Administration

Initiating treatment12

Patients treated with apomorphine will usually need to start domperidone at least two days prior to initiation of therapy. The domperidone dose should be titrated to the lowest effective dose and discontinued as soon as possible. Before the decision to initiate domperidone and apomorphine treatment, risk factors for QT interval prolongation in the individual patient should be carefully assessed to ensure that the benefit outweighs the risk.

To help determine if a patient is suitable for APO-go® therapy, a response test will be carried out in order to observe the efficacy and manage expected adverse events in addition to finding the correct dose for that particular patient.

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APO-go® PEN response test

To help determine if a patient is suitable for APO-go® therapy, a response test will be carried out in order to observe the efficacy and adverse events expected, in addition to finding the correct dose for that particular patient.

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Preparing for the response test12

Patients treated with apomorphine will need to start domperidone at least two days prior to initiation of therapy. The domperidone dose should be titrated to the lowest effective dose and discontinued as soon as possible. Before the decision to initiate domperidone and apomorphine treatment, risk factors for QT interval prolongation in the individual patient should be carefully assessed and an ECG should be carried out to establish the correct QT interval (QTc).

On the day of the response test12

Advise the patient on the appropriate dose of oral medication to take that morning. Typically this will be less than normal, as the test is aimed to assess which dose of APO-go® is most suitable in order to reverse an ‘OFF’ state into an ‘ON’ state.

To conduct the response test, administer 1mg of apomorphine and monitor the patients' response over 30 minutes. The dosage may be increased by incremental injections (with at least a 40 minute interval between injections) until a satisfactory motor response is obtained. At each dose level, the patients’ movement (such as standing and walking) should be assessed, in addition to manual dexterity e.g. finger tapping. Ensure vital signs (e.g. blood pressure, pulse) are constantly monitored during the APO-go® initiation. An ECG should also be performed during the initiation to assess QTc interval.

If the APO-go® therapy has been successful you will notice the improvement in tremor and muscle rigidity and the patient will have improved mobility.

After the response test

The optimal dosage of APO-go® PEN varies between individuals but, once established, remains relatively constant for each patient.

For full information about initiating APO-go® PEN please see the Summary of Product Characteristics, speak to a Britannia Nurse / Key Account Manager or call Medical Information on 01483 920 763.

APO-go® PEN administration

The steps below provide a comprehensive guide on how to set up each APO-go® PEN, as per the Summary of Product Characteristics.

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Attaching the needle

(a) Before using APO-go® PEN you will need some surgical wipes and one needle in its protective cone.

(b) Take the APO-go® PEN out of its box and remove the outer sleeve.

(c) Wipe the membrane of the APO-go® PEN with a surgical wipe.

(d) Peel off the paper from the needle cone.

(e) It is important to bring the needle to the APO-go® PEN in a straight line, as shown above. If the needle is presented at an angle it may cause the APO-go® PEN to leak.

(f) Screw the cone clockwise onto the membrane until it is tight. This securely attaches the needle.

(g) Remove the protective cone, but do not throw it away. Do not remove the needle protector at this stage.

(h) Replace the APO-go® PEN's outer sleeve.

Selecting the correct dose

(i) Press the red capped dosage dial and whilst holding it down, turn the dial clockwise until the arrow points to the dose your doctor chose for you. Release the downward pressure on the red-capped dial. The dose is now set and you do not need to redial for subsequent injections.

Important: If you pass your prescribed dose while turning the dial, just continue pressing and turning in the same direction until the arrow points to the dose your doctor chose for you.

Never pull and turn the red-capped dosage dial at the same time.

If your dose is 1 mg, start by emptying a 1 mg dose onto a paper tissue and discarding it. This is called 'priming' and is important because it ensures you get a full dose the first time you use your APO-go® PEN. Then, set the dose you require for injection and inject it in the usual way (see “Injecting”). If the first dose required is more than 1 mg, you do not need to prime the APO-go® PEN.

Injecting

(j) Once you have set the dose, gently pull out the red-capped dosage dial as far as it will go. Check the red scale on the plunger and inject only if the line that is just visible matches the intended dose.

(k) Using a surgical wipe, clean the area of skin where you plan to inject the medicine and around it.

(l) Remove the APO-go® PEN's outer sleeve.

(m) Remove the needle protector.

(n) Insert the needle into the skin as shown by your doctor.

(o) To inject, press the red-capped dosage dial down as far as it will go, using your thumb if possible. Once the red-capped dosage dial is fully depressed, count to three before withdrawing the needle.

(p) Replace the protective cone onto the used needle and push gently into place. Once secure, turn the needle anti-clockwise to unscrew it.

Keep the needle in its protective cone and discard it in a safe place, such as a “Sharps” bin or an empty
coffee jar.

Preparing for the next injection

(q) Remove the outer sleeve of the APO-go® PEN and check there is enough apomorphine left in the cartridge for your next injection. If there is, put a new needle in place in the same way as before.

(r) If there is not enough apomorphine left for another injection, prepare another APO-go® PEN.

(s) Finally, replace the outer sleeve of your APO-go® PEN.

APO-go® PUMP

The APO-go® PUMP uses a subcutaneous needle with an infusion line in order to deliver APO-go® in a continuous manner, throughout the day. Both the amount of APO-go® and the total infusion time will depend upon the personal needs of the patient. The amount that will work best will have been determined during the patients’ response test.

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Initiating treatment

Patients treated with apomorphine will usually need to start domperidone at least two days prior to initiation of therapy. The domperidone dose should be titrated to the lowest effective dose and discontinued as soon as possible. Before the decision to initiate domperidone and apomorphine treatment, risk factors for QT interval prolongation in the individual patient should be carefully assessed to ensure that the benefit outweighs the risk.

Infusion sites

A different site for infusions should be used every day. It is also important that the injection area is clean and that the patient rotates infusion sites. Advise your APO-go® patients to read our advice pages on skin management to make sure they are taking care of their skin.

Infusion site rotation is very important as it minimises the chance of infection, scarring and other skin problems, ensures good drug absorption and allows older injection sites to heal.

Setting up the APO-go® PUMP

APO-go® PUMP is simple to set up and you (or a member of the Parkinson Specialist Nurse team) will need to instruct the patient on how to do this when prescribing APO-go PUMP.

For a visual demonstration on how to set up the APO-go® PUMP, please follow the link below to see the set up videos, download the APO-go® PUMP Setup Guide or speak to a Britannia nurse.

APO-go PUMP MKIII (variable flow rate) Setup Video

APO-go PUMP MKI (fixed flow rate) Setup Video

The APO-go® PUMP is not water- or shock-proof. Instruct patients to remove the APO-go PUMP before bathing or getting into the shower and to keep it away from hot surfaces or electrical appliances.

Storage

All APO-go® therapies and associated items should be stored in a safe place away from children and animals. It should be kept out of direct sunlight and stored at room temperature (below 25˚C). APO-go® PFS should not be used and instead be discarded in a sharps bin if the solution has turned green, cloudy or contains visible particles. APO-go® PFS must not be used past its expiry date (shown on the APO-go® PFS box).

Precautions16

APO-go® PUMP infusion is given subcutaneously. Advise patients not to use a syringe if the solution has turned green.

The APO-go® Pre-filled syringe (PFS) has been designed for continuous infusion with the APO-go® PUMP. It is not to be used for intermittent injection. Continuous infusion is usually given during waking hours, but can vary between patients. The amount of apomorphine hydrochloride delivered each day should not exceed 100 mg. This medicine must not be administered into a vein. There is no need to dilute APO-go® PFS before use. In addition, it should not be mixed with other medicines.

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