Version July 2025
Dosage guidance:
Dosage form information: Kynmobi sublingual film has been discontinued in the United States for >1 year.
Clinical considerations: Beginning antiemetic therapy (eg, trimethobenzamide) is recommended 3 days prior to initiation; continue only as long as necessary, and generally no longer than 2 months, due to increased risk of adverse events. Apomorphine is intended to be used as adjunctive therapy with other anti-Parkinson agents.
Parkinson disease, advanced:
Note: Continuous infusion therapy initiations and dose titrations with Onapgo pump should be done under medical supervision. Patients and/or caregivers must be capable of understanding and trained on the delivery system prior to use.
Continuous infusion: SUBQ (98 mg per 20 mL with Onapgo pump): Initial: 1 mg/hour; adjust dose based on response and tolerability in 0.5 to 1 mg/hour increments at intervals ≥1 day up to a maximum continuous dosage of 6 mg/hour. Maximum total daily dose (including continuous infusion and extra doses): 98 mg/day administered over the waking day (eg, 16 hours).
Extra doses:
Note: May use extra doses upon starting dosing in the morning, when restarting the continuous infusion after a ≥1 hour break in use (eg, for use as a loading dose), or as a supplement to the continuous infusion to manage acute "off" symptoms that are not controlled.
SUBQ (98 mg per 20 mL with Onapgo pump): Usual dose: 0.5 to 2 mg; adjust extra doses based on response and tolerability in increments of 0.5 to 1 mg to a maximum of 3 extra doses per day over 16 hours with at least 3 hours between each extra dose. If 3 extra doses are routinely required, consider adjustment of the continuous dosage. Maximum total daily dose (including continuous infusion and extra doses): 98 mg/day administered over the waking day (eg, 16 hours).
Discontinuation of therapy: Taper therapy before discontinuing; sudden or rapid reduction could result in increased severity of motor symptoms.
Parkinson disease, "off" episode:
Sublingual film: Note: Determine starting dose when patient is in an "off" state and in a setting where a health care provider can monitor blood pressure and pulse. In clinical trials, to achieve an "off" state, the morning dose of carbidopa/levodopa (or any adjunctive Parkinson disease medications) was withheld and any Parkinson disease medications were avoided after midnight the night before. If response insufficient but dose tolerated, patient should resume usual Parkinson medications and return to health care provider in an "off" state to reinitiate at the next dose increment.
Initial: 10 mg as needed at intervals ≥2 hours for "off" episodes up to a maximum of 5 doses per day; may increase dose in 5 mg increments within 3 days based on response and tolerability up to a maximum single dose of 30 mg.
Intermittent injection (30 mg per 3 mL): SUBQ: Initial test dose 0.1 mL (1 mg) or 0.2 mL (2 mg), medical supervision required; see "Note." Consider initiating therapy at 0.1 mL (1 mg) as an alternative to trimethobenzamide therapy to reduce the incidence of nausea and vomiting. Subsequent dosing is based on both tolerance and response to initial test dose.
If patient tolerates and responds to 0.1 mL (1 mg) test dose: Starting dose: 0.1 mL (1 mg) as needed; may increase dose in 0.1 mL (1 mg) increments every few days; maximum dose: 0.6 mL (6 mg).
If patient tolerates or does not tolerate and responds to 0.2 mL (2 mg) test dose: Starting dose: 0.2 mL (2 mg) as needed; may increase dose in 0.1 mL (1 mg) increments every few days; patients who do not tolerate the 0.2 mL (2 mg) test dose may need the dose increased slowly; maximum dose: 0.6 mL (6 mg).
If patient tolerates but does not respond to 0.1 mL (1 mg) test dose: Second test dose: 0.2 mL (2 mg).
If patient tolerates but does not respond to 0.2 mL (2 mg) test dose: Second test dose: 0.4 mL (4 mg).
