1. Name Of The Medicinal Product
APO-go AMPOULES 10 mg/ml Solution for Injection or Infusion (Ireland, UK)
or
APO-go Ampullen 10 mg/ml Injektions-/Infusionslösung (Austria, Germany)
or
APO-go Ampul 10 mg/ml injektions-/infusionsvæske, opløsning (Denmark)
or
APO-go 10 mg/ml injektionsvätska, lösning / infusionsvätska, lösning (Sweden)
or
APOGO en solution injectable ou perfusion à 10 mg/ml en ampoules (France)
2. Qualitative And Quantitative Composition
1ml contains 10mg apomorphine hydrochloride
2ml contains 20mg apomorphine hydrochloride
5ml contains 50mg apomorphine hydrochloride
Excipient: Sodium metabisulphite (E223) 1mg per ml
For a full list of excipients, see section 6.1
3. Pharmaceutical Form
Solution for Injection or Infusion
Solution is clear and colourless
pH 3.0-4.0
4. Clinical Particulars
4.1 Therapeutic Indications
The treatment of disabling motor fluctuations (“on-off” phenomena) in patients with Parkinson's disease which persist despite individually titrated treatment with levodopa (with a peripheral decarboxylase inhibitor) and/or other dopamine agonists.
4.2 Posology And Method Of Administration
APO-go Ampoules 10 mg/ml Solution for Injection or Infusion is for subcutaneous use by intermittent bolus injection. APO-go Ampoules 10 mg/ml Solution for Injection or Infusion may also be administered as a continuous subcutaneous infusion by minipump and/or syringe-driver (see section 6.6).
Apomorphine must not be used via the intravenous route.
Dosage
Adults
Administration
Selection of Patients suitable for APO-go injections:
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Determination of the threshold dose.
The appropriate dose for each patient is established by incremental dosing schedules. The following schedule is suggested:-
1mg of apomorphine HCl (0.1ml), that is approximately 15-20 micrograms/kg, may be injected subcutaneously during a hypokinetic or 'off' period and the patient is observed over 30 minutes for a motor response.
If no response, or an inadequate response, is obtained a second dose of 2 mg of apomorphine HCl (0.2ml) is injected subcutaneously and the patient observed for an adequate response for a further 30 minutes.
The dosage may be increased by incremental injections with at least a forty minute interval between succeeding injections, until a satisfactory motor response is obtained.
Establishment of treatment.
Once the appropriate dose is determined, a single subcutaneous injection may be given into the lower abdomen or outer thigh at the first signs of an 'off' episode. It cannot be excluded that absorption may differ with different injection sites within a single individual. Accordingly, the patient should then be observed for the next hour to assess the quality of their response to treatment. Alterations in dosage may be made according to the patient's response.
The optimal dosage of apomorphine hydrochloride varies between individuals but, once established, remains relatively constant for each patient.
Precautions on continuing treatment.
The daily dose of APO-go varies widely between patients, typically within the range of 3-30 mg, given as 1-10 injections and sometimes as many as 12 separate injections per day.
It is recommended that the total daily dose of apomorphine HCl should not exceed 100 mg and that individual bolus injections should not exceed 10 mg.
In clinical studies it has usually been possible to make some reduction in the dose of levodopa; this effect varies considerably between patients and needs to be carefully managed by an experienced physician.
Once treatment has been established, domperidone therapy may be gradually reduced in some patients but successfully eliminated only in a few, without any vomiting or hypotension.
Continuous Infusion
Patients who have shown a good 'on' period response during the initiation stage, but whose overall control remains unsatisfactory using intermittent injections, or who require many and frequent injections (more than 10 per day), may be commenced on or transferred to continuous subcutaneous infusion by minipump and/or syringe-driver (see section 6.6) as follows:-
Continuous infusion is started at a rate of 1 mg apomorphine HCl (0.1 ml) per hour then increased according to the individual response. Increases in the infusion rate should not exceed 0.5 mg per hour at intervals of not less than 4 hours. Hourly infusion rates may range between 1 mg and 4 mg (0.1 ml and 0.4 ml), equivalent to 0.015 - 0.06 mg/kg/hour. Infusions should run for waking hours only. Unless the patient is experiencing severe night-time problems, 24 hour infusions are not advised. Tolerance to the therapy does not seem to occur as long as there is an overnight period without treatment of at least 4 hours. In any event, the infusion site should be changed every 12 hours.
