Patient leaflet - Apomorphine Hydrochloride 5 mg/ml, solution for infusion
1. What Apomorphine hydrochloride is and what it is used for
Apomorphine hydrochloride belongs to a group of medicines known as dopamine agonists which are used to treat Parkinson’s disease. It helps to reduce the amount of time spent in an “off” or immobile state in people who have previously been treated for Parkinson’s disease with levodopa and/or other dopamine agonists.
Your doctor or nurse will help you to recognise the signs of when to use your medicine.
2. What you need to know before you use Apomorphine hydrochloride
Do not use Apomorphine hydrochloride :
- if you are allergic to apomorphine or any of the other ingredients of this medicine (listed in section 6)
- if you are under 18 years of age
- if you have breathing difficulties or suffer from asthma
- if you have dementia or Alzheimer’s disease
- if you suffer from confusion, hallucinations or any other similar problems - if you have liver problems
- if you have severe overmobility, so called dyskinesia (involuntary movements), or abnormal muscle tension (so called dystonia) on account of the treatment with levodopa - if you are taking ondansetron (medicine to treat nausea and vomiting)
Warnings and precautions
Talk to your doctor before using Apomorphine hydrochloride
if you or someone in your family are known to have an abnormality of electrocardiogram (ECG)
called “long QT syndrome”.
- if you have kidney problems
- if you have lung problems
- if you have heart problems
- if you have low blood pressure or feel faint and dizzy when you stand
- if you are taking any medicines to treat high blood pressure
- if you feel sick or suffer from being sick
- if you are elderly or weak
- if you have any mental disorders when Apomorphine hydrochloride is started - if you are taking levodopa (another treatment for Parkinson’s disease) as well as apomorphine your doctor should check your blood regularly.
Before you use Apomorphine hydrochloride, your doctor will obtain an ECG (electrocardiogram) and will ask for a list of all other medicines you take. This ECG will be repeated in the first days of your treatment and at any point if your doctor thinks this is needed. He or she will also ask you about other diseases you may have, in particular concerning your heart. Some of the questions and investigations may be repeated at each medical visit. If you experience symptoms which may come from the heart, e.g. palpitations, fainting, or near-fainting, you should report this to your doctor immediately. Also if you experience diarrhoea or start a new medication, this should be reported to your doctor.
Tell your doctor if you or your family/carer notices that you are developing urges or cravings to behave in ways that are unusual for you and you cannot resist the impulse, drive or temptation to carry out certain activities that could harm yourself or others. These are called impulse control disorders and can include behaviours such as addictive gambling, excessive eating or spending, an abnormally high sex drive or an increase in sexual thoughts or feelings. Your doctor may need to adjust or stop your dose.
Some patients develop addiction-like symptoms leading to craving for large doses of Apomorphine hydrochloride and other medicines used to treat Parkinson’s disease.
If any of the above situations apply to you, please inform your doctor or nurse.
Other medicines and Apomorphine hydrochloride
Tell your doctor or pharmacist if you are taking, have recently taken or might take any other medicines.
If you take Apomorphine hydrochloride in combination with other medicines (such as clozapine or medicines to reduce your blood pressure or medicines for Parkinson’s disease) the effect of your medicines may be altered. Your doctor will advise you if you need to adjust the dose of Apomorphine hydrochloride or any of your other medicines.
If you are taking ondansetron (medicine to treat nausea and vomiting), as this may result in severe drop in blood pressure and loss of consciousness.
Talk to your doctor or pharmacist before you use this medicine if:
You use medicines that are known to affect how your heart beats. This includes medicines that are used for heart rythm problems (such as quinidine and amiodarone), for depression (e.g. tricyclic antidepressants such as amitriptyline and imipramine) and for bacterial infections (“macrolid antibiotics” such as erythromycine, azithromycine and clarithromycine) and domperidone.
Apomorphine hydrochloride with food and drink
Food and drink do not affect Apomorphine hydrochloride.
Pregnancy and breast-feeding
Pregnancy
Apomorphine hydrochloride should not be used during pregnancy if it is not absolutely necessary. Ask your doctor or nurse for advise before you use Apomorphine hydrochloride if you are pregnant, think you may be pregnant or you are planning to become pregnant.
Breast-feeding
It is not known if Apomorphine hydrochloride is excreted in breast milk. Talk to your doctor if you are breast-feeding or plan to breast-feed. Your doctor will explain to you if you should continue/discontinue breast-feeding or continue/discontinue medication.
If you are pregnant or breast-feeding, think you may be pregnant or are planning to have a baby, ask your doctor or pharmacist for advice before taking this medicine.
