APOKYN® (apomorphine hydrochloride, USP) is a non-ergoline dopamine agonist. Apomorphine hydrochloride is chemically designated as 6aβ-Aporphine-10,11-diol hydrochloride hemihydrate with a molecular formula of C₁₇H₁₇NO₂ • HCl•1/2H₂O. Its structural formula and molecular weight are:

M.W. 312.79

Apomorphine hydrochloride appears as minute, white or grayish-white glistening crystals or as white powder that is soluble in water at 80°C.

APOKYN® 10 mg/mL is a clear, colorless, sterile solution for subcutaneous injection and is available in 3 mL cartridges. Each mL of solution contains 10 mg of apo morphine hydrochloride, USP as apomorphine hydrochloride hemihydrate and 1 mg of sodium metabisulfite, NF in water for injection, USP. In addition, each mL of solution may contain sodium hydroxide, NF and/or hydrochloric acid, NF to adjust the pH of the solution and 5 mg/mL of benzyl alcohol, NF as a preservative.

APOKYN® (apomorphine hydrochloride injection) is indicated for the acute, intermittent treatment of hypomobility, "off" episodes ("end-of-dose wearing off" and unpredictable "on/off" episodes) associated with advanced Parkinson's disease. APOKYN has been studied as an adjunct to other medications (see CLINICAL PHARMACOLOGY: Clinical Trials).

The prescribed dose of APOKYN should always be expressed in mL to avoid confusion and doses greater than 0.6 mL (6 mg) are not recommended. Patients and caregivers must receive detailed instructions in the preparation and injection of doses, with particular attention paid to the correct use of the dosing pen (see PRECAUTIONS: Information for Patients).

APOKYN® is indicated for subcutaneous administration only. APOKYN should not be initiated without use of a concomitant antiemetic (see WARNINGS: Nausea and Vomiting). Most antiemetic experience is with trimethobenzamide and this should generally be used. Trimethobenzamide (300 mg tid orally) should be started 3 days prior to the initial dose of apomorphine and continued at least during the first two months of therapy. Based on reports of profound hypotension and loss of consciousness when apomor phine was administered with ondansetron, the concomitant use of apomorphine with drugs of the 5HT₃ antagonist class (including, for example, ondansetron, granisetron, dolasetron, palonosetron, and alosetron) is contraindicated (see CONTRAINDICATIONS).

The dose of APOKYN must be titrated on the basis of effectiveness and tolerance, starting at 0.2 mL (2 mg) and up to a maximum recommended dose of 0.6 mL (6 mg) as follows:

Patients in an "off" state should be given a 0.2 mL (2 mg) test dose in a setting where blood pressure can be closely monitored by medical personnel. Both supine and standing blood pressure should be checked predose and at 20, 40, and 60 minutes post dose. Patients who develop clinically significant orthostatic hy- potension in response to this test dose of apomorphine should not be considered candidates for treatment with APOKYN. If the patient tolerates the 0.2 mL (2 mg) dose, and re sponds, the starting dose should be 0.2 mL (2 mg) used on an as needed basis to treat existing "off" episodes. If needed, the dose can be increased in 0.1 mL (1 mg) increments every few days on an outpatient basis.

Beyond this, the general principle guiding dosing (described in detail below) is to determine a dose (0.3 mL or 0.4 mL) that the patient will tolerate as a test dose under monitored conditions, and then begin an outpatient dosing trial (periodically assessing both efficacy and tolerability) using a dose 0.1 mL (1 mg) lower than the tolerated test dose.

For patients who tolerate the test dose of 0.2 mL (2 mg) but achieve no response, a dose of 0.4 mL (4 mg) may be administered at the next observed "off" period, but no sooner than 2 hours after the initial test dose of 0.2 mL (2 mg). Both supine and standing blood pressure should be checked predose and at 20, 40, and 60 minutes post dose. If the patient tolerates a test dose of 0.4 mL (4 mg) the starting dose should be 0.3 mL (3 mg) used on an as needed basis to treat existing "off" episodes.

If needed, the dose can be increased in 0.1 mL (1 mg) increments every few days on an outpatient basis. If a patient does not tolerate a test dose of 0.4 mL (4 mg), a test dose of 0.3 mL (3 mg) may be administered during a separate "off" period, no sooner than 2 hours after the test dose of 0.4 mL (4 mg). Both supine and standing blood pressure should be checked predose and at 20, 40, and 60 minutes post dose. If the patient tolerates the 0.3 mL (3 mg) test dose, the starting dose should be 0.2 mL (2 mg) used on an as needed basis to treat existing "off" episodes. If needed, and the 0.2 mL (2 mg) dose is tolerated, the dose can be increased to 0.3 mL (3 mg) after a few days. In such a patient, the dose should ordinarily not be increased to 0.4 mL (4 mg) on an out-patient basis.

Most patients studied in the apomorphine development program responded to 0.3 mL to 0.6 mL (3 mg to 6 mg). There is no evidence from controlled trials that doses greater than 0.6 mL (6 mg) give an increased effect and these doses are not recommended. The average frequency of dosing was 3 times per day in the development program, and there is limited experience with single doses greater than 0.6 mL (6 mg), dosing more than 5 times per day and with total daily doses greater than 2.0 mL (20 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. The efficacy of a second dose for a single "off" episode has not been systematically studied and the safety of redosing has not been characterized.

Patients who have a significant interruption in therapy (more than a week) should be restarted on a 0.2 mL (2 mg) dose and gradually titrated to effect.

When dosing patients with mild and moderate hepatic impairment, caution should be exercised due to the increased Cmax and AUC in these patients (see CLINICAL PHARMACOLOGY and PRECAUTIONS).

For patients with mild and moderate renal impairment, the testing dose and subsequently the starting dose should be reduced to 0.1 mL (1 mg) (see CLINICAL PHARMACOLOGY and PRECAUTIONS).

Patients should be instructed to administer apomorphine as described in the Patient Instruction Leaflets.

APOKYN® (10 mg/mL) containing apomorphine hydrochloride (as apomorphine hydrochloride hemihydrate), USP is supplied as a clear, colorless, sterile, solution in 3 mL cartridges. The 3 mL glass cartridges are used with a manual reusable, multiple dose injector pen. The pen can deliver doses up to 1.0 mL in 0.02 mL increments. The pen is provided in a package with six needles and a carrying case. The 3 mL glass cartridges are provided as follows:

NDC 16887-211-05
Cartons of five 3 mL cartridges

Store at 25°C (77°F) Excursions permitted to 15 to 30°C (59 to 86°F) [See USP Controlled Room Temperature]

Manufactured for: Vernalis (R&D) Limited, Winnersh, Berkshire, RG41 5UA, United Kingdom, by: Vetter Pharma-Fertigung GmbH & Co. KG 88212 Ravensburg, Germany. Distributed by: Vernalis Pharmaceuticals, Inc., Morristown, NJ 07960. The injector pen is manufactured for Vernalis R&D Limited, Winnersh, Berkshire, RG41 5UA, United Kingdom by: Becton, Dickinson and Company Franklin Lakes, NJ 07417 or Becton Dickinson Europe 11, Rue Aristide Berges B.P. 4, 38800 Le Pont-De-Claix, France. Distributed by: Vernalis Pharmaceuticals Inc., Morristown, NJ. REVISED JUNE 2006. FDA Rev date: 4/20/2004

Adverse Event Incidence in Controlled Clinical Studies: APOKYN® has been administered to 550 Parkinson's disease patients who were taking some form of L-Dopa along with other Parkinson's disease medications. Eighty-six percent of patients were taking a concomitant dopamine agonist. All patients had some degree of spontaneously occurring hypomobility ("off episodes") at baseline. Adverse events were recorded by the clinical investigators using terminology of their own choosing. To provide a meaningful estimate of the proportion of individuals having adverse events, similar types of events were grouped into a smaller number of standardized categories using MEDDRA dictionary terminology.

