The number of on‐demand therapies for rapidly treating off episodes related to Parkinson's disease (PD) is limited and consists of the use of subcutaneous apomorphine pen (Apo‐pen) injections, sublingual apomorphine film (Apo‐film), or levodopa inhalation powder. 1 , 2 In France, only Apo‐pen is available, but other alternatives might be available in the future. However, the use of Apo‐pen injections remains relatively underutilized, with a lack of available data in the literature. 3 , 4
The NS‐PARK network is a clinical research network accredited by the French Clinical Research Infrastructure (F‐CRIN, https://parkinson.network/). It comprises all 27 French “Parkinson Disease Expert Centers” (PDEC) individually certified by the French Ministry of Health. These centers meet specific criteria ensuring they possess leading expertise in France for managing patients with PD, including those requiring advanced therapies.
To better understand the practices of neurologists working in French PDECs regarding the use of Apo‐pen injections, the NS‐PARK network developed a questionnaire on prescribing habits and limits, which was then distributed to all neurologists in the PDECs. The responses were collected between April 12, 2023, and May 24, 2023.
The survey data are summarized in Table 1. We received responses from 22 of 27 PDECs. Five PDECs did not participate in the survey, resulting in a response rate of 82%. The questionnaires were filled by 36 of 93 neurologists working in the PDECs. Indeed, it is important to note that, in most PDECs, a single neurologist provided input on behalf of multiple prescribers within the same center. However, in some PDECs, multiple prescribers from the same center individually responded to the questionnaire, typically when their practices or habits were not strictly identical.
TABLE 1.
Survey data
| Main characteristics | n, % |
|---|---|
| PDEC participants | 22/27, 82% |
| Use of Apo‐pen injections to treat “on‐demand” off episodes | 29/36, 81% |
| Proportion of patients treated with Apo‐pen injections in PDECs | |
| Less than 5% | 9/22, 41% |
| Less than 1% | 8/22, 36% |
| Range of doses administered per injection | |
| 2–3 mg | 7/29, 24% |
| 2–5 mg | 22/29, 76% |
| Estimated average number of daily injections performed by patients | |
| 1 per day | 4/29, 14% |
| 2 per day | 16/29, 55% |
| 3 per day | 9/29, 31% |
| >3 per day | 0/29, 0% |
| Estimated average number of Apo‐pen injections to treat daily off episodes | |
| Less than 50% of episodes | 22/29, 76% |
| More than 50% of episode | 7/29, 24% |
| Patient reluctance to use Apo‐pen injections | 27/29, 93% |
| Patients' (or caregivers') apprehension regarding self‐injections | 23/29, 79% |
| Technical difficulties related to pen handling | 3/29, 10% |
| Consequence of patient reluctance | |
| Under‐prescription of Apo‐pen injections | 24, 82% |
| Deprivation of a useful therapeutic option | 24, 82% |
| Consider continuous subcutaneous apomorphine infusion via a pump at an earlier stage | 2, 7% |
| Believe that the availability of sublingual apomorphine film could potentially overcome certain barriers and facilitate access to the treatment of “on‐demand” off episodes before considering more complex strategies | 29/29, 100% |
Abbreviations: PDECs, Parkinson Disease Expert Centers; Apo‐pen, subcutaneous apomorphine pen.
Key findings can be summarized as follows:
Usage rates: Apo‐pen injections were used by 81% of respondents but only in a minority of patients (≤5% in 77% of centers and ≤1% in 36% of centers).
Patient reluctance: 93% of prescribers identified patient reluctance, driven by apprehension about self‐injections (79%) and technical challenges (14%).
Impact on care: reluctance led to under‐prescription in 79% of centers, depriving patients of effective treatment options.
Potential solutions: 100% of prescribers believe Apo‐film could address key barriers by offering a less‐invasive alternative.
