Apomorphine (APO) infusion is a potent dopamine receptor agonist with an established role for the treatment of motor symptoms of Parkinson’s disease (PD), including tremor, bradykinesia, and rigidity (Muller 2020). APO is administered subcutaneously as either a pen injection or a continuous infusion. The injection can be used as an ‘on demand’ therapy for the management of OFF episodes as an adjunct to oral medication, whereas APO infusion is indicated when PD has advanced to the stage when the person is experiencing persistent motor fluctuations that can no longer be effectively controlled with optimized oral medication (APO-go PFS EU Summary of Product Characteristics 2018). The infusion is administered using a small, wearable pump, and provides continuous dopaminergic stimulation which is known to be better at controlling motor fluctuations than intermittently administered oral/injectable medication (Olanow et al. 2020). In a recent randomized, double-blind placebo-controlled trial, APO infusion proved to be effective at reducing OFF time in patients with advanced PD and provided a corresponding increase in ‘good’ ON time without troublesome dyskinesia (Katzenschlager et al. 2018), and these beneficial effects persisted with long-term use (Katzenschlager et al. 2021).

APO infusion has been used successfully in clinical practice use for the management of PD for over 30 years and is generally well tolerated by patients (Jenner and Katzenschlager 2016). Of the available device-aided therapies for PD, APO infusion is generally considered as the least invasive as it does not require surgery. In the UK, APO is recommended by current National Institute for Health and Care Excellence (NICE) guidelines as part of the best medical therapy and before surgical options are considered, such as deep brain stimulation or the insertion of a percutaneous endoscopic gastrostomy (PEG) tube for intestinal levodopa infusion (National Institute for Health and Care Excellence 2017).

Starting patients on APO infusion require input from various members of the healthcare team. At our regional specialist movement disorder centre, up until recently, the majority of patients were initiated on a day-case basis according to an established protocol which was implemented by an Advanced Therapy Specialist Nurse within the hospital team under the guidance of a neurologist with additional support, when available, from APO nurses, a service provided by the manufacturer of one of the commercially available apomorphine therapies, Britannia Pharmaceuticals Ltd.

However, as a result of the restrictions in place due to the COVID-19 pandemic, access to hospital day-case facilities was not available, and face-to-face appointments were restricted. There were long waiting lists to start APO infusion treatment and other device-aided therapies were unavailable due to the need for surgery or other procedures. These challenges required a rethink and change of process at Salford to ensure advanced PD patients could receive the treatment they urgently needed to provide them with an acceptable quality of life.

To avoid significant delays in patients receiving treatment and the consequent exacerbation of debilitating PD symptoms, it was decided to undertake initiation of APO infusion therapy in the patient’s own home with assistance from APO nurses. This article reports our experience with APO infusion home initiation, and shares best practice with this new protocol and innovative way of working.