Apomorphine belongs to the class of medications called anti-Parkinson's agents. It is used to treat the early return of stiffness and movement problems that occur when the effects of other medications for Parkinson's disease wear off early. This "end-of-dose wearing off" of medications occurs with advanced Parkinson's disease.

Apomorphine helps to control the symptoms of Parkinson's disease by correcting the chemical imbalance in the brain that produces symptoms. Although apomorphine helps relieve symptoms of Parkinson's disease, it does not slow down the progression of the disease.

This medication may be available under multiple brand names and/or in several different forms. Any specific brand name of this medication may not be available in all of the forms or approved for all of the conditions discussed here. As well, some forms of this medication may not be used for all of the conditions discussed here.

Your doctor may have suggested this medication for conditions other than those listed in these drug information articles. If you have not discussed this with your doctor or are not sure why you are taking this medication, speak to your doctor. Do not stop taking this medication without consulting your doctor.

Do not give this medication to anyone else, even if they have the same symptoms as you do. It can be harmful for people to take this medication if their doctor has not prescribed it.

The recommended starting dose of apomorphine is 2 mg injected subcutaneously (under the skin) when your regular medication wears off and causes symptoms of Parkinson's disease to return. Based on effectiveness and side effects of the medication, your doctor may increase the dose, until the dose that relieves your symptoms is determined. The maximum recommended dose is 6 mg.

If a single dose of apomorphine is ineffective for a particular "off" period, a second dose should not be given for that "off" episode. Do not take a repeat dose of apomorphine sooner than 2 hours after the last dose.

Many things can affect the dose of medication that a person needs, such as body weight, other medical conditions, and other medications. If your doctor has recommended a dose different from the ones listed here, do not change the way that you are taking the medication without consulting your doctor.

Apomorphine is used with the guidance and supervision of a doctor. Your doctor or nurse may ask you to inject the medication at home once they have instructed you and are certain that you won't have any problems with doing it at home. Do not attempt to prepare or inject this medication on your own until you completely understand how to mix and inject a dose. This medication should be clear and colourless. Do not inject it if it is green, cloudy, or if you see particles.

If you miss a dose, take the next dose when you need it. Doses of apomorphine must be spaced at least 2 hours apart. Do not take a double dose to make up for a missed one. If you are not sure what to do after missing a dose, contact your doctor or pharmacist for advice.

Store this medication at room temperature, protect it from light and moisture, and keep it out of the reach of children. Discard any medication remaining in a pre-filled pen 48 hours after first using it.

Ampule
Each mL of clear, colorless, particle free, sterile, preservative preservative-free, solution for subcutaneous injection contains 10 mg of apomorphine hydrochloride. Nonmedicinal ingredients: sodium metabisulfite (E223) and water for injection; may also contain hydrochloric acid and sodium hydroxide for pH adjustment.

Penfill
Each mL of clear, colourless, particle free, sterile, preservative preservative-free, solution for subcutaneous injection contains 10 mg of apomorphine hydrochloride. Nonmedicinal ingredients: sodium bisulfite (E222) and water for injection; may also contain hydrochloric acid and sodium hydroxide for pH adjustment.

Do not take this medication if you:

• are allergic to apomorphine or any ingredients of the medication
• are taking anti-emetic medications that affect serotonin (e.g., ondansetron, granisetron, palonosetron)
• are taking medications that decrease blood pressure or dilate blood vessels
• have severely decreased liver function
• have severely decreased kidney function

Many medications can cause side effects. A side effect is an unwanted response to a medication when it is taken in normal doses. Side effects can be mild or severe, temporary or permanent.

The side effects listed below are not experienced by everyone who takes this medication. If you are concerned about side effects, discuss the risks and benefits of this medication with your doctor.

The following side effects have been reported by at least 1% of people taking this medication. Many of these side effects can be managed, and some may go away on their own over time.

Contact your doctor if you experience these side effects and they are severe or bothersome. Your pharmacist may be able to advise you on managing side effects.

• bruising, swelling or itchy at the injection site
• confusion
• dizziness
• drowsiness
• fainting
• headache
• joint pain
• nausea
• runny nose
• swelling of your hands, arms, legs and feet
• trouble sleeping
• vomiting
• yawning

Although most of the side effects listed below don't happen very often, they could lead to serious problems if you do not seek medical attention.

