Movement disorder specialists and dermatologists have come together to create a protocol for managing skin nodules, the most commonly reported infusion-site reaction associated with the use of continuous subcutaneous infusions in Parkinson’s disease patients. This protocol was presented by Stuart H. Isaacson, MD, FAAN, the director of the Parkinson’s Disease & Movement Disorders Center of Boca Raton, and colleagues at the 2nd Annual Advanced Therapeutics in Movement and Related Disorders Congress held by the PMD Alliance from June 8 to 11, 2023, in Washington, DC.
According to the expert roundtable, infusion-site reactions are believed to reflect an inflammatory response to infused medication, its metabolites, and/or infusion excipients. The majority of these reactions are self-limited, resolve spontaneously, do not limit the successful continuation of treatment, and can be managed by a treating neurologist without any referral to dermatology or other medical professionals.
The presence of a variety of select signs and symptoms were suggested as the key factors to include in the classification of infusion-site reactions. These classifications include asymptomatic, symptomatic but mild, symptomatic but moderate, and symptomatic and severe. The clinical framework proposed for managing continuous subcutaneous apomorphine infusion-related infusion-site reactions includes primary intervention, evaluation, classification, and initial management, and secondary prevention.
The primary intervention involves physician education on proper insertion technique, skin hygiene, site rotation, and the cleaning of residual medication from skin. The evaluation includes a patient and care provider history and a neurologist examination to determine the size, presence of erythema, presence of tenderness, and state of drainage or fluctuance. The classification and initial management include specific guidelines for asymptomatic, symptomatic mild, symptomatic moderate, and symptomatic severe cases.
The secondary prevention involves reeducation on proper insertion technique, site rotation, skin hygiene, and avoiding problem skin areas. As infections are uncommon in the instance of infusion-site reactions/nodules, the group suggested that empiric antibiotics are not usually necessary.
The roundtable was convened in June 2022 to develop the proposed framework, where the experts reviewed the current knowledge of infusion-site reactions, discussed their clinical experience with continuous subcutaneous apomorphine infusion associated reactions, and shared their expertise on guiding patients with PD and educating and training clinicians.
The group concluded that further research will help to elucidate the underlying causes of these infusion-site reactions, but simple steps can be taken to minimize their occurrence, such as proper skin hygiene and site rotation. The full group included Stuart H. Isaacson, MD, FAAN, Mindy S. Grall, NP, Fiona Gupta, MD, Daniel Kremens, MD, Cuong Nguyen, MD, Raiesh Pahwa, MD, Marc Serota, MD, Matthew Zirwas, MD, and Steven Feldman, MD, PhD.
In conclusion, Parkinson’s disease patients who undergo continuous subcutaneous apomorphine infusion for treatment often face infusion-site reactions. However, these reactions can be managed with proper care and awareness. The newly created protocol by a group of experts aims to assist physicians in managing these reactions efficiently and effectively, and subsequently improve the quality of treatment for Parkinson’s patients.