If patient tolerates and responds to 0.4 mL (4 mg) test dose: Starting dose: 0.3 mL (3 mg), as needed for “off” episodes; may increase dose in 0.1 mL (1 mg) increments every few days; maximum dose: 0.6 mL (6 mg).
If patient does not tolerate 0.4 mL (4 mg) test dose: Third test dose: 0.3 mL (3 mg).
If patient tolerates 0.3 mL (3 mg) test dose: Starting dose: 0.2 mL (2 mg) as needed for “off” episodes; after a few days, may increase dose up to 0.3 mL (3 mg). Medically supervise for any subsequent dose increases >0.3 mL (3 mg).
If therapy is interrupted for >1 week, restart at 0.2 mL (2 mg) and gradually titrate dose.
Note: Medical supervision is required for all test doses with standing and supine blood pressure monitoring predose and 20-, 40-, and 60 minutes postdose (and after 60 minutes, if there is significant hypotension at 60 minutes). If subsequent test doses are required, wait >2 hours before another test dose is given; next test dose should be timed with another “off” episode. If a single dose is ineffective for a particular “off” episode, then a second dose should not be given. The average dosing frequency was 3 times/day in the development program with limited experience in dosing >5 times/day, single doses >0.6 mL (6 mg), and with total daily doses >2 mL (20 mg).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
Sublingual film:
CrCl ≥30 mL/minute: No dosage adjustment necessary.
CrCl <30 mL/minute: Avoid use.
SUBQ:
Continuous infusion (98 mg per 20 mL with Onapgo pump):
Mild to moderate impairment:
Continuous infusion: No dosage adjustment necessary.
Extra doses: Initial dose: 0.5 to 1 mg; no dosage adjustment necessary for subsequent extra doses.
Severe impairment: There are no dosage adjustments provided in the manufacturer's labeling (has not been studied).
Intermittent injection (30 mg per 3 mL):
Mild to moderate impairment: Initial test dose: 0.1 mL (1 mg); Starting dose: 0.1 mL (1 mg) as needed.
Severe impairment: There are no dosage adjustments provided in the manufacturer's labeling (has not been studied).
Sublingual film:
Mild to moderate impairment (Child-Pugh class A or B): No dosage adjustment necessary.
Severe impairment (Child-Pugh class C): Avoid use.
SUBQ:
Continuous infusion (98 mg per 20 mL with Onapgo pump):
Mild to moderate impairment: There are no dosage adjustments provided in the manufacturer's labeling; however, studies demonstrate increased apomorphine concentrations and drug exposure. Use with caution and closely monitor.
Severe impairment: There are no dosage adjustments provided in the manufacturer's labeling (has not been studied); use with caution and closely monitor.
Intermittent injection (30 mg per 3 mL):
Mild to moderate impairment: No dosage adjustment necessary; use caution.
Severe impairment: There are no dosage adjustments provided in the manufacturer's labeling (has not been studied).
Use with caution; adverse effects (confusion and hallucinations), some serious, are reported more frequently in patients ≥65 years of age. Refer to adult dosing.
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.