Check with your doctor as soon as possible if any of the following side effects occur:

• abnormal thinking – holding false beliefs that cannot be changed by fact
• agitation
• anxiety
• blurred vision
• clumsiness or unsteadiness
• compulsive behaviour (e.g., gambling, spending)
• colour, shape or size changes to moles
• dizziness when rising from a sitting or lying position
• fainting when standing up
• fast, irregular, or pounding heart beat
• hallucinations (e.g., seeing or hearing things that are not there)
• hand tremor (increased)
• patches of discolouration on the skin
• sudden onset of sleep
• sudden uncontrolled movements
• unusual skin changes, discolouration or moles
• unusual and uncontrolled movements of the body, including face, tongue, arms, hands, head, and upper body
• vision changes

Stop taking the medication and seek immediate medical attention if any of the following occur:

• long-lasting (greater than 4 hours) and painful erection of the penis
• symptoms of a severe allergic reaction (hives; difficulty breathing; difficulty swallowing; swelling of the face, mouth, throat, or tongue)
• very stiff muscles with high fever, rapid or irregular heartbeat, sweating, confusion, or reduced consciousness

Some people may experience side effects other than those listed. Check with your doctor if you notice any symptom that worries you while you are taking this medication.

Before you begin using a medication, be sure to inform your doctor of any medical conditions or allergies you may have, any medications you are taking, whether you are pregnant or breast-feeding, and any other significant facts about your health. These factors may affect how you should use this medication.

Abnormal thinking: Medications that affect dopamine can cause changes in how a person thinks. Apomorphine may cause people to become paranoid, agitated, and aggressive. It is not unusual to experience hallucinations, confusion or disorientation. If you notice changes in your thoughts, or you become aware of changes in thought from a person under your care, contact the doctor as soon as possible.

Alcohol: Consuming alcohol can make some of the side effects of apomorphine worse. Avoid drinking alcohol while you are using this medication.

Behaviour and mood changes: This medication has been known to cause mood swings, changes in behaviour and symptoms of psychosis. If you have a history of mental health concerns, discuss with your doctor how this medication may affect your medical condition, how your medical condition may affect the dosing and effectiveness of this medication, and whether any special monitoring is needed.

You may notice compulsive behaviour, such as gambling, increased sexual activity or inappropriate spending. If you experience symptoms of depression such as poor concentration, changes in weight, changes in sleep, decreased interest in activities, contact your doctor as soon as possible. If you notice compulsive behaviour or signs of depression in a family member, ensure that they see their doctor.

Drowsiness/reduced alertness: Apomorphine may affect the mental or physical abilities needed to drive or operate machinery. Avoid driving, operating machinery, or performing other potentially hazardous tasks until you have determined how you are affected by this medication.

Falls: People with Parkinson's disease are more likely to experience falls because the illness prevents them from moving smoothly to correct unbalanced posture. The use of apomorphine may increase the risk of falls due to the decreasesd blood pressure and changes in ability to move.

After using a dose of apomorphine, remember to rise slowly from a sitting or lying position and stay near something that offers support until you have established your balance.

Heart rhythm: Apomorphine can cause changes to the normal rhythm of the heart, including an irregular heartbeat called QT prolongation. QT prolongation is a serious life-threatening condition that can cause fainting, seizures, and sudden death. If you are at risk for heart rhythm problems (e.g., people with heart failure, angina, low potassium or magnesium levels), discuss with your doctor how this medication may affect your medical condition, how your medical condition may affect the dosing and effectiveness of this medication, and whether any special monitoring is needed.

Kidney function: The kidneys are partially responsible for removing this medication from your body. Kidney disease or reduced kidney function may cause this medication to build up in the body, causing side effects. If you have reduced kidney function or kidney disease, discuss with your doctor how this medication may affect your medical condition, how your medical condition may affect the dosing and effectiveness of this medication, and whether any special monitoring is needed.

Liver function: Liver disease or reduced liver function may cause this medication to build up in the body, causing side effects. If you have liver problems, discuss with your doctor how this medication may affect your medical condition, how your medical condition may affect the dosing and effectiveness of this medication, and whether any special monitoring is needed. Your doctor may want to test your liver function regularly with blood tests while you are taking this medication.

If you experience symptoms of liver problems such as fatigue, feeling unwell, loss of appetite, nausea, yellowing of the skin or whites of the eyes, dark urine, pale stools, abdominal pain or swelling, and itchy skin, contact your doctor immediately.

Low blood pressure: Apomorphine can cause blood pressure to drop, particularly when rising from a sitting or lying position. The combination of decreased blood pressure and improved mobility can contribute to the risk of falls for people with Parkinson's disease. If you feel dizzy or lightheaded or feel your pulse is racing, and this feeling does not go away after a few minutes, call your doctor. Because this medication can cause dizziness or lightheadedness, do not get up too quickly after you have been sitting or lying for prolonged periods. If you have heart disease (e.g., heart failure, heart attack) or are taking medications that lower blood pressure, discuss with your doctor how this medication may affect your medical condition, how your medical condition may affect the dosing and effectiveness of this medication, and whether any special monitoring is needed.