The most common adverse events seen in controlled trials were yawning, dyskinesias, nausea and/or vomiting, somnolence, dizziness, rhinorrhea, hallucinations, edema, chest pain, increased sweating, flushing, and pallor.

The most extensive experience with apomorphine in randomized, controlled trials comes from a multicenter randomized placebo-controlled parallel group trial conducted in apomorphine-naïve PD patients treated for up to 4 weeks (Table 1). Individual apomorphine doses in this trial ranged from 2-10 mg, optimized to achieve control of symptoms comparable to each patient's response to his or her usual dose of L-dopa. The prescriber should be aware that these figures cannot be used to predict the incidence of adverse events in the course of usual medical practice where patient characteristics and other factors differ from those that prevailed in the clinical studies. Similarly, the cited frequencies cannot be compared with figures obtained from other clinical investigations involving different treatments, uses, and investigators. However, the cited figures do provide the prescribing physician with some basis for estimating the relative contribution of drug and nondrug factors to the adverse event incidence rate in the population studied.

Table 1: Summary of Adverse Events Occurring in Two or More Patients

Other Adverse Events Observed During All Phase 2/3 Clinical Trials: APOKYN has been administered to 550 patients; 89% had at least one adverse event (AE). The most common AEs in addition to those in Table 1 (occurring in at least 5% of the patients and at least plausibly related to treatment) in descending order were in jection site complaint, fall, arthralgia, insomnia, headache, depression, urinary tract infection, anxiety, congestive heart failure, limb pain, back pain, Parkinson's disease aggravated, pneumonia, confusion, sweating increased, dyspnea, fatigue, ecchymosis, constipation, diarrhea, weakness, and dehydration.

Drug Abuse And Dependence

Potential for Abuse: A rarely reported motivation for apomorphine abuse (escalation of dose beyond prescribed frequency) is the use of apomorphine to attempt to avoid all symptoms of all "off" events when "off" events occur frequently. A second, rarely reported, motivation for apomorphine abuse is a psychosexual reaction related to the stimulation of penile erection and increase in libido. Adverse events that have been reported in males with overuse include frequent penile erections, atypical sexual behavior, heightened libido, dyskinesias, agitation, confusion, and depression. No studies have been conducted to evaluate the potential for dependence when apomorphine is used as acute (rescue) treatment of "off" episodes in the patients with "on/off" or "wearing-off" effects associated with late stage Parkinson's disease.

5HT₃ Antagonists: Based on reports of profound hypotension and loss of consciousness when apomorphine was administered with ondansetron, the concomitant use of apomorphine with drugs of the 5HT₃ antagonist class (including, for example, ondansetron, granisetron, dolasetron, palonosetron, and alosetron) is contraindicated (see CONTRAINDICATIONS).

Antihypertensive Medications and Vasodilators: The following adverse events were experienced more commonly in patients receiving concomitant antihypertensive medications or vasodilators (n = 94) compared to patients not receiving these concomitant drugs (n = 456): hypotension 10% vs 4%, myocardial infarction 3% vs 1%, serious pneumonia 5% vs 3%, serious falls 9% vs 3%, and bone and joint injuries 6% vs 2%. The mechanism underlying many of these events is unknown, but may represent increased hypotension (see WARNINGS: Symptomatic Hypotension).

Dopamine Antagonists: Since apomorphine is a dopamine agonist, it is possible that dopamine antagonists, such as the neuroleptics (phenothiazines, butyrophenones, thioxanthenes) or metoclopramide, may diminish the effectiveness of APOKYN. Patients with major psychotic disorders, treated with neuroleptics, should be treated with dopamine agonists only if the potential benefits outweigh the risks.

Drugs Prolonging the QT/QTc Interval: Caution should be exercised when prescribing apomorphine concomitantly with drugs that prolong the QT/QTc interval (see WARNINGS: QT Prolongation and Potential for Proarrhythmic Effects). Drug/Laboratory Test Interactions:There are no known interactions between APOKYN and laboratory tests.

Avoid Intravenous Administration: Serious adverse events (such as intravenous crystallization of apomorphine, leading to thrombus formation and pulmonary em bolism) have followed the intravenous administration of apomorphine. Consequently, apomorphine should not be administered intravenously.

General: The significant adverse events described below have been reported in association with the use of subcutaneous apomorphine, but almost all of them occurred during open-label, uncontrolled studies. In the development program, the controlled trial data involved relatively few patients, and examined primarily the effects of single doses. Because the background rate of many of these events in a population of patients with advanced Parkinson's disease is unknown, it is difficult to assess the role of apomorphine in their causation.

Nausea and Vomiting: At the recommended doses of apomorphine, severe nausea and vomiting can be expected. Because of this, in domestic clinical studies, 98% of all patients were treated with the antiemetic trimethobenzamide for three days prior to beginning apomorphine and were then encouraged to continue trimeth o benzamide for at least 6 weeks. Among 522 patients treated, 262 (50%) discontinued trimethobenzamide while continuing apomorphine. The average time to discontinuation of trimethobenzamide was about 2 months (range: 1 day to 33 months). For the 262 patients who discontinued trimethobenzamide, 249 patients continued apomorphine without trimethobenzamide for a duration of follow-up that averaged 1 year (range: 0-3 years). Even with the use of trimethobenzamide in clinical trials, 31% of the patients experienced nausea and 11% of the patients experienced vomiting. In clinical trials, 3% of the patients discontinued apomorphine due to nausea and 2% discontinued due to vomiting.

In the domestic development of apomorphine, there was no experience with antiemetics other than trimethobenzamide. Some antiemetics with antidopaminergic actions have the potential to worsen the clinical state of patients with Parkinson's disease and should be avoided.

Syncope: In clinical studies, about 2% of patients experienced syncope.

QT Prolongation and Potential for Proarrhythymic Effects: In a study in which patients received increasing single doses of apomorphine from 2 to 10 mg (if tolerated) as well as placebo, the mean difference in QTc between apomorphine and placebo, as measured by Holter monitor, was 0 msec at 4 mg, 1 msec at 6 mg, and 7 msec at 8 mg. Too few patients received a 10 mg dose to be able to adequately characterize the change in QTc interval at that dose. In a controlled trial in which patients were administered placebo or a single dose of apomorphine (mean dose of 5.2 mg; range of 2-10 mg, with 30 of 35 patients receiving a dose of 6 mg or less), the mean difference between apomorphine and placebo in the change in QTc was about 3 msec at 20 and 90 minutes. In the entire database, 2 patients (one at 2 and 6 mg, one at 6 mg) exhibited large QTc increments ( > 60msecs from pre-dose) and had QTc intervals greater than 500 msecs acutely after dosing. Doses of 6 mg or less thus are associated with minimal increases in QTc. Doses greater than 6 mg do not provide additional clinical benefit and are not recommended.