Driving and using machines
Take special care when driving or operating machinery since apomorphine may cause sleepiness including sudden sleep onset episodes (you must not drive or operate machinery if Apomorphine hydrochloride makes you sleepy.)
Apomorphine hydrochloride contains sodium metabisulfite and sodium
Sodium metabisulfite may rarely cause severe hypersensitivity reactions and bronchospasm.
This medicine contains 3.3 mg sodium (main component of cooking/table salt) in each ml of solution. This is equivalent to 0.17 % of the recommended maximum daily dietary intake of sodium for an adult.
3. How to use Apomorphine hydrochloride
Before you use Apomorphine hydrochloride, your doctor will ensure that you tolerate the medicine and an antiemetic medicine that you need to use simultaneously.
The infusion is given subcutaneously (i.e. into the area under the skin).
Always use this medicine exactly as your doctor or pharmacist has told you. Check with your doctor or pharmacist if you are not sure.
Apomorphine hydrochloride has been designed for continuous infusion with an infusion pump. Your doctor will decide which infusion pump and which dosage settings you should use. Follow the instructions and advice given by your doctor how to use Apomorphine hydrochloride in an infusion pump. Read the instruction leaflet for the infusion pump and follow it carefully.
Both the amount of Apomorphine hydrochloride that you should use and the total amount of time you should receive your medicine each day, will depend upon your personal needs. Your doctor will tell you how much of your medicine you should administer.
The dose that will work best for you have been determined on an initial evaluation at a specialist clinic. Usual infusion dose per hour is between 1 mg and 4 mg apomorphine hydrochloride. This is usually given when you are awake and generally stopped before sleeping. The amount of apomorphine hydrochloride that you receive each day should not exceed 100 mg. Your doctor or nurse will decide which dose is best for you.
A different site for your infusion should be used every 12 hours.
This medicine must not be administered into a vein. There is no need to dilute Apomorphine hydrochloride before use. Apomorphine hydrochloride should not be mixed with other medicines.
Instructions for how to use Apomorphine hydrochloride
- Clean the rubber stopper with a disinfectant swab
- Insert the needle of the syringe into the vial through the centre of the rubber stopper − Turn the vial and syringe upside down
- Draw the desired volume from the vial into the syringe
- Remove the needle from the vial
- Follow thereafter carefully the instructions that accompany your infusion pump
The treatment will be started by your doctor who will inform you thoroughly about how to use the infusion pump, infusion technique and handling for administration of the medicine. If you use more Apomorphine hydrochloride than you should
- if you have received too much medicine or if e.g. a child has received the medicine by mistake contact immediately doctor or hospital for risk evaluation and advice.
- it is important to use the correct dose of Apomorphine hydrochloride and not to use more than the amount recommended by your doctor. Higher doses may cause a slow heart rate, excessive sickness, excessive sleepiness and/or difficulty breathing. You may also feel faint or dizzy particularly when you stand up, due to low blood pressure. Lying down and raising your feet will help to treat low blood pressure.
If you forget to use Apomorphine hydrochloride
- take it when you next require it
- do not take a double dose to make up for a forgotten dose
If you stop using Apomorphine hydrochloride
- contact your doctor before stopping treatment and discuss whether this is appropriate or not.
If you have any further questions on the use of this medicine, ask your doctor or pharmacist.
4. Possible side effects
Like all medicines, this medicine can cause side effects, although not everybody gets them. Tell your doctor if you think your medicine is making you feel unwell or if you get any of the following:
Serious side effects:
An allergic reaction which may be serious may rarely occur, with symptoms such as:
- difficulty breathing or tightness of the chest
- puffiness of the eyelids, face or lips
- swelling or redness of the tongue
Other side effects:
Very common (may affect more than 1 in 10 people)
- hallucinations (seeing, hearing or feeling things that are not there), lumps under the skin at the site of injection which are sore, troublesome and may be red and itchy. In order to avoid getting these lumps, it is advisable to change the site of injection every time you insert the needle.
Common (may affect up to 1 in 10 people)
feeling sick or being sick, particularly when starting Apomorphine hydrochloride .
Domperidone should be started at least 2 days before Apomorphine hydrochloride to stop you feeling or being sick. If you are taking domperidone and still feel sick, or if you are not taking domperidone and have sickness, tell your doctor or nurse as soon as possible. - transient tiredness with each dose of Apomorphine hydrochloride at the start of therapy. This usually resolves over the first few weeks of treatment.
- feeling tired or excessive sleepiness
- dizziness, light-headedness
- confusion or hallucinations
- yawning
Uncommon (may affect up to 1 in 100 people)
- increased involuntary movements (so called dyskinesia, overmobility) or increased shakiness during “on” periods (i.e. when the medicine is working).
