Clinical Trial of Apomorphine Subcutaneous Infusion in Patients With Advanced Parkinson's Disease

The primary efficacy variable is the mean change in time spent "OFF" from baseline (start of blinded treatment) to the end of a 12 weeks' double-blind treatment period based on patient diaries. Patients recorded their motor symptoms in half-hour blocks as OFF, ON without dyskinesia, ON without troublesome dyskinesia, or sleeping using the Hauser Parkinson's Disease home diary.

Key secondary Endpoints (tested hierarchically):

• Change in time spent "ON without troublesome dyskinesia"
• Patient Global Impression of Change

Other Endpoints:

• Percentage of patients with response to therapy, defined as a mean OFF time reduction of at least 2 hours
• Change in oral levodopa and levodopa equivalent dose

Inclusion criteria

• Male or female patients aged ≥30 years
• Diagnosis of idiopathic PD of >3 years' duration, defined by the UK Brain Bank criteria (with the exception of >1 affected relative being allowed), without any other known or suspected cause of Parkinsonism
• Hoehn & Yahr stage up to 3 in the ON and 2 to 5 in the OFF state
• Motor fluctuations not adequately controlled on medical treatment including levodopa which was judged by the treating physician to be optimal
• Average of OFF time > 3 hours/day based on screening and baseline diary entries with no day with < 2 hours of OFF time recorded
• Stable medication regimen, with a stable dose of levodopa administered in at least 4 intakes, for at least 28 days prior to baseline. All oral or transdermal antiparkinsonian drugs were permitted, with the exception of budipine. This regimen might include the use of levodopa/DDCI rescue medication, if this occurred up to 2 times a day, at doses of up to 200 mg levodopa/day
• Patients must be able to differentiate between the ON and OFF state and between troublesome and non-troublesome dyskinesias
• Male and female patients must be compliant with a highly effective contraceptive method (oral hormonal contraception alone is not considered highly effective and must be used in combination with a barrier method) during the study and for the 12-month OLP, if sexually active
• Females of childbearing potential must have a negative serum human chorionic gonadotropin (hCG) or urine pregnancy test at screening
• Ability to accurately complete a paper diary on designated days (with assistance from caregivers, if required), recording periods when they are "ON without troublesome dyskinesia", "ON with troublesome dyskinesia", OFF, and sleeping
• Written informed consent prior to enrolment, after being provided with detailed information about the nature, risks, and scope of the clinical trial as well as the expected desirable and adverse effects of the study treatments
• Patients considered reliable and capable of adhering to the protocol, visit schedule, and medication intake according to the judgment of the investigator

Exclusion criteria

• History of respiratory depression
• Hypersensitivity to apomorphine or any excipients of the medicinal product
• High suspicion of other parkinsonian syndromes
• Presence of severe freezing or clinically relevant postural instability leading to falls during the ON state
• Concomitant therapy or within 28 days prior to baseline with: apomorphine pen injections; alpha-methyl dopa, metoclopramide, reserpine, neuroleptics, methylphenidate, or amphetamine; intrajejunal levodopa
• Previous use of apomorphine pump treatment
• History of deep brain stimulation or lesional surgery for PD
• Any medical condition that is likely to interfere with an adequate participation in the study, including e.g. current diagnosis of unstable epilepsy; clinically relevant cardiac dysfunction and/or myocardial infarction or stroke within the last 12 months
• Symptomatic, clinically relevant and medically uncontrolled orthostatic hypotension
• Patients with a borderline QT interval corrected for heart rate according to Bazett's formula (QTcB) of >450 msec for male and >470 msec for female at screening or history of long QT syndrome; or >450 msec absolute duration
• Clinically relevant hepatic dysfunction (total bilirubin >2.0 mg/dL, alanine transaminase [ALT] and aspartate transaminase [AST] >2 times the upper limit of normal)
• Clinically relevant renal dysfunction (serum creatinine >2.0 mg/dL)
• Pregnant and breastfeeding women
• Clinically relevant cognitive decline, defined as MMSE ≤24 or according to Diagnostic and Statistical Manual of Mental Disorders (DSM) IV criteria for dementia
• Active psychosis or history of at least moderate psychosis in the past year, or with medically uncontrolled severe depression; very mild illusions or hallucinations in the sense of "feelings of passage or presence" with fully retained insight are not an exclusion criterion
• Known history of melanoma
• Any investigational therapy in the 4 weeks prior to randomization
• History or current drug or alcohol abuse or dependencies