Some drugs that prolong the QT/QTc interval have been associated with the occurrence of torsades depointes and with sudden unexplained death. The relationship of QT prolongation to torsades de pointes is clearest for larger increases (20 msec and greater), but it is possible that smaller QT/QTc prolongations may also increase risk, or increase it in susceptible individuals, such as those with hypokalemia, hypomagnesemia, bradycardia, concomitant use of other drugs that prolong the QTc interval, or genetic predisposition (e.g., congenital prolongation of the QT interval). Although torsades de pointes has not been observed in association with the use of apomorphine at recommended doses in premarketing studies, ex perience is too limited to rule out an increased risk. Palpitations and syncope may signal the occurrence of an episode of torsades depointes.

Caution is recommended when administering apomorphine to patients with the risk factors described above. Symptomatic

Hypotension: Dopamine agonists may cause orthostatic hypotension at any time, especially during dose escalation. Parkinson's disease patients, in addition, may have an impaired capacity to respond to an orthostatic challenge. For these reasons, Parkinson's disease patients being treated with dopaminergic agonists ordinarily require careful monitoring for signs and symptoms of orthostatic hypotension, especially during dose escalation, and should be informed of this risk.

Apomorphine causes dose-related decreases in systolic (SBP) and diastolic blood pressure (DBP). Dose-dependent mean decrements in SBP ranged from 5 mm Hg after 2 mg to 16 mm Hg after 10 mg. Dose-dependent mean decrements in DBP ranged from 3 mm Hg after 2 mg to 8 mm Hg after 10 mg. These changes were observed at 10 minutes, appeared to peak at about 20 minutes after dosing, and persisted up to at least 90 minutes post-dosing. Patients undergoing titration of apomorphine showed an increased incidence (from 4% predose to 18% post-dose) of systolic orthostatic hypotension ( ≥ 20 mmHg decrease) when evaluated at various times after in-office dosing. A small number of patients developed severe systolic orthostatic hypotension ( ≥ 30 mmHg decrease and systolic BP ≤ 90 mmHg) after subcutaneous apomorphine injection.

In clinical trials of apomorphine in patients with advanced Parkinson's disease, 59 of 550 patients (11%) had orthostatic hypotension, hypotension, and/or syncope. These events were considered serious in 4 patients ( < 1%) and resulted in withdrawal of apomorphine in 10 patients (2%). These events occurred both with initial dosing and during long-term treatment. Whether or not hypotension contributed to other significant adverse events seen (e.g., falls), is unknown. The effects of apomorphine on blood pressure may be increased by the concomitant use of alcohol, antihypertensive medications, and vasodilators (especially nitrates). Alcohol should be avoided when using APOKYN and extra caution should be exercised if APOKYN must be administered with concomitant antihypertensive medications and/or vasodilators (see PRECAUTIONS: DRUG INTERACTIONS and Information for Patients).

Falls: Patients with Parkinson's disease (PD) are at risk of falling due to the underlying postural instability and concomitant autonomic instability seen in some patients with PD, and from syncope caused by the blood pressure lowering effects of the drugs used to treat PD. Subcutaneous apomorphine might increase the risk of falling by simultaneously lowering blood pressure and altering mobility (see WARNINGS: Symptomatic Hypotension; PRECAUTIONS: Dyskinesias).

In clinical trials, 30% of patients had events that could reasonably be con sidered falls and about 5% of patients had falls that were considered serious. Because these data were obtained in open, uncontrolled studies, and given the unknown background rate of falls in a population of pa tients with advanced Parkinson's disease, it is impossible to definitively assess the contribution of apomorphine to these events.

Hallucinations: During clinical development, hallucinations were reported by 14% of the patients. Hallucinations resulted in discontinuation of apomorphine in 1% of patients.

Falling Asleep During Activities of Daily Living: There have been reports in the literature of patients treated with apomorphine subcutaneous injections who suddenly fell asleep without prior warning of sleepiness while engaged in activities of daily living. It is clear that somnolence is commonly associated with APOKYN and many clinical experts believe that falling asleep while engaged in activities of daily living always oc curs in a setting of pre-existing somnolence even if patients do not give such a history. Prescribers should therefore continually reassess pa tients for drowsiness or sleepiness, especially since some of the events occur well after the start of treatment. Prescribers should also be aware that patients may not acknowledge drowsiness or sleepiness until directly questioned about drowsiness or sleepiness during specific activities.

Before initiating treatment with APOKYN, patients should be advised of the possibility that they may develop drowsiness and specifically asked about factors that could increase the risk with APOKYN, such as concomitant sedating medications and the presence of sleep disorders. If a pa tient develops significant daytime sleepiness or episodes of falling asleep during activities that require active participation (e.g., conversations, eating, etc.), APOKYN should ordinarily be discontinued. If a decision is made to continue APOKYN, patients should be advised not to drive and to avoid other potentially dangerous activities. There is insufficient information to de termine whether dose reduction will eliminate episodes of falling asleep while en gaged in activities of daily living.

Coronary Events: During clinical development, 4% of patients treated with apomorphine experienced angina, myocardial infarction, cardiac ar rest and/or sudden death; some cases of angina and myocardial infarction occurred in close proximity to apomorphine dosing (within 2 hours), while other cases of cardiac arrest and sudden death were observed at times unrelated to dosing. Apomorphine has been shown to reduce resting systolic and diastolic blood pressure and, as such, it has the potential to exacerbate coronary (and cerebral) ischemia. Extra caution should be used in prescribing apomorphine for patients with known cardiovascular and cerebrovascular disease. If patients develop signs and symptoms of coronary or cerebral ischemia, the continued use of apomorphine should be carefully re-evaluated.

Contains Sulfite: APOKYN contains sodium metabisulfite, a sulfite that may cause allergic-type reactions, including anaphylactic symptoms and life-threatening or less severe asthmatic episodes in certain susceptible people. The overall prevalence of sulfite sensitivity in the general population is unknown and probably low. Sulfite sensitivity is seen more frequently in asthmatic than in non-asthmatic people.

Injection Site Reactions: Among the 550 patients treated with apomorphine subcutaneous injections during development, 26% of patients complained of injection site reactions, including bruising (16%), granuloma (4%), and pruritus (2%). There was a limited experience (both for overall numbers of patients as well as the total number of injections per patient) with apomorphine injections in controlled trials. In this limited controlled experience, the number of injection site reactions reported by patients receiving apomorphine was similar to that reported by patients receiving placebo.

Potential for Abuse: There are rare reports of apomorphine abuse by patients with Parkinson's disease in other countries. These cases are characterized by increasing ly frequent dosing leading to hallucinations, dyskinesia, and abnormal behavior. Psychosexual stimulation with increased libido is believed to underlie these cases. Prescribers should be vigilant for evidence that patients are abusing apomorphine, such as use out of proportion to motor signs (see Drug Abuse And Dependence).

Dyskinesias: Apomorphine may cause dyskinesia or exacerbate pre-existing dyskinesia. During clinical development, dyskinesia or worsening of dyskinesia was reported in 24% of patients. Overall, 2% of patients withdrew from studies due to dyskinesias.