>10%:
Cardiovascular: Angina pectoris (SUBQ injection: ≤15%), chest pain (SUBQ injection: ≤15%), chest pressure (SUBQ injection: ≤15%), hypotension (SUBQ injection: ≤11%; SUBQ infusion: 7%; sublingual film: ≤4%), orthostatic hypotension (SUBQ injection: ≤20%; SUBQ infusion: 4% [including orthostatic intolerance: 2%]; sublingual film: ≤4%), syncope (SUBQ injection: ≤11%; sublingual film: ≤4%)
Gastrointestinal: Nausea (SUBQ injection: ≤30%; SUBQ infusion: 22%; sublingual film: 21% to 28%; can be severe nausea; can occur with antiemetic pretreatment), oral paresthesia (sublingual film: ≤13%), vomiting (SUBQ injection: ≤30%; SUBQ infusion: 7%; sublingual film: 4% to 7%; can be severe vomiting; can occur with antiemetic pretreatment)
Local: Infusion-site reaction (SUBQ infusion: 63%; including bruising, discoloration, edema, erythema [17%], hematoma, hemorrhage, hypersensitivity reaction [2%], infection [4%], induration, inflammation, nodule [44%], pain, pruritus [4%], skin rash [2%], swelling), injection-site reaction (SUBQ injection: 5% to 26%; bruising at injection site [16%], injection-site granuloma [4%], injection-site pruritus [2%])
Nervous system: Dizziness (SUBQ injection: ≤20%; SUBQ infusion: 9%; sublingual film: 9% to 11%), drowsiness (SUBQ injection: 35%; SUBQ infusion: 22%; sublingual film: 11% to 13%), falling (SUBQ injection: 30%; sublingual film: 4% to 6%), hallucination (SUBQ injection: ≤14%, sublingual film: ≤6%), headache (SUBQ injection: ≥5%; SUBQ infusion: 13%; sublingual film: 6% to 8%), insomnia (SUBQ injection: ≥5%; SUBQ infusion: 11%), yawning (SUBQ injection: 40%)
Neuromuscular & skeletal: Dyskinesia (SUBQ injection: 24% to 35%; SUBQ infusion: 15%)
Respiratory: Oropharyngeal edema (sublingual film: 1% to 15%), oropharyngeal pain (sublingual film: ≤13%), rhinorrhea (SUBQ injection: 20%; sublingual film: 6% to 7%)
1% to 10%:
Cardiovascular: Acute myocardial infarction (SUBQ injection: ≤4%; SUBQ infusion: 2%), edema (SUBQ injection: ≤10%), heart failure (SUBQ injection: ≥5%), left bundle branch block (SUBQ infusion: 2%), palpitations (SUBQ infusion: 2%), presyncope (sublingual film: ≤4%), prolonged QT interval on ECG (SUBQ infusion: 4%), swelling of extremities (SUBQ injection: ≤10%), tachycardia (SUBQ infusion: 2%)
Dermatologic: Diaphoresis (SUBQ injection: ≥5%), ecchymoses (SUBQ injection: ≥5%), hyperhidrosis (sublingual film: 4% to 6%), skin rash (SUBQ infusion: 4%), urticaria (sublingual film: ≤6%)
Endocrine & metabolic: Dehydration (SUBQ injection: ≥5%)
Gastrointestinal: Constipation (SUBQ injection: ≥5%; SUBQ infusion: 7%), diarrhea (SUBQ injection: ≥5%), oral mucosa ulcer (sublingual film: ≤7%), oral mucosal erythema (sublingual film: 4% to 7%), stomatitis (sublingual film: ≤7%), xerostomia (sublingual film: 1% to 6%)
Genitourinary: Urinary tract infection (SUBQ injection: ≥5%)
Hematologic & oncologic: Hemolytic anemia (SUBQ infusion: 2%)
Hypersensitivity: Facial swelling (sublingual film: ≤6%), hypersensitivity reaction (SUBQ infusion: 2%; sublingual film: 6%)
Nervous system: Anxiety (SUBQ injection: ≥5%), asthenia (SUBQ injection: ≥5%; SUBQ infusion: 7%), confusion (SUBQ injection: ≤10%; sublingual film: ≤6%), delusion (sublingual film: ≤6%), depression (SUBQ injection: ≥5%), disorientation (sublingual film: ≤6%), exacerbation of Parkinson disease (SUBQ injection: ≥5%), fatigue (SUBQ injection: ≥5%; SUBQ infusion: 7%; sublingual film: 3% to 7%), psychotic reaction (SUBQ infusion: 2%)
Neuromuscular & skeletal: Arthralgia (SUBQ injection: ≥5%), back pain (SUBQ injection: ≥5%), limb pain (SUBQ injection: ≥5%)
Respiratory: Dyspnea (SUBQ injection: ≥5%), pneumonia (SUBQ injection: ≥5%)
Miscellaneous: Laceration (sublingual film: 1% to 6%)
<1%: Genitourinary: Priapism (SUBQ injection)
Frequency not defined (any formulation): Nervous system: Abnormal gait
Postmarketing (any formulation): Nervous system: Aggressive behavior, agitation, behavioral changes, impulse control disorder (including increased libido, pathological gambling), mental status changes, paranoid ideation, sudden onset of sleep
Hypersensitivity to apomorphine, any component of the formulation, or to a sulfite; concomitant use with 5-HT3 antagonists.
Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
Canadian labeling: Additional contraindications (not in US labeling): Concomitant use with antihypertensives or vasodilators (Movapo); severe hepatic or renal impairment.
Concerns related to adverse effects:
• Cardiac events: Cardiac events including angina, left bundle branch block, myocardial infarction, palpitations, tachycardia, QTc prolongation, cardiac arrest, and sudden death have occurred with treatment; some cases have occurred within 2 hours of dosing while other cases were unrelated to dosing. Consider the risks and benefits of therapy in patients with risk factors for prolonged QTc.
• Dyskinesias: May cause or exacerbate dyskinesias.
• GI effects: Severe nausea and vomiting may occur. Pretreatment with antiemetic (eg, trimethobenzamide) is necessary and should be started 3 days prior to initiation of therapy and continued only as long as necessary to control nausea/vomiting, and generally no longer than 2 months. Trimethobenzamide increases the risk of somnolence, dizziness, and falls. Avoid use of antidopaminergic antiemetic agents (eg, promethazine, prochlorperazine, chlorpromazine, metoclopramide, haloperidol).
• Hallucinations/psychosis: May cause hallucinations or psychotic-like behavior or thoughts (eg, paranoia, delusions, confusion, disorientation, aggression, agitation, delirium) which may be severe; avoid in patients with major psychotic disorders.
• Hemolytic anemia: Hemolytic anemia, requiring hospitalization and including severe anemia, angina, and dyspnea, has been reported and may occur at any time after treatment; most cases included a positive direct antiglobulin test (Coombs test) suggesting a potential immune-mediated hemolysis. If hemolytic anemia occurs, consider discontinuing treatment.
• Hypersensitivity: Hypersensitivity reactions (including angioedema or anaphylaxis) to apomorphine or its sulfite component may occur. If a hypersensitivity reaction to apomorphine occurs, discontinue and do not restart.
• Impulse control disorders: Has been associated with compulsive behaviors and/or loss of impulse control, which has manifested as pathological gambling, libido increases (hypersexuality), binge eating, and/or other intense urges. Dose reduction or discontinuation of therapy has been reported to reverse these behaviors in some, but not all cases.
• Orthostatic hypotension/syncope: May cause orthostatic hypotension, especially during dose escalation, and syncope. Parkinson disease patients appear to have an impaired capacity to respond to a postural challenge. The hypotensive effects of apomorphine are exacerbated by concomitant ethanol consumption and sublingual nitroglycerin use. Additional risk factors for hypotension may include concomitant use of other antihypertensive drugs or vasodilators or where transient hypotensive episodes would be poorly tolerated (cardiovascular disease or cerebrovascular disease). Carefully monitor for signs and symptoms of postural hypotension (especially during dose escalation). Avoid ethanol during therapy.
• Pleural/retroperitoneal fibrosis: Ergot-derived dopamine agonists have also been associated with fibrotic complications (eg, retroperitoneal fibrosis, pleural thickening, cardiac valvulopathy, and pulmonary infiltrates); monitor closely for signs and symptoms of fibrosis; effects may or may not be reversible.
• Priapism: Has been reported; severe priapism may require medical attention.