Patients may need to supplement their continuous infusion with intermittent bolus boosts via the pump system as necessary, and as directed by their physician.
A reduction in dosage of other dopamine agonists may be considered during continuous infusion.
Children and adolescents:
APO-go Ampoules 10 mg/ml Solution for Injection or Infusion is contraindicated for children and adolescents under 18 years of age (see section 4.3).
Elderly:
The elderly are well represented in the population of patients with Parkinson's disease and constitute a high proportion of those studied in clinical trials of APO-go. The management of elderly patients treated with APO-go has not differed from that of younger patients.
Renal impairment:
A dose schedule similar to that recommended for adults, and the elderly, can be followed for patients with renal impairment (see section 4.4).
4.3 Contraindications
In patients with respiratory depression, dementia, psychotic diseases or hepatic insufficiency.
Intermittent apomorphine HCl treatment is not suitable for patients who have an 'on' response to levodopa which is marred by severe dyskinesia or dystonia.
APO-go should not be administered to patients who have a known hypersensitivity to apomorphine or any excipients of the medicinal product.
APO-go is contraindicated for children and adolescents under 18 years of age.
4.4 Special Warnings And Precautions For Use
Apomorphine HCl should be given with caution to patients with renal, pulmonary or cardiovascular disease and persons prone to nausea and vomiting.
Extra caution is recommended during initiation of therapy in elderly and/or debilitated patients.
Since apomorphine may produce hypotension, even when given with domperidone pretreatment, care should be exercised in patients with pre-existing cardiac disease or in patients taking vasoactive medicinal products such as antihypertensives, and especially in patients with pre-existing postural hypotension.
Since apomorphine, especially at high dose, may have the potential for QT prolongation, caution should be exercised when treating patients at risk for torsades de pointes arrhythmia.
Apomorphine is associated with local subcutaneous effects. These can sometimes be reduced by the rotation of injection sites or possibly by the use of ultrasound (if available) to areas of nodularity and induration.
APO-go Ampoules 10mg/ml Solution for Injection or Infusion contains sodium metabisulphite which may rarely cause severe allergic reactions and bronchospasm.
Haemolytic anaemia and thrombocytopenia have been reported in patients treated with apomorphine. Haematology tests should be undertaken at regular intervals as with levodopa, when given concomitantly with apomorphine.
Caution is advised when combining apomorphine with other medicinal products, especially those with a narrow therapeutic range (see section 4.5).
Neuropsychiatric problems co-exist in many patients with advanced Parkinson's disease. There is evidence that for some patients neuropsychiatric disturbances may be exacerbated by apomorphine. Special care should be exercised when apomorphine is used in these patients.
Apomorphine has been associated with somnolence, and other dopamine agonists can be associated with sudden sleep onset episodes, particularly in patients with Parkinson's disease. Patients must be informed of this and advised to exercise caution while driving or operating machines during treatment with apomorphine. Patients who have experienced somnolence must refrain from driving or operating machines. Furthermore, a reduction of dosage or termination of therapy may be considered.
Pathological gambling, increased libido and hypersexuality have been reported in patients treated with dopamine agonists for Parkinson's disease, including apomorphine.
4.5 Interaction With Other Medicinal Products And Other Forms Of Interaction
Patients selected for treatment with apomorphine HCl are almost certain to be taking concomitant medications for their Parkinson's disease. In the initial stages of apomorphine HCl therapy, the patient should be monitored for unusual side-effects or signs of potentiation of effect.
Neuroleptic medicinal products may have an antagonistic effect if used with apomorphine. There is a potential interaction between clozapine and apomorphine, however clozapine may also be used to reduce the symptoms of neuropsychiatric complications.
