 and at month 2. Nodules were examined and rated by a nurse.

Results: The skin nodules were less frequent and less severe in patient two when compared to patient one  It was also noted that the recovery rate of skin nodules developed in patient one was more rapid than compared with patient two. There was a higher incident of necrosis when apomorphine was administered undiluted. The data is not significant due to it small sample group, however these findings show promising outcomes in the reduction of painful skin nodules through dilution.

Conclusion: These observations suggest that dilution of the apomorphine with normal saline may reduce nodules. Further case studies are required to support this observational study. The reduction in nodules may improve patient adherence and tolerability of this advanced therapy.

References: (1) Apomine Solution for infusion Approved Product Information 2017. (2) ND0701, A Novel Formulation of Apomorphine for Subcutaneous Infusion, in Comparison to a Commercial Apomorphine Formulation: 28-Day Pharmacokinetic Study in Minipigs and a Phase I Study in Healthy Volunteers to Assess the Safety, Tolerability, Pharmacokinetics and Relative Bioavailability Ramot, Y ; Nyska, A ; Adar, L ; Durlach, C ; Fishelovitch, D; Sacco, G ; Manno, R ; Oren, S ; Perlstein, Itay ; Yacobi-Zeevi, Oron CNS Drugs, 2018, Vol.32(5), pp.443-454 [Peer Reviewed Journal] (3) Panniculitis in association with apomorphine infusion Acland ; Churchyard ; Fletcher ; Turner ; Lees ; Dowd British Journal of Dermatology, March 1998, Vol.138(3), pp.480-482 [Peer Reviewed Journal] (4) Fat necrosis and subcutaneous abscesses due to apomorphine García-Zamora E ; Elosua-González M; Floristán-Muruzábal U, Medicina Clinica, 12 October 2018, Vol.151(7), pp.294-295 [Peer Reviewed Journal] (5)Cutaneous side effects of infused apomorphine: The patient and carer experience Poltawski L, Edwards E, Todd A, Watson T, James C A, Lees A, Published Online:27 Sep 2013https://doi.org/10.12968/bjnn.2008.4.12.31962 (6)111 Multiple necrotic ulcers resulting from subcutaneous apomorphine infusion Ganesalingam, J ; Bain, P G Journal of Neurology, Neurosurgery and Psychiatry, Mar 2012, Vol.83(3), p.e1

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MDS Abstracts - https://www.mdsabstracts.org/abstract/the-power-of-normal-saline-in-reducing-skin-nodules-in-apomorphine/