• Somnolence: Somnolence and falling asleep while engaging in activities of daily living, without prior warning signs, has been reported; symptoms may occur well after start of therapy. Monitor for daytime somnolence or preexisting sleep disorder; caution with concomitant sedating medication; discontinue if significant daytime sleepiness or episodes of falling asleep occur. There is insufficient information to determine if dose reduction will resolve somnolence. Patients must be cautioned about performing tasks which require mental alertness (eg, operating machinery or driving). Use with caution in patients receiving other CNS depressants or psychoactive agents. Effects with other sedative drugs or ethanol may be potentiated.
Disease-related concerns:
• Cardiovascular disease: Use with caution in patients with cardiovascular disease; hypotension may cause coronary ischemia.
• Cerebrovascular disease: Use with caution in patients with cerebrovascular disease; hypotension may cause cerebral ischemia.
• Hepatic impairment: Use with caution in patients with hepatic impairment; avoid use in severe hepatic impairment (sublingual film).
• Renal impairment: Use with caution in patients with renal impairment; avoid use in severe renal impairment (sublingual film).
Special populations:
• Older adult: Adverse effects (confusion and hallucinations), some serious, are reported more frequently in patients ≥65 years; use with caution.
• Patients at risk for torsades de pointes: Use with caution in patients with risk factors for torsades de pointes (hypokalemia, hypomagnesemia, bradycardia, concurrent use of drugs that prolong QTc, or genetic predisposition).
Dosage form specific issues:
• Benzyl alcohol: Injection may contain benzyl alcohol which has been associated with "gasping syndrome" in neonates.
• Metabisulfite: Contains metabisulfite, which may cause hypersensitivity reactions. Sensitivity to sulfites is more common in patients with asthma and may cause hypersensitivity reactions (including anaphylaxis and life-threatening asthma exacerbations).
• Sublingual film: Mild to moderate oral mucosal irritation (ulceration, stomatitis, pain, paresthesia) has occurred; usually resolved after discontinuation (rechallenge is not recommended).
• SUBQ continuous infusion: May cause infusion-site reactions and infections including cellulitis, nodules, erythema, hematomas, inflammation, pruritus, swelling, discoloration, hemorrhage, hypersensitivity, induration, edema, pain, rash, or bruising. If an infusion-site infection is suspected, remove the cannula and place a new cannula at a new infusion site. If there is a prolonged therapy interruption, manage with oral Parkinson disease treatments.
Other warnings/precautions:
• Abuse: Rare cases of abuse have been reported.
• Appropriate administration: Do not give SUBQ formulations IV; thrombus formation or pulmonary embolism may occur.
• Discontinuation of therapy: Dopaminergic agents have been associated with a syndrome resembling neuroleptic malignant syndrome (eg, hyperpyrexia, confusion) on abrupt withdrawal or significant dosage reduction after long-term use.
• Falling: Patients with Parkinson disease are at risk of falling; apomorphine may increase this risk.
Kynmobi sublingual film has been discontinued in the United States for >1 year.