If neuroleptic medicinal products have to be used in patients with Parkinson's disease treated by dopamine agonists, a gradual reduction in apomorphine dose may be considered when administration is by minipump and/or syringe-driver (symptoms suggestive of neuroleptic malignant syndrome have been reported rarely with abrupt withdrawal of dopaminergic therapy).
It is recommended to avoid the administration of apomorphine with other drugs known to prolong the QT interval.
4.6 Pregnancy And Lactation
There is no experience of apomorphine usage in pregnant women.
Animal reproduction studies do not indicate any teratogenic effects, but doses given to rats which are toxic to the mother can lead to failure to breathe in the newborn. The potential risk for humans is unknown. See Section 5.3.
APO-go should not be used in pregnancy unless clearly necessary.
It is not known whether apomorphine is excreted in breast milk. A decision on whether to continue/discontinue breastfeeding or to continue/discontinue therapy with APO-go should be made taking into account the benefit of breast-feeding to the child and the benefit to APO-go to the women..
4.7 Effects On Ability To Drive And Use Machines
Patients being treated with apomorphine and presenting with somnolence and/or sudden sleep episodes must be informed to refrain from driving or engaging in activities (e.g. operating machines) where impaired alertness may put themselves or others at risk of serious injury or death until such recurrent episodes and somnolence have resolved (see also section 4.4).
4.8 Undesirable Effects
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Blood and lymphatic system disorders
Uncommon:
Haemolytic anaemia and thrombocytopenia have been reported in patients treated with apomorphine.
Rare:
Eosinophilia has rarely occurred during treatment with apomorphine HCl.
Immune system disorders
Rare:
Due to the presence of sodium metabisulphite, allergic reactions (including anaphylaxis and bronchospasm) may occur.
Psychiatric disorders
Common:
Neuropsychiatric disturbances are common in parkinsonian patients. APO-go should be used with special caution in these patients. Neuropsychiatric disturbances (including transient mild confusion and visual hallucinations) have occurred during apomorphine HCl therapy.
Not known:
Patients treated with dopamine agonists for treatment of Parkinson's disease, including apomorphine, especially at high doses, have been reported as exhibiting signs of pathological gambling, increased libido and hypersexuality; generally reversible upon reduction of the dose or treatment discontinuation.
Nervous system disorders
Common:
Transient sedation with each dose of apomorphine HCl at the start of therapy may occur; this usually resolves over the first few weeks.
Apomorphine is associated with somnolence.
Dizziness / light-headedness have also been reported.
Uncommon:
Apomorphine may induce dyskinesias during 'on' periods, which can be severe in some cases, and in a few patients may result in cessation of therapy.
Vascular disorders
Uncommon:
Postural hypotension is seen infrequently and is usually transient (See Section 4.4).
Respiratory, thoracic and mediastinal disorders
Common:
Yawning has been reported during apomorphine therapy.
Uncommon:
Breathing difficulties have been reported.
Gastrointestinal disorders
Common:
Nausea and vomiting, particularly when apomorphine treatment is first initiated, usually as a result of the omission of domperidone (See Section 4.2).
Skin and subcutaneous tissue disorders
Uncommon:
Local and generalised rashes have been reported.
General disorders and administration site conditions
Very common:
Most patients experience injection site reactions, particularly with continuous use. These may include subcutaneous nodules, induration, erythema, tenderness and panniculitis. Various other local reactions (such as irritation, itching, bruising and pain) may also occur.
Uncommon:
Injection site necrosis and ulceration have been reported.
Not Known:
Peripheral oedema has been reported.
Investigations
Uncommon:
Positive Coombs' tests have been reported for patients receiving apomorphine.
4.9 Overdose
There is little clinical experience of overdose with apomorphine by this route of administration. Symptoms of overdose may be treated empirically as suggested below:-
Excessive emesis may be treated with domperidone.
Respiratory depression may be treated with naloxone.
Hypotension: appropriate measures should be taken, e.g. raising the foot of the bed.
