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Parkinson's Disease

Understanding Parkinson’s disease

Parkinson’s disease is a progressive, neurological disease that causes dopaminergic neurones in the brain to die over many years. It is characterised by motor symptoms - specifically tremor, muscle rigidity and slowness of movement (bradykinesia).1

The disease is also associated with non-motor symptoms including tiredness, pain, depression, problems with memory, swallowing and sleep, problems urinating, anxiety and constipation.1

In early Parkinson’s disease, therapeutic strategies rely on dopamine replacement (oral levodopa). As P arkinson’s disease progresses, patients typically start to experience motor fluctuations and dyskinesia, which negatively affect quality of life and characterize the transition from early to advanced Parkinson’s disease.4

Understanding gastrointestinal dysfunction

Although attention is primarily focused on the motor features of Parkinson’s disease, there is growing recognition that many clinical symptoms of PD have little or nothing to do with motor function.5

a) Mouth

Pooling of saliva and problems with movements to brush teeth can cause dental problems. Motor effects cause jaw tremors.

b) Oesophagus

Symptoms of oesophageal dysphagia include slow oesophageal transit, oesophageal spasms, spontaneous contractions of proximal oesophagus, air trapping, aperistalsis, and gastroesophageal reflux.

c) Small intestine


d) Colon

Colonic dysmotility constipation ,megacolon, volvulus, and bowel perforation.

e) Salivary glands

Reduced saliva production, but low swallowing frequency causes drooling.

f) Pharynx

Oropharyngeal dysphagia increases risk of aspiration.

g) Stomach

Impaired gastric emptying (gastroparesis) causes nausea, bloating, early satiety.

h) Rectum

Anorectal dysfunction leads to difficulty with defecation.

Delay in gastric emptying. Photograph taken during gastroscopy. Arrow points to a carbidopa tablet remaining in a patient’s stomach about 1.5h after intake. Fasano et al. 20156

The most common non-motor feature of the condition is gastrointestinal dysfunction and this can occur at virtually all levels of the gastrointestinal tract.5

This can be a significant issue for patients taking oral medications due to issues with swallowing (dysphagia) and impaired gastric emptying (gastroparesis), which can affect the absorption of oral medications and is recognized as a significant contributor to OFF time.6

Understanding APO-go® treatments

APO-go® is a treatment for advanced Parkinson's disease and its active constituent is apomorphine hydrochloride.2,3 It is marketed as APO-go® in the UK. It is also available in many other countries, with brand names including APOKYN®, APOKINON® and MOVAPO®.

As APO-go® therapy is administered via subcutaneous injection or pre-filled syringes (PFS) as a continuous infusion by minipump and/or syringe driver. Apomorphine is absorbed from the subcutaneous tissue resulting in a rapid onset of effect (typically within 4-12 minutes).2,3

APO-go® is available via two types of devices

Please explore the APO-go® PEN and the APO-go® INFUSION pages to learn more about the use of these products in advanced Parkinson’s disease.