Onapgo: FDA approved February 2025; availability anticipated in the second quarter of 2025. Information pertaining to this product within the monograph is pending revision. Onapgo, a wearable subcutaneous infusion device, is indicated for the treatment of motor fluctuations in adults with advanced Parkinson’s disease. Consult the prescribing information for additional information.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Film, Sublingual, as hydrochloride:
Kynmobi: 10 mg (30 ea [DSC]); 15 mg (30 ea [DSC]); 20 mg (30 ea [DSC]); 25 mg (30 ea [DSC]); 30 mg (30 ea [DSC]) [contains edetate (edta) disodium dihydrate, fd&c blue #1 (brilliant blue), levomenthol, sodium metabisulfite]
Kit, Sublingual, as hydrochloride:
Kynmobi Titration Kit: 10 mg (2s), 15 mg (2s), 20 mg (2s), 25 mg (2s), 30 mg (2s) [DSC] [contains edetate (edta) disodium dihydrate, fd&c blue #1 (brilliant blue), levomenthol, sodium metabisulfite]
Solution Cartridge, Subcutaneous, as hydrochloride:
Apokyn: 30 mg/3 mL (3 mL) [contains benzyl alcohol, sodium metabisulfite]
Generic: 30 mg/3 mL (3 mL)
Solution Cartridge, Subcutaneous, as hydrochloride [preservative free]:
Onapgo: 98 mg/20 mL (20 mL) [contains sodium metabisulfite]
May be product dependent
Solution Cartridge (Apokyn Subcutaneous)
30 mg/3 mL (per mL): $591.32
Solution Cartridge (Apomorphine HCl Subcutaneous)
30 mg/3 mL (per mL): $469.18
Solution Cartridge (Onapgo Subcutaneous)
98 mg/20 mL (per mL): $17.26
Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Film, Sublingual, as hydrochloride:
Kynmobi: 10 mg ([DSC]); 15 mg ([DSC]); 20 mg ([DSC]); 25 mg ([DSC]); 30 mg ([DSC]) [contains edetate (edta) disodium dihydrate, fd&c blue #1 (brilliant blue), levomenthol, sodium metabisulfite]
Solution Pen-injector, Subcutaneous:
Movapo: 10 mg/mL ([DSC])
Apokyn is only available through specialty pharmacies and cannot be obtained through a retail pharmacy. For more information, contact 1-877-7APOKYN (1-877-727-6596).
Sublingual film: Do not remove from pouch until immediately before use. Drink water to moisten mouth, then place film under the tongue and allow to dissolve (~3 minutes). Do not talk or swallow saliva while dissolving because this can impact absorption. Administer whole; do not cut, chew, or swallow.
SUBQ:
Continuous infusion (98 mg per 20 mL with Onapgo pump): For SUBQ administration only; do not administer IV (thrombus formation or pulmonary embolism may occur due to IV crystallization). Administer in the abdomen at least 2 inches away from the navel, the top of thigh, upper back (if infusion site is prepared by a caregiver or health care provider), or lower back. Do not infuse in areas that are bruised, irritated, or with bumps or nodules. Change infusion site every day. Use a new single-dose cartridge and cartridge holder every day; discard unused portion.
Intermittent injection (30 mg per 3 mL): For SUBQ administration only; do not administer IV (thrombus formation or pulmonary embolism may occur due to IV crystallization). Administer in abdomen, upper arm, or upper leg; change site with each injection. Three mL cartridges are used with a manual, reusable, multidose injector pen. Injector pen can deliver up to 1 mL (10 mg) in 0.02 mL (0.2 mg) increments.
Hazardous agent (NIOSH 2024 [table 2]).
Use appropriate precautions for receiving, handling, storage, preparation, dispensing, transporting, administration, and disposal. Follow NIOSH and USP 800 recommendations and institution-specific policies/procedures for appropriate containment strategy (NIOSH 2023; NIOSH 2024; USP-NF 2020).
Note: Facilities may perform risk assessment of some hazardous drugs to determine if appropriate for alternative handling and containment strategies (USP-NF 2020). Refer to institution-specific handling policies/procedures.
Parkinson disease:
Sublingual film: Treatment of acute, intermittent "off" episodes in patients with Parkinson disease.
SUBQ:
Continuous infusion: Treatment of motor fluctuations in patients with advanced Parkinson disease.
Intermittent injection: Treatment of acute, intermittent hypomobility "off" episodes in patients with advanced Parkinson disease.
Substrate of CYP1A2 (Minor), CYP2C19 (Minor), CYP3A4 (Minor); Note: Assignment of Major/Minor substrate status based on clinically relevant drug interaction potential;
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program by clicking on the “Launch drug interactions program” link above.