Events Reported with Dopaminergic Therapy: Although the events enumerated below have not been reported in association with the use of apomorphine, they are associated with the use of other dopaminergic drugs.

Withdrawal-emergent Hyperpyrexia and Confusion: Although not reported with apo morphine, a symptom complex resembling the neuroleptic malignant syndrome (characterized by elevated temperature, muscular rigidity, altered consciousness, and autonomic instability), with no other obvious etiology, has been reported in association with rapid dose reduction, withdrawal of, or changes in antiparkinsonian therapy.

Fibrotic Complications: Cases of retroperitoneal fibrosis, pulmonary infiltrates, pleural effusion, pleural thickening, and cardiac valvulopathy have been reported in some patients treated with ergotderived dopaminergic agents. While these complications may resolve when the drug is discontinued, complete resolution does not always occur. Although these adverse events are believed to be related to the ergoline structure of these compounds, whether other, nonergot derived dopamine agonists can cause them is unknown.

Priapism: Apomorphine may cause prolonged painful erections in some patients. During clinical development, painful erections were reported by 3 of 361 males ( < 1%), and one patient withdrew from apomorphine therapy because of priapism. Although no patients in the clinical development program required surgical intervention, severe priapism may require surgical intervention.

Hepatic Impairment: Caution should be exercised when administrating apomorphine to patients with mild and moderate hepatic impairment due to the increased C max and AUC in these patients. Studies of subjects with severe hepatic impairment have not been conducted (see CLINICAL PHARMACOLOGY and DOSAGE AND ADMINISTRATION).

Renal Impairment: The starting dose should be reduced to 1 mg when administrating apomorphine to patients with mild or moderate renal impairment because the Cmax and AUC are increased in these patients. Studies in subjects with severe renal impairment have not been conducted (see CLINICAL PHARMACOLOGY and DOSAGE AND ADMINISTRATION).

Retinal Pathology in Albino Rats: Retinal degeneration has been observed in albino rats treated with dopamine agonists for prolonged periods (generally during 2-year carcinogenicity studies). This lesion has also been observed when albino rats were exposed to these agents for shorter periods under higher intensity light exposures. Similar changes have not been observed in 2-year carcinogenicity studies in albino mice or in rats or monkeys treated for 1 year. APOKYN has not been tested in carcinogenicity studies, but based on its mechanism of action it would be expected to cause similar toxicity. The significance of this effect in humans has not been established, but cannot be disregarded because disruption of a mechanism that is universally present in vertebrates (e.g., disk shedding) may be involved.

Information for Patients: APOKYN is intended only for subcutaneous injection and must not be given intravenously. Patients and caregivers should be urged to read the attached Patient Package Insert and Directions for Use for the dosing pen. Patients should be instructed to use APOKYN only as prescribed.

Patients and/or caregivers who are advised to administer APOKYN in medically unsupervised situations should receive instruction on the proper use of the product from the physician or other suitably qualified health care professional and then observed during the initial dosing.

In particular, patients and caregivers must receive detailed instruction in the use of the dosing pen, with particular attention paid to two issues: 1) Patients need to be aware that the drug is dosed in milliliters, not milligrams. Patients should be particularly cautioned that a dose of 1 mg is represented on the dosing pen as 0.1 mL, and not as 1.0 (the latter representing a dose of 10 mg). It is critical that patients and caregivers be made to understand this distinction to prevent potentially life-threatening overdose if a dose of 1 mg is prescribed. 2) Patients and caregivers must be informed that it is possible to dial in their usual dose of apomorphine even though the cartridge may contain less than that amount of drug. In this case, they will receive only a partial dose with the injection, and the amount left to inject will appear in the dosing window. To complete the correct dose, patients/caregivers will need to "re-arm" the device and dial in the correct amount of the remaining dose. If at all possible, this situation should be avoided, and patients and caregivers should be alerted to the fact that there may be insufficient drug left in the cartridge to deliver a complete dose (for example, patients and caregivers should be urged to keep records of how many doses they have delivered for each cartridge, so that they can re place any cartridge that has an inadequate amount of drug remaining).

Patients should be instructed to rotate the injection site and to observe proper aseptic technique.

Patients should be informed that hallucinations can occur.

Patients should be advised that they may develop postural (orthostatic) hypotension with or without symptoms such as dizziness, nausea, syncope, and sometimes sweat ing. Hypotension and/or orthostatic symptoms may occur more frequently during initial therapy or with an increase in dose at any time (cases have been seen after months of treatment). Accordingly, patients should be cautioned against rising rapidly after sitting or lying down, especially if they have been sitting or lying for prolonged periods, and especially at the initiation of treatment with APOKYN. Alcohol, antihypertensive medications, and vasodilating medications may potentiate the hypotensive effect of apomorphine (see WARNINGS: Symptomatic Hypotension; PRECAUTIONS: DRUG INTERACTIONS).

Patients should be alerted to the potential sedating effects of APOKYN, including somnolence and the possibility of falling asleep while engaged in activities of daily living. Since somnolence is a frequent adverse event with potentially serious consequences, patients should neither drive a car nor engage in other potentially dangerous activities until they have gained sufficient experience with APOKYN to gauge whether or not it affects their mental and/or motor performance adversely. Patients should be advised that if increased somnolence or episodes of falling asleep during activities of daily living (e.g., watching television, passenger in a car, etc.) are experienced at any time during treatment, they should not drive or participate in potentially dangerous activities until they have contacted their physician.

Because of possible additive effects, caution should be advised when patients are taking other sedating medications or alcohol in combination with APOKYN. Because apomorphine has not been evaluated for effects on reproduction and em bryo-fetal development, patients should be advised to notify their physicians if they become pregnant or intend to become pregnant (see PRECAUTIONS: Pregnancy).

Because of the possibility that apomorphine may be excreted in breast milk, patients should be advised to notify their physicians if they intend to breast-feed.

Rare cases of abuse (use of apomorphine significantly in excess of prescribed frequency) have been reported. Apomorphine abuse may be associated with inappropriate sexual behavior.

Carcinogenesis, Mutagenesis, Impairment of Fertility: Carcinogenicity studies have not been conducted with APOKYN. Apomorphine was mutagenic in the in vitro bacterial Ames test and the in vitro mam malian mouse lymphoma assay. Apomorphine was also clastogenic in the in vitro chromosomal aberration assay in human lymphocytes and the in vitro mouse lymphoma assay. Apomorphine was negative in the in vivo micronucleus assay in mice.

In a published fertility study in male rats, an adverse effect on fertility was ob served at a dose of 2 mg/kg administered subcutaneously (0.6 times the MRHD in a mg/m² basis). A significant decrease in testis weight was observed in a 39-week study in cynomolgus monkey at subcutaneous doses of 1.0 and 1.5 mg/kg (0.6 and 1 times the MRHD on a mg/m² basis).

Pregnancy: Pregnancy Category C: Reproduction studies have not been conducted with apomorphine. It is also not known whether apomorphine can cause fetal harm when administered to a pregnant woman or can affect reproductive capacity. Apomorphine should be given to a pregnant woman only if clearly needed.

Nursing Mothers: It is not known whether apomorphine is excreted in human milk. Because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants from apomorphine, a decision should be made as to whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.

Pediatric Use: The safety and efficacy of APOKYN in pediatric patients has not been established.