- haemolytic anaemia, abnormal degradation of red blood cells in vessels or in other parts of the body, which can turn the skin weakly yellow and cause weakness and breathlessness, may occur in patients also taking levodopa.
- rashes
- shortness of breath
- a fall in blood pressure on standing up which causes dizziness, light-headedness or fainting - ulceration at the injection site
decreased count of platelets, which can increase the risk for bleeding and bruises - the use of levodopa and apomorphine may affect the result of a certain laboratory test, called
Coombs test.
Rare (may affect up to 1 in 1,000 people)
- eosinophilia, an unusually high count of white blood cells in the blood or tissues.
Not known: frequency cannot be estimated from the available data
- fainting
swelling of legs, feet or fingers
- inability to resist the impulse, drive or temptation to perform an action that could be harmful to you or others, which may include:
- strong impulse to gamble excessively despite serious personal or family consequences. - altered or increased sexual interest and behaviour of significant concern to you or to others, for example, an increased sexual drive
- uncontrollable excessive shopping or spending
- binge eating (eating large amounts of food in a short time period) or compulsive eating (eating more food than normal and more than is needed to satisfy your hunger) - aggression
- agitation
- headache.
Tell your doctor if you experience any of these behaviours; they will discuss ways of managing or reducing the symptoms
Reporting of side effects
If you get any side effects, talk to your doctor or pharmacist. This includes any possible side effects not listed in this leaflet. You can also report side effects directly via:
Yellow Card Scheme
Website: www.mhra.gov.uk/yellowcard
Yellow Card Scheme
Website: www.mhra.gov.uk/yellowcard.
By reporting side effects you can help provide more information on the safety of this medicine.
5. How to store Apomorphine hydrochloride
Keep this medicine out of the sight and reach of children.
Do not use this medicine after the expiry date which is stated on the carton and vial label after EXP. The expiry date refers to the last day of that month.
Keep the vial in the outer carton in order to protect from light.
Do not store above 25 ºC.
For single use only. After opening and filling the drug product in syringes: chemical and physical in-use stability has been demonstrated for 96 hours (4 days) at 30-35°C, when protected from light. From a microbiological point of view, unless the method of opening and further handling precludes the risk of microbial contamination, the product should be used immediately. If not used immediately, in-use storage times and conditions are the responsibility of the user.Discard any unused solution. The solution should be inspected visually prior to use. Do not use Apomorphine hydrochloride if the solution has turned green. Apomorphine hydrochloride should only be used if the solution is clear and free of any visible particles.
Take care not to splash any of the solution onto yourself, or e.g. on textiles or household surfaces since the solution may cause green discolouring. Any used needles and the vial should be discarded in a sharp’s bin.
Do not throw away any medicines via wastewater or household waste. Ask your pharmacist how to throw away medicines you no longer use. These measures will help to protect the environment.
6. Contents of the pack and other information
What Apomorphine hydrochloride contains
- The active substance is apomorphine hydrochloride hemihydrate. 1 ml contains 5 mg apomorphine hydrochloride hemihydrate. One vial with 20 ml solution contains 100 mg apomorphine hydrochloride hemihydrate.
- The other ingredients are:
- Sodium chloride
- Sodium metabisulfite (E223)
- Hydrochloric acid for pH adjustment
- Water for injections
What Apomorphine hydrochloride looks like and contents of the pack
Apomorphine hydrochloride is a solution for infusion. The solution is clear and practically colourless. Apomorphine hydrochloride is supplied in glass vials with bromobutyl rubber stoppers and aluminum seal, containing 20 ml.
Pack sizes: 1 vial, 5 vials or 30 (6x5) vials (bundled pack).
Not all pack sizes may be marketed.
Marketing Authorisation Holder:
Evolan Pharma AB
Box 120
182 12 Danderyd
Sweden
Manufacturer:
Anfarm Hellas S.A
61st km National Road Athens-Lamia,
Schimatari Viotias, 32009
Greece
This medicinal product is authorised in the Member States of the EEA under the following names:
Sweden Apomorfin PharmSwed
Denmark Apomorfin PharmSwed
Norway Apomorfin PharmSwed
Iceland Apomorfin PharmSwed
Netherlands Apomorfine hydrochloride PharmSwed 5 mg/ml, oplossing voor infusie Germany Apomorphinhydrochlorid PharmSwed 5 mg/ml Infusionslösung UK Apomorphine hydrochloride 5 mg/ml solution for infusion Ireland Apomorphine hydrochloride 5 mg/ml solution for infusion