Alcohol (Ethyl): May increase hypotensive effects of Apomorphine. Risk X: Avoid
Alfuzosin: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Alizapride: May decrease therapeutic effects of Anti-Parkinson Agents (Dopamine Agonist). Risk X: Avoid
Amifostine: Blood Pressure Lowering Agents may increase hypotensive effects of Amifostine. Management: When used at chemotherapy doses, hold blood pressure lowering medications for 24 hours before amifostine administration. If blood pressure lowering therapy cannot be held, do not administer amifostine. Use caution with radiotherapy doses of amifostine. Risk D: Consider Therapy Modification
Amisulpride (Injection): May decrease therapeutic effects of Anti-Parkinson Agents (Dopamine Agonist). Risk X: Avoid
Amisulpride (Oral): Anti-Parkinson Agents (Dopamine Agonist) may decrease therapeutic effects of Amisulpride (Oral). Amisulpride (Oral) may decrease therapeutic effects of Anti-Parkinson Agents (Dopamine Agonist). Risk X: Avoid
Antiemetics (5HT3 Antagonists): May increase hypotensive effects of Apomorphine. Risk X: Avoid
Antipsychotic Agents (First Generation [Typical]): May decrease therapeutic effects of Anti-Parkinson Agents (Dopamine Agonist). Management: Avoid concomitant therapy if possible. If antipsychotic use is necessary, consider using atypical antipsychotics such as clozapine, quetiapine, or ziprasidone at lower initial doses, or a non-dopamine antagonist (eg, pimavanserin). Risk D: Consider Therapy Modification
Antipsychotic Agents (Second Generation [Atypical]): May decrease therapeutic effects of Anti-Parkinson Agents (Dopamine Agonist). Management: Consider avoiding atypical antipsychotic use in patients with Parkinson disease. If an atypical antipsychotic is necessary, consider using clozapine, quetiapine, or ziprasidone at lower initial doses, or a non-dopamine antagonist (eg, pimavanserin). Risk D: Consider Therapy Modification
Arginine: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Barbiturates: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Blood Pressure Lowering Agents: May increase hypotensive effects of Hypotension-Associated Agents. Risk C: Monitor
Brimonidine (Topical): May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Brivudine: May increase adverse/toxic effects of Anti-Parkinson Agents (Dopamine Agonist). Specifically, the risk of chorea may be increased. Risk C: Monitor
Bromopride: May decrease therapeutic effects of Anti-Parkinson Agents (Dopamine Agonist). Risk C: Monitor
Bromperidol: May decrease hypotensive effects of Blood Pressure Lowering Agents. Blood Pressure Lowering Agents may increase hypotensive effects of Bromperidol. Risk X: Avoid
BuPROPion: Anti-Parkinson Agents (Dopamine Agonist) may increase adverse/toxic effects of BuPROPion. Risk C: Monitor
Diazoxide: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
DULoxetine: Blood Pressure Lowering Agents may increase hypotensive effects of DULoxetine. Risk C: Monitor
Fluorodopa F18: Coadministration of Anti-Parkinson Agents (Dopamine Agonist) and Fluorodopa F18 may alter diagnostic results. Management: Discontinue medications used to treat Parkinson disease, including dopamine agonists, 12 hours prior to fluorodopa F 18 administration if these medications can be safely withheld. Risk D: Consider Therapy Modification
Herbal Products with Blood Pressure Lowering Effects: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Hypotension-Associated Agents: Blood Pressure Lowering Agents may increase hypotensive effects of Hypotension-Associated Agents. Risk C: Monitor
Kava Kava: May decrease therapeutic effects of Anti-Parkinson Agents (Dopamine Agonist). Kava Kava may increase adverse/toxic effects of Anti-Parkinson Agents (Dopamine Agonist). Risk C: Monitor
Levodopa-Foslevodopa: Blood Pressure Lowering Agents may increase hypotensive effects of Levodopa-Foslevodopa. Risk C: Monitor
Lormetazepam: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Metergoline: May decrease antihypertensive effects of Blood Pressure Lowering Agents. Blood Pressure Lowering Agents may increase orthostatic hypotensive effects of Metergoline. Risk C: Monitor
