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2nd Parkinson’s Review Meeting

Posted in Sponsored Feature on 8th Dec 2012

Conference details:  Friday 21st September 2012, Eden Building, Hope University, Liverpool.
Chairs: Prof Andrew Lees & Dr Malcolm Steiger
Reviewed by: Sarah Woozley, Genus Pharmaceuticals.

On Friday 21st September, the second annual Parkinson’s Review Meeting (PRM) was held at Liverpool’s Hope University.  The meeting was supported by an unrestricted grant from Genus Pharmaceuticals Ltd and attracted 6 CPD points with its keynote speakers and comprehensive review of apomorphine, management options in Complex Parkinson’s and the effect of the changing NHS on Neurological services.

The day was chaired by Professor Andrew Lees, Clinical Director of Queen Square Brain Bank for Neurological Disorders, London, and Dr Malcolm Steiger, Consultant Neurologist and Director of Research and Development at The Walton Centre, Liverpool. Over 140 delegates registered for the event and included Parkinson’s disease Nurse Specialists, Consultant Neurologists and Elderly Care, SpRs, GPs and Pharmacists.

The day started with Prof Lees’ overview of the history of apomorphine, which was licensed in the UK as APO-go 20 years ago this year.  Following the recognition that this therapy can improve Parkinson’s symptoms,1,2 it is now believed that continuous subcutaneous infusion of apomorphine may reset the dyskinesia threshold.3

Prof Lees spoke about the two presentations of apomorphine available in the UK: the intermittent injection and continuous infusion.  He noted that the intermittent injection tended to be used earlier for ‘milder’ cases: in patients with active lives, with one or two predictable ‘off’ periods a day. With the Infusion, he recommended getting the patients off as much of their concomitant oral medication as possible, with apomorphine offering a cleaner therapeutic option. The use of apomorphine has been shown to have a sustained effect, allowing for many years of therapy, as was demonstrated in the following session.

Dr Steiger presented his long-term experience of using apomorphine, declaring that the therapy is underused and questioning why this might be when you consider the results seen.  “If you think the drug is expensive, consider the cost of the condition to the economy, to the patient and their family” he stated.

Misunderstandings around apomorphine include (1) the inaccurate belief that it is morphine – yet apomorphine has no narcotic properties and is NOT morphine; and (2) clinicians think it is a cumbersome therapy – it isn’t, stated Dr Steiger: patients will use what works.  The delivery mechanism means the drug avoids the gut, removing issues around absorption and gastric emptying. So, although there is an initial investment of time by HCPs, use in appropriate patients offers a reliable, quick and effective treatment. Dr Steiger recommended that the dialogue about what therapeutic options are available as the condition progresses should be held early on to remove fear of the unknown.

The next session from Prof David Burn, IAH Director & Professor of Movement Disorder Neurology at the University of Newcastle, covered cognition in Parkinson’s: There is a known link between the D3 receptor and behavioural issues in Parkinson’s, which is not surprising considering the D3 receptors are found in the limbic areas of the brain – those areas implicated in psychosis, noted Prof Burn.

Newer dopamine agonists tend to have high D3 affinity. Concern that apomorphine, with weak D3 affinity, may cause adverse neuropsychiatric effects is not founded in evidence, explained Prof Burn. Published studies tended to be small or have methodological flaws but the balance of evidence does not suggest neuropsychiatric issues are a major issue with apomorphine. Apomorphine has powerful antioxidant effects and has been shown to inhibit fibril formation, which may have implications across other disease areas.

Dr Biju Mohamed, Consultant Physician and Geriatrician, Rockwood Hospital, Cardiff subsequently discussed dopamine dysregulation syndrome (DDS) and impulse control disorders (ICDs), and the link with D3 receptor activity.

Healthcare professionals need to be vigilant for potential ICD issues, commented Dr Mohamed, by listening to the patient and their family member or carer who may accompany them to clinic. There are questionnaires available to aid in identifying at-risk individuals, and one audience member highlighted a tool available from Parkinson’s UK: http://www.parkinsons.org.uk/pdf/CompulsiveBehaviourInformationTool.pdf

The role of long-acting non-ergot dopamine agonists in complex Parkinson’s was covered by Dr Sandip Raha, Associate Specialist in Integrated Medicine, Movement Disorder Clinic, Princess of Wales Hospital, Bridgend.  Continuous dopaminergic stimulation with a long-acting dopamine agonist is a more physiological option for the treatment of complex Parkinson’s than using short-acting formulations. Dr Raha covered data on various long-acting dopamine agonists – oral formulations, the patch, and continuous infusions of apomorphine.

Next, Sue Thomas, Chief Executive, Neurological Commissioning Support (NCS), covered the topic of how the changes now underway in the NHS mean that clinicians will be increasingly involved in commissioning services.  NCS was created to help clinicians influence service development. HCPs must become familiar with the efficiency indicators that are used to measure the performance of their services, e.g. admission ratios and length of stay, and identify potential savings, such as through avoiding unplanned admissions or reducing in-patient stays.

The final session of the day covered the role of PDNS’, with Brian Magennis from Mater Misericordiae University Hospital, Dublin and Anne Martin from the National Parkinson Foundation International Centre of Excellence, Kings College Hospital, London.

Mr Magennis covered his apomorphine audit data, which showed a substantially reduced tablet burden and polypharmacy dose reduction in patients  successfully initiated onto apomorphine infusion, as well as significant UPDRS and Webster motor score improvements and reduction in ICDs.

Ms Martin then described her experience at the tertiary centre, managing an array of Complex Parkinson’s patients, with a restriction on in-patient beds. She highlighted the importance of patient selection, not leaving it too late to consider non-oral treatment options, and covered her protocol for managing the polypharmacy reduction when initiating apomorphine patients, including the crucial point of planning existing dopamine agonist withdrawal and levodopa dose reduction.

Thereafter followed a debate on planned admission versus day-case initiation of apomorphine therapy, taking into consideration the pressure on NHS resources, the needs of the patient and those around them.  In-patient initiation can mean respite for the family or carer of a Parkinson’s patient, with the opportunity to review the patient more fully.  Day case initiation is carried out increasingly frequently, removing the anxiety associated with having to stay in hospital, and also saving hospital resources surrounding the need for a planned admission.

Ultimately, the needs of the patients need to be taken into consideration on an individual basis, but there shouldn’t be any fear associated with day-case initiations on apomorphine.

The day included frequent audience interaction and informative question and answer sessions, as well as panel discussions. The feedback from the delegates has been extremely positive and a similar one day meeting is planned for 2013.

For further information on the day’s talks and outcomes, please contact Genus on Tel. 01635 568400, Email. info@genuspharma.com

 References

1.      Hagell P, Odin P 2001. Apomorphine in the treatment of Parkinson’s disease. Journal of Neuroscience Nursing, 9(33):No.1.

2.      Katzenschlager R, Hughes A, Evans A et al 2005. Continuous Subcutaneous Apomorphine Therapy Improves Dyskinesia in Parkinson’s Disease: A Prospective Study Using Single-Dose Challenges. Movement Disorders, 20(2):151-7.

This report was supplied by Genus Pharmaceuticals who have sponsored its inclusion in ACNR

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