Geriatric Use: In the apomorphine clinical development program, there were 239 patients less than 65 years of age and 311 who were 65 years of age or older. Adverse events were about equally common in older and younger patients (90 vs 87%), but with older patients more likely to experience confusion and hallucinations. Serious adverse events (life-threatening events or events resulting in hospitalization and/or increased disability) were also more common in older patients (27 vs 17%), with older patients more likely to fall (experiencing bone and joint injuries), have cardiovascular events, develop respiratory disorders, and have gastrointestinal events. Older patients were more likely to discontinue apomorphine treatment as a result of adverse events (29 vs 21%).

Intermittent Injection: A report of an accidental overdose of 25 mg injected subcutaneously in a 62 year old man was published in Journal of Neurology, Neurosurgery, and Psychiatry (1990), Vol. 53, pp. 96-102. After 3 minutes, the patient felt nauseated and lost consciousness for 20 minutes. Afterwards, he was alert with a heart rate 40/minute and a supine blood pressure of 90/50. He recovered completely within an hour.

Based on reports of profound hypotension and loss of consciousness when apomorphine was administered with ondansetron, the concomitant use of apomorphine with drugs of the 5HT₃ antagonist class (including, for example, on- 3 dansetron, granisetron, dolasetron, palonosetron, and alosetron) is contraindicated.

APOKYN is contraindicated in patients who have demonstrated hypersensitivity to the drug or its ingredients (notably sodium metabisulfite).

Mechanism of Action: APOKYN is non-ergoline dopamine agonist with high in vitro binding affinity for the dopamine D₄ receptor (K_i = 4.4 nM), moderate affinity for the dopamine D₂, D₃, and D₅ (K_i = 35-83, 26, and 15 nM,respectively), and adrenergic α_1D,α_2B,α_2C (K_i = 65, 66, and 36 nM, respectively) receptors, and low affinity for the dopamine D₁, serotonin 5HT_1A, 5HT_2A, 5HT_2B, and 5HT_2C (K_i = 370, 120, 120, 130, and 100 nM, respectively) receptors. Apomorphine exhibits no affinity for the adrenergic β₁ and β₂ orhistamine H₁ receptors (K_i > 10,000 nM).

The precise mechanism of action of APOKYN as a treatment for Parkinson's disease is unknown, although it is believed to be due to stimulation of post-synaptic dopamine D₂ -type receptors within the caudate-putamen in the brain. Apomorphine has been shown to improve motor function in an animal model of Parkinson's disease. In particular, apomorphine attenuates the motor deficits induced by lesions in the ascending nigrostriatal dopaminergic pathway with the neurotoxin 1-methyl-4-phenyl- 1,2,3,6-tetrahydropyridine (MPTP) in primates.

Pharmacokinetics:Absorption: Apomorphine hydrochloride is a lipophilic compound that is rapidly absorbed (time to peak concentration ranges from 10 to 60 minutes) following subcutaneous administration into the abdominal wall. After sub cutaneous administration, apomorphine appears to have bioavailability equal to that of an in tra venous administration. Apomorphine exhibits linear pharmacokinetics over a dose range of 2 to 8 mg following a single subcutaneous injection of apomorphine into the abdominal wall in patients with idiopathic Parkinson's disease.

Distribution: The plasma-to-whole blood apomorphine concentration ratio is equal to one. Mean (range) apparent volume of distribution was 218L (123 - 404 L). Maximum concentrations in cerebrospinal fluid (CSF) are less than 10% of maximum plasma concentrations and occur 10 to 20 minutes later.

Metabolism and Elimination: The mean apparent clearance (range) is 223 L/hr (125 - 401 L/hr) and the mean terminal elimination half-life is about 40 minutes (range about 30 to 60 minutes).

The route of metabolism in humans is not known. Potential routes of metabolism in humans include sulfation, N-demethylation, glucuronidation and oxidation. In vitro, apomorphine undergoes rapid autooxidation.

Special Populations: The clearance of apomorphine does not appear to be influenced by age, gender, weight, duration of Parkinson's disease, levodopa dose or duration of therapy.

Hepatic Impairment: In a study comparing subjects with hepatic impairment (moderately impaired as determined by the Child- Pugh classification method) to healthy matched volunteers, the AUC_0-∞ and Cmax values were increased by approximately 10% and 25%, respectively, following a single subcutaneous administration of apomorphine into the abdominal wall. Studies in subjects with severe hepatic im pairment have not been conducted (see PRECAUTIONS and DOSAGE AND ADMINISTRATION).

Renal Impairment: In a study comparing renally-impaired subjects (moderately im paired as determined by estimated creatinine clearance) to healthy matched volunteers, the AUC_0-∞ and Cmax values were increased by approximately 16% and 50%, respectively, following a single subcutaneous administration of apomorphine into the abdominal wall. The mean time to peak concentrations and the mean terminal half-life of apomorphine were unaffected by the renal status of the individual. Studies in subjects with severe renal impairment have not been conducted. The starting dose for patients with mild or moderate renal impairment should be reduced (see PRECAUTIONS and DOSAGE AND ADMINISTRATION).

Drug-Drug Interactions: Carbidopa/levodopa: Levodopa pharmacokinetics were unchanged when subcutaneous apomorphine and levodopa were co-administrated in patients. However, motor response differences were significant. The threshold levo dopa concentration necessary for an improved motor response was reduced significantly, leading to an increased duration of effect without a change in the maxi mal response to levodopa therapy.

Other Drugs Eliminated Via Hepatic Metabolism: Based upon an in vitro study, cytochrome P450 enzymes play a minor role in the metabolism of apomorphine. In vitro studies have also demonstrated that drug interactions are unlikely due to apomorphine acting as a substrate, an inhibitor, or an inducer of cytochrome P450 enzymes.

COMT Interactions: A pharmacokinetic interaction of apomorphine with catechol-O-methyl transferase (COMT) inhibitors or drugs metabolized by this route is unlikely since apomorphine appears not to be metabolized by COMT.

Clinical Studies: The effectiveness of APOKYN in the acute symptomatic treatment of the recurring episodes of hypomobility, "off" episodes ("end-of-dose wearing off" and unpredictable "on/off" episodes), associated with advanced Parkinson's disease was established in three randomized, controlled trials. On average, pa tients participating in these trials had Parkinson's disease for 11.3 years and were being treated with L-dopa and at least one other agent, usually an oral dopamine agonist. One of the three studies was conducted in patients who did not have prior exposure to apomorphine and two were conducted in patients with at least 3 months of apomorphine use immediately prior to study enrollment. Almost all patients without prior exposure to apomorphine began taking an antiemetic (trimeth obenzamide) three days prior to starting apomorphine. After exposure to apomorphine, 50% of patients were able to discontinue use of a concomitant antiemetic, on average 2 months after initiating apomorphine.

Change in Part III (Motor Examination) of the Unified Parkinson's Disease Rating Scale (UPDRS) served as the primary outcome assessment measure in each study. Part III of the UPDRS contains 14 items designed to assess the severity of the cardinal motor findings (e.g., tremor, rigidity, bradykinesia, postural instability, etc.) in patients with Parkinson's disease.

