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Symposium Report A Landmark Year for Apomorphine – Advancing Parkinson’s Disease Management with New Clinical Evidence Highlights of a Britannia-sponsored symposium held at the 21st International Congress of Parkinson's Disease and Movement Disorders, Vancouver, Canada, 4–8 June 2017 Andrew Lees, 1 Regina Katzenschlager 2 and K Ray Chaudhuri 3 1. The National Hospital for Neurology and Neurosurgery and Reta Lila Weston Institute of Neurological Studies, Institute of Neurology, University College London, London, UK; 2. Department of Neurology, Karl Landsteiner Institute for Neuroimmunological and Neurodegenerative Disorders, Danube Hospital, Vienna, Austria; 3. National Parkinson Foundation Centre of Excellence, Kings College London, Denmark Hill Campus, London, UK. I t has now been almost 30 years since the publication of the pivotal clinical trial in The Lancet in 1988, which confirmed that subcutaneous apomorphine (APO) has equivalent antiparkinsonian efficacy to levodopa for the management of ‘off’ symptoms in patients with Parkinson’s disease (PD). The study’s findings led to subcutaneous APO (APO-go ® , Britannia Pharmaceuticals Ltd, UK) being licensed initially in the UK in 1993 for PD treatment and since that time it has been used successfully in clinical practice in Europe and many other parts of the world for the management of ‘off period’ disability. This symposium, chaired by Professor Andrew Lees (UK), who was a key investigator in that original trial, set out to review what has been another landmark year for APO and to discuss how recent clinical evidence can help inform our daily practice and improve outcomes for our patients with PD. APO is the only other drug with an antiparkinsonian effect equal to levodopa. When used as intermittent subcutaneous injections, it is also the most rapidly effective treatment for motor fluctuations and its efficacy has been confirmed in randomised trials. Extensive clinical experience and many uncontrolled studies have shown the efficacy of APO for the relief of motor fluctuations when administered either as an intermittent injection or as a continuous subcutaneous infusion using ambulatory mini-pumps, depending on the patient’s symptoms. However, unlike other therapies commonly used for these types of patients, such as levodopa/carbidopa intestinal gel and deep-brain stimulation, up to now Level 1 evidence for the efficacy and safety of APO infusion from large, randomised studies has been lacking. Professor Regina Katzenschlager (Austria) provided an overview of the clinical trial of apomorphine subcutaneous infusion in patients with advanced Parkinson's disease (TOLEDO study), the first randomised, double-blind clinical trial to investigate the efficacy, safety and tolerability of APO-go 5 mg/ml solution for infusion compared with placebo in patients with PD whose motor fluctuations are uncontrolled despite optimised PD therapy. Results from this study will fill an important knowledge gap in the currently available evidence for APO infusion. Professor K Ray Chaudhuri (UK) went on to review the clinical indications for APO infusion and other continuous dopaminergic therapies, illustrated with patient case studies and supported by his experience since the 1990s in initiating and monitoring medication to obtain the best long-term results. Recently, wearable sensors have been used to monitor patients with PD undergoing treatment to help inform clinical management. Although APO is more than 150 years old, it is apparent that there are still many important lessons to learn about its mode of action and optimum clinical application which will be of benefit to patients with PD. Keywords Parkinson’s disease (PD), motor fluctuations, subcutaneous apomorphine infusion, randomised clinical trial Disclosure: Andrew Lees is funded by the Reta Lila Weston Institute of Neurological Studies, Institute of Neurology, University College London, and reports consultancies for Britannia Pharmaceuticals and BIAL Portela. He also reports grants and/or research support from the Frances Renee Hock Fund and honoraria from Britannia Pharmaceuticals, Profile Pharma, UCB, Roche, Lundbeck, Teva, BIAL, Nordiclnfu Care, NeuroDerm, Decision Resources and Windrose Consulting Group. Regina Katzenschlager has received research support from Acorda Therapeutics, Adamas, BIAL, Biotie Therapies Inc., Britannia Pharmaceuticals and Stada, and fees for speaking or consulting from AbbVie, AOP Pharma, BIAL, Britannia Pharmaceuticals, Cynapsus, Global Kinetics Corporation, Grünenthal, UCB and Zambon. K Ray Chaudhuri has received research support from AbbVie, Britannia Pharmaceuticals, BIAL, GKC and UCB, and fees for speaking or consulting from AbbVie, Britannia Pharmaceuticals, UCB, Mundipharma, Sunovion, Pfizer, GKC, BIAL, Novartis and Teva. This article reports the proceedings of a sponsored satellite symposium held at the 21st International Congress of Parkinson's Disease and Movement Disorders, Vancouver, Canada, 4–8 June 2017, and, as such, has not been subject to this journal’s usual peer-review process. The report was reviewed for scientific accuracy by the symposium speakers and editorial board before publication. Compliance with Ethics: Written informed consent was not obtained from the patient case included in this report; no identifying information or images have been used. Acknowledgements: Editorial assistance was provided by Dr Karen Wolstencroft, a consultant to Helen Lawn & Associates PR Ltd, funded by Britannia Pharmaceuticals Ltd. Authorship: All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship of this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval for the version to be published. Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any non-commercial use, distribution, adaptation and reproduction provided the original author(s) and source are given appropriate credit. Received: 22 September 2017 Published Online: 26 October 2017 Citation: European Neurological Review, 2017;12(Suppl. 4):2–7 Corresponding Author: Andrew Lees, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK; E: andrew.lees@ucl.ac.uk 2 TOUC H ME D ICA L ME D IA