  1. 1. Parkinson’s and You. A guide for people new to the condition. https://www.parkinsons.org.uk/sites/default/files/2018-09/B181%20Parkinson%27s%20and%20you%20WEB.pdf. Accessed 20 Nov 2020.
  2. SmPC: APO-go Pen 10mg/ml Solution for Injection. https://www.medicines.org.uk/emc/product/2232/smpc. Accessed 20 Nov 2020.
  3. 3. SmPC: APO-go PFS 5mg/ml Solution for Infusion in Pre-filled Syringe. https://www.medicines.org.uk/emc/product/3908/smpc. Accessed 20 Nov 2020.
  4. 4. Antonini A & Jenner P. Apomorphine infusion in advanced Parkinson disease. Nat Rev Neurol. 2018;14:693-94.
  5. 5. Pfeiffer RF. Gastrointestinal dysfunction in Parkinson’s disease. Lancet Neurology 2003;2:107–16
  6. 6. Fasano A, Visanji NP, Liu LWC, et al. Gastrointestinal dysfunction in Parkinson’s disease. Lancet Neurol. 2015;14:625-39.
  7. 7. Stocchi F. The levodopa wearing-off phenomenon in Parkinson’s disease: pharmacokinetic considerations. Exp Opin Pharmacother 2006;7:1399-407.
  8. 8. Chapuis S, Ouchchane L, Metz O, et al. Impact of the motor complications of Parkinson’s disease on the quality of life. Mov Disord. 2005;20:224-30.
  9. 9. Trenkwalder C, Chaudhuri KR, García Ruiz PJ, et al. on behalf of an Expert Consensus Group for the use of apomorphine in Parkinson's disease. Expert Consensus Group report on the use of apomorphine in the treatment of Parkinson's disease - clinical practice recommendations. Parkinsonism Rel Disord 2015;21:1023-30.
  10. 10. Dewey RB Jr, Hutton JT, LeWitt PA, Factor SA. A randomized, double-blind, placebo-controlled trial of subcutaneously injected apomorphine for parkinsonian off-state events. Arch Neurol. 2001;58:1385-92.
  11. 11. Pfeiffer RF, Gutmannb L, Hull KL Jr, et al., the APO302 Study Investigators. Continued efficacy and safety of subcutaneous apomorphine in patients with advanced Parkinson’s disease. Parkinsonism Rel Disord 2007;13:93–100.
  12. 12. Katzenschlager R, Poewe W, Rascol O, et al. Apomorphine subcutaneous infusion in patients with Parkinson’s disease with persistent motor fluctuations (TOLEDO): a multicentre, double-blind, randomised, placebo-controlled trial. Lancet Neurol 2018;17:749-59.
  13. 13. Silverdale M. Continuous dopaminergic stimulation in Parkinson’s disease. Prog Neurol Psychiatr 2007;11:24-8.
  14. 14. Pietz K, Hagell P, Odin P. J Neurol Neurosurg Psychiatry 1998;65:709–716.
  15. 15. Kanovsky P, et al. Mov Disord 2002;17(1):188–191.


AM IMPAKT Study interim results. Presented at International Parkinson and Movement Disorder Society. Treatment of Parkinson’s Disease: Past, Present and Future. March 2014, Miami, Florida, USA.
Antonini A, et al. Parkinsonism and Relat Disord 2009;15S:S97-S100.
Chaudhuri KR, Ondo W. Handbook of Movement Disorders, Current Medicine Group, 2009.
Deleu D, Hanssens Y, Northway MG. Drugs and Aging 2004;21(11):687–709.
Dewey et al. Arch.Neurol 2001;58(9):1385–92.
Drapier S, et al.Parkinsonism and Relat Disord 2012;18:40-44.
Hagell P, Odin P. J Neurosci Nurs 2001;33(1):21–38.
NICE Guidelines for Parkinson’s Disease: National clinical guidelines for diagnosis and management in primary and secondary care. Royal College of Physicians, published June 2006.
Pietz K, Hagell P, Odin P. J Neurol Neurosurg Psychiatry 1998;65(5):709–16.
Riederer P et al. Parkinsonism Relat Disord 2007;13(8):466–79.
Rizos A, et al. Poster presented at MDPD, Seoul, 2013.
Ruiz PJG, et al. Movement Disord 2008;23(8):1130-1136.
Silverdale M. Continuous dopaminergic stimulation in Parkinson’s disease. Progress in Neurology and Psychiatry .2007;11(1):24-28.
Stacy M. J Neural Transm 2010;117:837-846.
Stocchi F. Neurol Sci 2008;29:S383-S386.
Todd A, James C-A. Apomorphine nodules in Parkinson’s disease: Best Practice management. British Journal of Community Nursing, Clinical Review 2008;13(10):457-63.
Bhidayasiri R, Chaudhuri K R, LeWitt P, et al. Clin Neuropharm 2015;38:89–103.

Parkinson’s UK Website. https://www.parkinsons.org.uk/content/parkinsons-symptoms.

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