Methotrimeprazine: May decrease therapeutic effects of Anti-Parkinson Agents (Dopamine Agonist). Anti-Parkinson Agents (Dopamine Agonist) may decrease therapeutic effects of Methotrimeprazine. Risk X: Avoid
Metoclopramide: May decrease therapeutic effects of Anti-Parkinson Agents (Dopamine Agonist). Risk X: Avoid
Molsidomine: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Naftopidil: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Nicergoline: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Nicorandil: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Nitroglycerin: May increase hypotensive effects of Apomorphine. Management: Patients taking apomorphine should lie down before and after taking sublingual nitroglycerin. Monitor blood pressure for hypotension and orthostatic hypotension when these agents are combined. Risk D: Consider Therapy Modification
Nitroprusside: Blood Pressure Lowering Agents may increase hypotensive effects of Nitroprusside. Risk C: Monitor
Obinutuzumab: May increase hypotensive effects of Blood Pressure Lowering Agents. Management: Consider temporarily withholding blood pressure lowering medications beginning 12 hours prior to obinutuzumab infusion and continuing until 1 hour after the end of the infusion. Risk D: Consider Therapy Modification
Pentoxifylline: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Pholcodine: Blood Pressure Lowering Agents may increase hypotensive effects of Pholcodine. Risk C: Monitor
Phosphodiesterase 5 Inhibitors: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Prostacyclin Analogues: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
QT-prolonging Agents (Highest Risk): QT-prolonging Agents (Indeterminate Risk - Caution) may increase QTc-prolonging effects of QT-prolonging Agents (Highest Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor
Quinagolide: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Silodosin: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Solriamfetol: May increase adverse/toxic effects of Anti-Parkinson Agents (Dopamine Agonist). Risk C: Monitor
Sulpiride: May decrease therapeutic effects of Anti-Parkinson Agents (Dopamine Agonist). Risk X: Avoid
Tiapride: Anti-Parkinson Agents (Dopamine Agonist) may decrease therapeutic effects of Tiapride. Tiapride may decrease therapeutic effects of Anti-Parkinson Agents (Dopamine Agonist). Management: If treatment with tiapride cannot be avoided in a patient with Parkinson disease, discontinuation of the dopamine agonist should be done gradually to minimize the risk for neuroleptic malignant syndrome. Risk D: Consider Therapy Modification
Adverse events have been observed in animal reproduction studies.
It is not known if apomorphine is excreted in breast milk. According to the manufacturer, the decision to continue or discontinue breastfeeding during therapy should take into account the risk of infant exposure, the benefits of breastfeeding to the infant, and benefits of treatment to the mother.
Supine and standing BP and pulse (for SUBQ intermittent injection [30 mg/mL] test dose, monitor predose and 20-, 40-, and 60 minutes postdose with each test dose); signs and symptoms of hemolytic anemia; orthostatic hypotension; drowsiness or sleepiness; mental status and behavioral changes.
Stimulates postsynaptic D2-type receptors within the caudate putamen in the brain.
Onset of action: SUBQ: Rapid.
Distribution: Vd: Sublingual: 3,630 L; SUBQ: 218 L.
Protein binding: SUBQ: 89%.
Metabolism: Not established; potential routes of metabolism include sulfation, N-demethylation, glucuronidation, and oxidation.
Half-life elimination: Terminal: Sublingual: ~1.7 hours (range: 0.8 to 3 hours); SUBQ: ~40 minutes.
Time to peak, plasma: Sublingual: 0.5 to 1 hour; SUBQ: 10 to 60 minutes.
Excretion: SUBQ: Urine (86%); feces (4.6%).
Altered kidney function: SUBQ: AUC was increased by 16% and Cmax was increased by 50% in patients with moderate renal impairment.
Hepatic function impairment: SUBQ: AUC was increased by 10% and Cmax was increased by 25% in patients with moderate hepatic impairment.
