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Dopamine Agonist — Parkinson's Disease Rescue / Continuous Infusion Pregnancy: Avoid — limited data; theoretical teratogenic risk

Apomorphine

Brand names: APO-go Pen, Dacepton

Adult dose

Dose: Rescue pen: 2–6 mg SC per off episode (titrated by specialist); Continuous SC infusion: 1–4 mg/hour
Route: Subcutaneous injection (rescue) or SC infusion (pump)
Frequency: Rescue: as needed for off episodes (max ~10 injections/day); Infusion: continuous 16–24 hours/day
Max: Rescue: 10 mg/dose; Infusion: titrated individually — typically 3–7 mg/hour
Must be initiated in hospital under specialist supervision. Pre-treat with domperidone 20 mg TDS for minimum 3 days before first dose (antiemetic — metoclopramide crosses BBB and worsens Parkinson's). Test dose: 1 mg SC with BP monitoring. Infusion sites must be rotated daily. NOT for IV use.

Paediatric dose

Route:
Seek specialist opinion — not licensed in paediatrics

Dose adjustments

Renal

Use with caution — no specific dose adjustment; monitor for enhanced hypotension

Hepatic

Contraindicated in severe hepatic impairment

Clinical pearls

  • Apomorphine is a potent D1/D2 agonist with rapid SC absorption — onset 5–10 minutes, duration 45–90 minutes; ideal rescue for unpredictable off episodes
  • Domperidone is the ONLY antiemetic to use — it does not cross the BBB and does not worsen motor function
  • Infusion site complications are the major limiting factor — EMLA cream, rotation protocols, ultrasound-guided site selection
  • Haemolytic anaemia monitored with Coombs test — occurs with chronic high-dose infusion
  • Specialist nurse support essential for infusion programme success

Contraindications

  • Dementia or psychiatric comorbidity (relative)
  • Severe renal/hepatic impairment
  • Respiratory depression
  • IV administration
  • On-demand use without domperidone cover

Side effects

  • Nausea and vomiting (prevent with domperidone)
  • Hypotension (including orthostatic)
  • Drowsiness and sudden sleep onset
  • Hallucinations and psychosis
  • Impulse control disorders
  • Injection site nodules, skin necrosis (with prolonged infusion)
  • Haemolytic anaemia (rare, with long-term infusion)
  • QTc prolongation

Interactions

  • Metoclopramide — contraindicated (central dopamine antagonism worsens Parkinson's + reduces apomorphine efficacy)
  • Antihypertensives — additive hypotension
  • Antipsychotics — antagonise apomorphine effect
  • QT-prolonging drugs — additive risk
  • Alcohol — enhanced sedation and hypotension

Monitoring

  • BP lying and standing (especially at initiation)
  • ECG (QTc)
  • FBC and Coombs test (long-term infusion)
  • Neuropsychiatric assessment
  • Injection site inspection

Reference: BNFc; BNF 90; NICE NG71 (Parkinson's Disease); Parkinson's UK Apomorphine Guidelines 2024. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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