The first trial used a parallel design, randomizing 29 patients with advanced Parkinson's disease to subcutaneous apomorphine or placebo in a 2:1 ratio. Patients had no prior exposure to apomorphine. In an office setting, hypomobility was allowed to occur by withholding the patients' Parkinson's disease medications overnight. The following morning, patients (in a hypomobile state) were started in a blinded fashion on study treatment (placebo or 2 mg of apomorphine) and redosed at increasing doses, after at least 2 hours, until a therapeutic response approximately equivalent to the individual patient's response to their usual dose of levodopa was observed (or until 10 mg apomorphine or placebo equivalent was given). At each redosing, study drug was increased by 2 mg or 0.2 mL (to 4 mg, 6 mg, 8 mg, or 10 mg of apomorphine) or placebo equivalent. Of the 20 patients assigned to apomorphine, 18 a chieved a therapeutic response at about 20 minutes that was approximately equivalent to the therapeutic response to a usual dose of levodopa. The average apomorphine dose was 5.4 mg (3 patients on 2 mg, 7 on 4 mg, 5 on 6 mg, 3 on 8 mg, and 2 on 10 mg). In contrast, of the 9 patients assigned to placebo, none reached such a therapeutic response. The mean changes-from-baseline for UPDRS Part III scores at the best dose were 23.9 and 0.1 for the apomorphine and placebo respectively (p < 0.0001).

The second trial used a crossover design, randomizing 17 patients who had been us ing apomorphine for at least 3 months. Patients received their usual morning doses of Parkinson's disease medications and were followed until hypomobility occurred, at which time they received either a single dose of subcutaneous apomorphine (at their usual dose) or placebo. Their UPDRS Part III scores were then evaluated over time. The average dose of apomorphine was 4 mg (2 patients on 2 mg, 9 on 3 mg, 2 on 4 mg, and 1 each on 4.5 mg, 5 mg, 8 mg, and 10 mg). On average, the mean changes-from-baseline UPDRS Part III scores at 20 minutes were 20.0 and 3.0 points for the apomorphine and placebo groups respectively (p < 0.0001).

The third trial used a parallel design, randomizing 62 patients who had been using apomorphine for at least 3 months. Patients were randomized in a 2:1 (active: placebo) ratio to one of four groups and were dosed once. The groups were: apomorphine at the usual dose, placebo at a volume matching the usual apomorphine dose, apomorphine at the usual dose + 2 mg (0.2 mL), or placebo at a volume matching the usual apomorphine dose + 0.2 mL. Patients received their usual morning doses of Parkinson's disease medications and were followed until hypomobility occurred, at which time they received the randomized treatment. The mean changes-from-baseline for UPDRS Part III scores at 20 minutes post dosing were 24.2 and 7.4 points for the pooled apomorphine groups and the pooled placebo groups, respectively (p < 0.0001). The figure below describes the mean change in UPDRS Motor Scores over time after pooled apomorphine and pooled placebo administration.

In this third trial, comparing patients randomized to apomorphine at the usual dose (mean dose about 4.5 mg) and patients randomized to apomorphine + 2 mg (mean dose about 6 mg), the mean changes-from-baseline for UPDRS Part III scores at 20 minutes post dosing were 24 and 25, respectively. This suggests that patients chronically treated at a dose of 4 mg might derive little additional benefit from a dose increment of 2 mg. There was an increased incidence of adverse events in patients randomized to apomorphine + 2 mg.

APOKYN® (AY-po-kin)
(apomorphine hydrochloride injection)

Read the Patient Information that comes with APOKYN before you start taking it and each time you get a refill. There may be new information. Share this information with your caregiver. This leaflet does not take the place of talking with your doctor about your medical condition or treatment. If you or your caregiver do not understand the information, or have any questions about APOKYN, talk with your doctor or pharmacist.

What is APOKYN?

APOKYN is used by injection, as needed, only to treat loss of control of body movements in people with advanced Parkinson's disease (PD). This condition is also called hypomobility or "off" episodes. An "off" episode may include symptoms such as muscle stiffness, slow movements, and difficulty starting movements. APOKYN may improve your ability to control your movements when it is used during an "off" episode. This may help you walk, talk, or move around easier. APOKYN is not used to prevent "off" episodes. APOKYN does not take the place of your other medicines for PD.

Who should not take APOKYN?

Do not take APOKYN if you are:

• allergic to APOKYN or to any of its ingredients. The active ingredient is apomorphine hydrochloride. APOKYN also contains a sulfite called metabisulfite. Sulfites can cause severe, life-threatening allergic reactions in some people, especially in people with asthma. Tell your doctor if you have had an allergic reaction to any "sulfite" containing medicines. See the end of this leaflet for a complete list of ingredients in APOKYN.
• being treated with certain drugs to treat nausea and vomiting or irritable bowel syndrome. These medications (including, for example, ondansetron, granisetron, dolasetron, palonosetron, and alosetron) are called 5HT 3 antagonists or blockers. People taking this type of drug together with apomorphine have had severely low blood pressure and lost consciousness or "blacked out."

APOKYN has not been studied in children.

Before using APOKYN, tell your doctor

• about all your medical conditions including if you:
• have dizziness
• have fainting spells
• have low blood pressure
• have asthma
• are allergic to any medicines containing sulfites
• have liver problems
• have kidney problems
• have heart problems
• have had a stroke or other brain problems
• have a mental problem called a major psychotic disorder
• drink alcohol
• are pregnant or planning to become pregnant. It is not known if APOKYN can harm your unborn baby.
• are breastfeeding. It is not known if APOKYN passes into your milk and if it can harm your baby. You should choose to either use APOKYN or breastfeed, but not both.
• about all the medicines you take, including prescription and non-prescription medicines, vitamins, and herbal supplements.

APOKYN and certain other medicines interact with each other, causing serious side effects. This happens especially when you take APOKYN with certain medicines called "vasodilators" and some other medications that lower blood pressure, or take medicines that make you sleepy. Keep a list of all the medicines you take. Your doctor or pharmacist will tell you if you can take APOKYN with your other medicines.

How should I take APOKYN?

Read the APOKYN "Instructions for Use" for complete instructions on pre paring and giving an injection of APOKYN. Do not inject APOKYN unless you and your caregiver have been taught the right way and both of you understand all the directions. Ask your doctor if you do not understand something.

Use APOKYN exactly as prescribed by your doctor. APOKYN should be injected just under the skin (i.e., subcutaneously), and not into a vein.

Your doctor or other qualified health professional must show you and your caregiver how to inject APOKYN before you start using it. Your doctor will prescribe APOKYN that comes in prefilled glass cartridges that are used with a special multiple-dose injector pen.

• Your doctor will tell you what dose of APOKYN to use and how often you should take it. Your doctor will also tell you how to change your dose of APOKYN, if needed. Do not change your dose of APOKYN or use it more often unless your doctor has told you to.
• Choose an injection site on your stomach area, upper arm, or upper leg. Change your injection site each time APOKYN is used. This will lower your chances of having a skin reaction at the site where you inject APOKYN. Do not inject APOKYN into an area of skin that is sore, red, infected or damaged.
• Never reuse needles with your APOKYN Injections. Use a new needle with each injection.
• Only use APOKYN that is clear and colorless. Do not use APOKYN that is cloudy, green, or contains particles. Call your pharmacy for a replacement.
• Your doctor will usually prescribe another medicine called an "antiemetic", to take when you are using APOKYN. Antiemetic medicines help to lessen the symptoms of nausea and vomiting that can happen with APOKYN.
• If you take too much APOKYN, you may experience more side effects than usual and they may be stronger than usual. If you are experiencing more side effects or stronger side effects than you commonly have, you should contact your doctor immediately If you are unable to contact your doctor, you should have someone take you to the Emergency Room. It is a good idea to discuss this potential problem with your doctor at the time that you start APOKYN.