Melanoma: People with Parkinson's disease may be at increased risk of developing melanoma (a type of skin cancer). It is not known if this increased risk is due to Parkinson's disease or to the medications used to treat Parkinson's disease. Your doctor will monitor you for skin cancer while you are taking this medication. Talk to your doctor if you have any concerns.

Nausea and vomiting: Apomorphine causes severe nausea and vomiting when it is taken at normal doses. Your doctor will likely prescribe a medication to prevent these effects, to be started a few days before the first dose of apomorphine.

Neuroleptic malignant syndrome (NMS): Rarely, apomorphine can cause a potentially fatal syndrome known as neuroleptic malignant syndrome (NMS). If you notice the symptoms of NMS such as high fever, muscle stiffness, confusion or loss of consciousness, sweating, racing or irregular heartbeat, or fainting, get immediate medical attention.

Sudden onset of sleep: There are reports of people who take this medication falling asleep with no warning or drowsiness. If you have a sleep disorder or you have experienced this with other medications to treat Parkinson's disease, discuss this with your doctor. If you experience drowsiness while taking this medication, avoid driving or using machinery.

Pregnancy: This medication should not be used during pregnancy unless the benefits outweigh the risks. If you become pregnant while taking this medication, contact your doctor immediately.

Breast-feeding: It is not known if apomorphine passes into breast milk. If you are a breast-feeding mother and are taking this medication, it may affect your baby. Talk to your doctor about whether you should continue breast-feeding.

Children: The safety and effectiveness of using this medication have not been established for children.

Seniors: Seniors are more likely to experience severe adverse side effects when taking apomorphine. This medication is more likely to be prescribed at lower doses for seniors to reduce this risk.

There may be an interaction between apomorphine and any of the following:

• alcohol
• aldesleukin
• aliskiren
• alpha blockers (e.g., alfuzosin, doxazosin, tamsulosin)
• alpha agonists (e.g., clonidine, methyldopa)
• angiotensin converting enzyme inhibitors (ACEIs; captopril, enalapril, ramipril)
• angiotensin receptor blockers (ARBs; e.g., candesartan, irbesartan, losartan)
• antiarrhythmics (e.g., amiodarone, disopyramide, flecainide, procainamide, quinidine)
• anti-psychotics (e.g., chlorpromazine, clozapine, haloperidol, olanzapine, quetiapine, risperidone)
• barbiturates (e.g., butalbital, phenobarbital)
• beta-adrenergic blockers (e.g., atenolol, propranolol, sotalol)
• brimonidine
• bupropion
• calcium channel blockers (e.g., amlodipine, diltiazem, nifedipine, verapamil)
• clomipramine
• conivaptan
• diazoxide
• diuretics (water pills; e.g., furosemide, hydrochlorothiazide, triamterene)
• duloxetine
• hydralazine
• imipramine
• kava kava
• levodopa
• methadone
• metoclopramide
• minoxidil
• nitrates (e.g., nitroglycerin, isosorbide dinitrate, isosorbide mononitrate)
• obinutuzumab
• pentoxifylline
• phosphodiesterase 5 inhibitors (e.g., sildenafil, tadalafil, vardenafil)
• pramipexole
• protein kinase inhibitors (e.g., lapatinib, pazopanib, sunitinib)
• quinine
• quinolone antibiotics (e.g., ciprofloxacin, ofloxacin, sparfloxacin)
• ropinirole
• serotonin antagonists (anti-emetic medications; e.g., granisetron, ondansetron)
• tetrabenazine
• tizanidine
• tretinoin

If you are taking any of these medications, speak with your doctor or pharmacist. Depending on your specific circumstances, your doctor may want you to:

• stop taking one of the medications,
• change one of the medications to another,
• change how you are taking one or both of the medications, or
• leave everything as is.

An interaction between two medications does not always mean that you must stop taking one of them. Speak to your doctor about how any drug interactions are being managed or should be managed.

Medications other than those listed above may interact with this medication. Tell your doctor or prescriber about all prescription, over-the-counter (non-prescription), and herbal medications you are taking. Also tell them about any supplements you take. Since caffeine, alcohol, the nicotine from cigarettes, or street drugs can affect the action of many medications, you should let your prescriber know if you use them.