Bradycardia may be treated with atropine.
5. Pharmacological Properties
5.1 Pharmacodynamic Properties
Pharmacotherapeutic group: Dopamine agonists
ATC Classification: N04B C07
Apomorphine is a direct stimulant of dopamine receptors and, while possessing both D1 and D2 receptor agonist properties, does not share transport or metabolic pathways with levodopa.
Although in intact experimental animals, administration of apomorphine suppresses the rate of firing of nigro-striatal cells and in low dose has been found to produce a reduction in locomotor activity (thought to represent pre-synaptic inhibition of endogenous dopamine release) its actions on parkinsonian motor disability are likely to be mediated at post-synaptic receptor sites. This biphasic effect is also seen in humans.
5.2 Pharmacokinetic Properties
After subcutaneous injection of apomorphine its fate can be described by a two-compartment model, with a distribution half-life of 5 (±1.1) minutes and an elimination half-life of 33 (±3.9)minutes. Clinical response correlates well with levels of apomorphine in the cerebrospinal fluid; the active substance distribution being best described by a two-compartment model. Apomorphine is rapidly and completely absorbed from subcutaneous tissue, correlating with the rapid onset of clinical effects (4-12 minutes), and that the brief duration of clinical action of the active substance (about 1 hour) is explained by its rapid clearance. The metabolism of apomorphine is by glucuronidation and sulphonation to at least ten per cent of the total; other pathways have not been described.
5.3 Preclinical Safety Data
Repeat dose subcutaneous toxicity studies reveal no special hazard for humans, beyond the information included in other sections of the SmPC.
In vitro genotoxicity studies demonstrated mutagenic and clastogenic effects, most likely due to products formed by oxidation of apomorphine. However, apomorphine was not genotoxic in the in vivo studies performed.
The effect of apomorphine on reproduction has been investigated in rats. Apomorphine was not teratogenic in this species, but it was noted that doses which are toxic to the mother can cause loss of maternal care and failure to breathe in the newborn.
No carcinogenicity studies have been performed.
6. Pharmaceutical Particulars
6.1 List Of Excipients
Sodium metabisulphite (E223)
Hydrochloric acid, concentrated (for pH adjustment)
Sodium hydroxide (for pH adjustment)
Water for injections
6.2 Incompatibilities
In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal products.
6.3 Shelf Life
3 years
Once opened, use immediately. Discard any unused contents.
6.4 Special Precautions For Storage
Do not store above 25°C.
Store in the original package in order to protect from light.
6.5 Nature And Contents Of Container
Type I glass ampoules containing 2ml Solution for Injection or Infusion, in packs of 5 ampoules.
Type I glass ampoules containing 5ml Solution for Injection or Infusion, in packs of 5 ampoules.
Bundle pack of 25 and 50 ampoules are available in some territories.
The 25 ampoule bundles pack consists of 5 packs each containing 5 ampoules.
The 50 ampoule bundles pack consists of 10 packs each containing 5 ampoules.
Not all pack sizes are marketed.
6.6 Special Precautions For Disposal And Other Handling
Do not use if the solution has turned green.
The solution should be inspected visually prior to use. Only clear and colourless solutions should be used.
For single use only. Any unused solution should be discarded.
Continuous infusion and the use of a minipump and/or syringe-driver.
The choice of which minipump and/or syringe-driver to use, and the dosage settings required, will be determined by the physician in accordance with the particular needs of the patient.
7. Marketing Authorisation Holder
Genus Pharmaceuticals Limited
Park View House
65 London Road
Newbury
Berkshire
RG14 1JN
United Kingdom (IE and UK only)
Britannia Pharmaceuticals Limited
41 - 51 Brighton Road
Redhill
Surrey
RH1 6YS
United Kingdom (All other CMS)
8. Marketing Authorisation Number(S)
PL 06831/0245
PA 1496/2/1
9. Date Of First Authorisation/Renewal Of The Authorisation
January 2000 / January 2010
10. Date Of Revision Of The Text
May 2010
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