What should I avoid while taking APOKYN?

• Do not take APOKYN with any of these drugs: ondansetron, dolasetron, granisetron, palonosetron, and alosetron or any drug of the 5HT₃ antagonist class or group.
• Do not drink alcohol while you are taking APOKYN. Alcohol used with APOKYN can cause worse side effects.
• Do not take medicines that make you sleepy while you are taking APOKYN.
• Do not drive a car, operate machinery, or do anything that might put you at risk of getting hurt until you know how APOKYN affects you. APOKYN may cause dizziness or fainting. Tell your doctor if you get dizzy or faint with APOKYN.
• Do not change your body position too fast. Get up slowly from sitting or lying. APOKYN can lower your blood pressure and cause dizziness or fainting.

What are the possible side effects of APOKYN?

• heart problems. If you develop shortness of breath, fast heart- beat, or chest pain while taking APOKYN, call your doctor right away or get emergency help.
• severe nausea and vomiting can happen with APOKYN. Tell your doctor if this is a problem for you. Your doctor may prescribe a medicine called Tigan to help prevent nausea and vomiting. Some patients can stop taking Tigan after using APOKYN for some time. Some patients may need to continue taking Tigan to help prevent nausea and vomiting. Talk to your doctor before you stop taking Tigan.
• sleepiness or falling asleep during the day. Some patients treat- ed with APOKYN may get sleepy during the day or fall asleep without warning while doing everyday activities such as talking, eating, or driving a car. Tell your doctor if you (or your caregiver) see either of these effects.
• falls. The changes that occur with PD, and the effects of some PD medicines, can increase the risk of falling. APOKYN can also increase this risk.
• sudden uncontrolled movements (dyskinesias). Some people with PD may get sudden, uncontrolled movements after treatment with some PD medicines used to treat PD. APOKYN can cause or worsen this effect.
• dizziness. APOKYN can lower your blood pressure and cause dizziness. This effect usually happens when APOKYN treatment is started or when the APOKYN dose is increased. With dizziness, there may also be other symptoms such as nausea, fainting, and sometimes sweating. Do not get up too fast from sitting or after lying down, especially if you have been sitting or lying down for a long period of time. Tell your doctor if dizziness is a problem for you.
• hallucinations. APOKYN may cause hallucinations (seeing or hearing things that are not real) in some people. Call your doctor right away if you get hallucinations with APOKYN.
• depression. Some people get depression while taking APOKYN. Call your doctor right away if you get depression with APOKYN.
• headache. APOKYN can cause headaches. If these become severe or do not go away, call your doctor.
• injection site reactions. Soreness, redness, bruising and itching may happen at the injection site. Changing the injection site with each injection, and putting ice on the injection site before and after injections, may help lower these effects.

APOKYN can also cause yawning, a runny nose, and swelling of your hands, arms, legs, and feet.

Talk to your doctor about any side effects that bother you or that don't go away.

These are not all the side effects with APOKYN. For more information, ask your doctor or pharmacist.

How should I store APOKYN?

• Store APOKYN cartridges at room temperature, 77°F (25°C).
• When traveling, keep the cartridges at 59 to 86°F (15 to 30°C).
• Keep APOKYN and all medicines out of the reach of children.

General information about APOKYN.

Medicines are sometimes prescribed for conditions that are not mentioned in patient information leaflets. Do not use APOKYN for a condition for which it was not prescribed. Do not give APOKYN to other people, even if they have the same symptoms you have. It may harm them.

This leaflet summarizes the most important information about APOKYN. If you would like more information, talk with your doctor. You can ask your pharmacist or doctor for information about APOKYN that is written for health professionals. You can also call 1-877- 727-6596 or visit www.apokyn.com for more information.

What are the ingredients in APOKYN?

Active ingredient: apomorphine hydrochloride, USP

Inactive ingredients: sodium metabisulfite, NF, water for injection, USP It may also contain sodium hydroxide, NF and/or hydrochloric acid, NF. The cartridges also contain benzyl alcohol.

IMPORTANT NOTE: This is a summary and does not contain all possible information about this product. For complete information about this product or your specific health needs, ask your health care professional. Always seek the advice of your health care professional if you have any questions about this product or your medical condition. This information is not intended as individual medical advice and does not substitute for the knowledge and judgment of your health care professional. This information does not contain any assurances that this product is safe, effective, or appropriate for you.

APOMORPHINE - INJECTION

(a-poe-MOR-feen)

COMMON BRAND NAME(S): Apokyn

USES: This medication is used to treat the symptoms of Parkinson's disease. It can improve your ability to move during frequent "off" periods. It can decrease shakiness (tremor), stiffness, slowed movement, and unsteadiness. This medication is thought to work by helping to restore the balance of a certain natural substance (dopamine) in the brain.

Apomorphine is used to treat "off" episodes when they occur. It is not used to prevent "off" episodes. This drug should not be used instead of your usual medications for Parkinson's disease. Continue taking all your medications as directed by your doctor.

HOW TO USE: Read the Patient Information Leaflet provided by your pharmacist before you start using apomorphine and each time you get a refill. If you have any questions, consult your doctor or pharmacist.

Learn all preparation and usage instructions in the product package. If any of the information is unclear, consult your doctor or pharmacist.

Before using, check this product visually for particles or discoloration. If either is present, do not use the liquid. Check the dose carefully before injecting. Apomorphine is given by the milliliter, not by the milligram. There are 10 milligrams of drug in each milliliter of this liquid, so if the wrong measuring unit is used, you may accidentally inject 10 times the amount of drug you need. Be sure you have the correct dose to prevent accidental overdose. If you are not sure how to measure your dose correctly, consult your pharmacist before injecting.

If you are using the prefilled cartridge/pen, keep track of the doses used to make sure there is enough medication left in the device to give you a full dose.

Clean the injection site before injecting. Inject this medication under the skin as needed to treat decreased/frozen muscle movement ("off" episode) as directed by your doctor. You may need to use this medication several times a day. Do not use a second injection for the same "off" episode. Wait at least 2 hours between injections.

Do not inject this medication into a vein. It is important to change the location of the injection site with each dose to avoid problem areas under the skin. Therefore, choose a different injection site with each dose. The abdomen, thighs, and upper arms are recommended sites for the injection. Do not inject into skin that is irritated, sore, or infected. Learn how to store and discard needles and medical supplies safely. Never reuse syringes or needles. Consult your pharmacist for details.

Dosage is based on your medical condition and response to treatment. To decrease the risk of side effects (e.g., nausea, drowsiness, low blood pressure) when you first start using apomorphine, your doctor will slowly increase your dosage until the best dose for you is reached. Your doctor will usually have you use the first dose in the office where your blood pressure can be checked and you can be watched for side effects. A health care professional will also teach you to inject this medication correctly. Nausea is very common with this medication. To decrease the risk of nausea, your doctor may direct you to start taking another medication (e.g., trimethobenzamide) 3 days before your first dose of apomorphine and to continue taking it for at least 2 months.

Use this medication as prescribed. If you stop using this medication for longer than 1 week, you may need to increase your dose slowly back to your previous dosage. Talk with your doctor about how to restart the medication. Do not stop using this medication without your doctor's approval. If you have been using this medication frequently and suddenly stop using this drug, withdrawal reactions may occur. Such reactions can include fever, muscle stiffness, and confusion. Report any such reactions to your doctor immediately.

Rarely, abnormal drug-seeking behavior (drug abuse) is possible with this medication. Do not increase your dose or use it more frequently than prescribed. Properly stop the medication when so directed.

Tell your doctor if your condition persists or worsens.

SIDE EFFECTS: Redness/swelling/pain/itching at the injection site, nausea, vomiting, headache, sweating, dizziness, drowsiness, yawning, or runny nose may occur. If any of these effects persist or worsen, tell your doctor or pharmacist promptly.

Remember that your doctor has prescribed this medication because he or she has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.

Tell your doctor immediately if any of these unlikely but serious side effects occur: uncontrolled movements, mental/mood changes (e.g., depression, hallucinations, trouble sleeping), muscle cramps/spasm, swelling of the hands/legs/ankles/feet.

Seek immediate medical attention if any of these rare but very serious side effects occur: chest pain, shortness of breath, unusually fast/pounding/irregular heartbeat, severe dizziness, fainting, slurred speech, vision changes, weakness on one side of the body.

Some people using apomorphine have reported falling asleep suddenly during their usual daily activities (e.g., talking on the phone, driving). In some cases, sleep occurred without any feelings of drowsiness beforehand. This sleep effect may occur any time during treatment. Therefore, you should not drive or take part in other possibly dangerous activities until you are certain that this medication will not cause drowsiness or sudden sleep. If you experience increased sleepiness or fall asleep during the day, do not drive or take part in other possibly dangerous activities until you have discussed this effect with your doctor. Your risk is increased with use of alcohol or other medications that can make you drowsy.

You may also develop a sudden drop in blood pressure that can cause dizziness, nausea, and fainting. This effect may also increase your risk of a fall. This drop in blood pressure is more likely when you are first starting the medication, when your dose is increased, or when you get up suddenly. To lower your risk, get up slowly from a sitting or lying position. Avoid alcohol.

For males, in the very unlikely event you have a painful, prolonged erection (lasting more than 4 hours), stop using this drug and seek immediate medical attention, or permanent problems could occur.

A very serious allergic reaction to this drug is rare. However, seek immediate medical attention if you notice any symptoms of a serious allergic reaction, including: rash, itching, swelling, severe dizziness, trouble breathing.

This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.

Contact your doctor for medical advice about side effects. The following numbers do not provide medical advice, but in the US you may report side effects to the Food and Drug Administration (FDA) at 1-800-FDA-1088. In Canada, you may call Health Canada at 1-866-234-2345.

PRECAUTIONS: Before using apomorphine, tell your doctor or pharmacist if you are allergic to it; or to sulfites; or if you have any other allergies.

Before using this medication, tell your doctor or pharmacist your medical history, especially of: asthma, heart problems (e.g., chest pain, heart attack, QT prolongation in the EKG), slow/fast/irregular heartbeat (e.g., arrhythmia), mental/mood disorders (e.g., confusion, hallucinations, psychosis, schizophrenia), kidney problems, liver problems, symptoms of low blood pressure (e.g., dizziness, fainting), low levels of magnesium/potassium in the blood, sleep disorder (e.g., sleep apnea, narcolepsy), stroke or other brain problem.

This drug may make you dizzy or drowsy. Use caution while driving, using machinery, or doing any activity that requires alertness. Avoid alcoholic beverages.

Caution should be taken when using this drug in the elderly because they may be at greater risk for certain side effects such as falls and hallucinations.

During pregnancy, this medication should be used only when clearly needed. Discuss the risks and benefits with your doctor.

It is not known whether this drug passes into breast milk. Therefore, breast-feeding while using this medication is not recommended. Consult your doctor before breast-feeding.

DRUG INTERACTIONS: Your doctor or pharmacist may already be aware of any possible drug interactions and may be monitoring you for them. Do not start, stop, or change the dosage of any medicine before checking with your doctor or pharmacist first.

This drug should not be used with the following medications because very serious interactions may occur: certain drugs for nausea/bowel problems (5HT-3 antagonists such as alosetron, granisetron, ondansetron).

If you are currently using any of these medications listed above, tell your doctor or pharmacist before starting apomorphine.

Apomorphine may affect the heartbeat when used at higher doses. Other drugs besides apomorphine may affect the heartbeat (QTc prolongation in the EKG). They include amiodarone, dofetilide, pimozide, quinidine, sotalol, procainamide, and erythromycin, among others. QTc prolongation can infrequently result in a serious (rarely fatal) irregular heartbeat. If you are taking any of these medications, consult your doctor or pharmacist for more details and for instructions on how you may reduce your risk of this effect.

Before using this medication, tell your doctor or pharmacist of all prescription and nonprescription/herbal products you may use, especially of: antipsychotics (e.g., chlorpromazine, haloperidol, thiothixene), certain drugs for nausea (e.g., metoclopramide, phenothiazines such as prochlorperazine), drugs for high blood pressure (e.g., beta blockers such as atenolol), vasodilators (e.g., nitrates), "water pills" (diuretics such as furosemide, thiazides).

Tell your doctor or pharmacist if you also take drugs that cause drowsiness such as: certain antihistamines (e.g., diphenhydramine), anti-seizure drugs (e.g., carbamazepine), medicine for sleep or anxiety (e.g., alprazolam, diazepam, zolpidem), muscle relaxants, narcotic pain relievers (e.g., codeine), psychiatric medicines (e.g., risperidone, amitriptyline, trazodone). Check the labels on all your medicines (e.g., cough-and-cold products) because they may contain ingredients that cause drowsiness. Ask your pharmacist about using those products safely.

This document does not contain all possible interactions. Therefore, before using this product, tell your doctor or pharmacist of all the products you use. Keep a list of all your medications with you, and share the list with your doctor and pharmacist.

OVERDOSE: If overdose is suspected, contact your local poison control center or emergency room immediately. US residents can call the US National Poison Hotline at 1-800-222-1222. Canada residents can call a provincial poison control center. Symptoms of overdose may include: very severe nausea/vomiting, loss of consciousness.

NOTES: Do not share this medication with others.

MISSED DOSE: Not applicable.

STORAGE: Store at room temperature at 77 degrees F (25 degrees C) away from light and moisture. Brief storage between 59-86 degrees F (15-30 degrees C) is permitted. Do not store in the bathroom. Keep all medicines away from children and pets.

Syringes can be filled the night before use and stored in the refrigerator until the next day. Discard this type of pre-filled syringe if not used in 24 hours.

Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company for more details about how to safely discard your product.

MEDICAL ALERT: Your condition can cause complications in a medical emergency. For information about enrolling in MedicAlert, call 1-800-854-1166 (USA) or 1-800-668-1507 (Canada).

Information last revised July 2008 Copyright(c) 2008 First DataBank, Inc.