Overall, the study revealed that, according to PDEC prescribers' opinion in France, Apo‐pen injections are utilized by most of them in their clinical practice, although patient reluctance and concerns regarding self‐injections and pen handling are prevalent. This hesitancy in adopting Apo‐pen injections may lead to underutilization and limit access to a potentially highly efficacious treatment option for PD patients. Our results are consistent with other studies. 1 , 3 , 4 The present survey did not explicitly ask whether PDEC prescribers refrained from proposing Apo‐pen use to patients due to their perceived complexity of the process, but several of them spontaneously raised this issue. Other limiting factors, such as apomorphine safety profile or the lack of a caregiver to assist with injections, warrant consideration. Further educational initiatives, such as practical training sessions, instructional videos, and structured support during treatment initiation should be encouraged. Additionally, exploring alternative delivery methods, such as Apo‐film, could provide viable options for PD patients who may prefer or benefit from easier administration routes. 1 , 5
Author Roles
(1) Research project: A. Conception, B. Organization, C. Execution; (2) Statistical analysis: A. Design, B. Execution, C. Review and critique; (3) Manuscript preparation: A. Writing of the first draft, B. Review and critique.
M.A.: 1A, 1B, 1C, 2B, 3A
F.K.: 1B, 1C, 3B
O.R.: 1A, 1B, 1C, 2A, 2C, 3B
Disclosures
Ethical Compliance Statement: The authors confirm that the approval of an institutional review board was not required for this work. Informed consent was not required. They confirm that they have read the journal's position on issues involved in ethical publication and affirm that this work is consistent with those guidelines.
Funding Sources and Conflicts of Interest: The NS‐PARK/FCRIN network has received financial support from Bial to perform this survey. The authors declare that there are no funding sources or conflicts of interest relevant to this work.
Financial Disclosures for the Previous 12 Months: M.A. and F.K. have no financial disclosures. O.R. has provided scientific advice for Apopharma, Astra‐Zeneca, Bial, Biogen, Britannia, Cerevel, Contera, GE Healthcare, Ionis, Lundbeck, Merz, Neuralight, Neuroderm, ONO Pharma, Orion Pharma, Roche Therapeutics, Supernus, Thelonius Mind, Takeda, Teva, UCB, and Zambon.
Acknowledgments
We would like to express our gratitude to the members of the centers of the NS‐PARK Network who contributed to this survey: Amiens (Tir M.), Bordeaux (Foubert‐Samier A.), Caen (Thiriez C.), Dijon (Dupont G.), Grenoble (Fraix V.), Lille (Carriére N., Defebvre L., Kreisler A., Moreau C.), Lyon (Danaila T., Thobois S.), Marseille (Azulay J.P., Grimaldi S.), Montpellier (Charif M., Geny C., Prin P.), Nantes (Rouaud T.), Nancy (Frismand S.), Nice (Giordana C.), Paris‐Avicenne (Degos B.), Paris‐Creteil (Remy P., Salhi H.), Paris‐Pitié‐Salpetriere (Corvol J.C., Grabli D., Meneret A., Vidailhet M.), Reims (Doe A.), Rennes (Drapier S.), Rouen (Maltete D.), Strasbourg (Tranchant C.), Toulouse (Brefel‐Courbon C., Fabbri M., Ory‐Magne F., Rascol O.), Tours (Belin J.).
Members of the NS‐PARK/FCRIN Network group are listed in the Acknowledgments.
Contributor Information
Mickael Aubignat, Email: aubignat.mickael@chu-amiens.fr.
the NS‐PARK/FCRIN Network:
Mélissa Tir, MD, PhD, Alexandra Foubert‐Samier, MD, Claire Thiriez, MD, Gwendoline Dupont, MD, Valérie Fraix, MD, Nicolas Carrière, MD, Luc Defebvre, MD, PhD, Alexandre Kreisler, MD, Caroline Moreau, MD, PhD, Teodor Danaila, MD, Stéphane Thobois, MD, PhD, Jean‐Philippe Azulay, MD, PhD, Stephan Grimaldi, MD, Mahmoud Charif, MD, Christian Geny, MD, Pauline Prin, MD, Tiphaine Rouaud, MD, PhD, Solène Frismand, MD, Caroline Giordana, MD, Bertrand Degos, MD, PhD, Philippe Remy, MD, PhD, Hayet Salhi, MD, Jean‐Christophe Corvol, MD, PhD, David Grabli, MD, PhD, Aurélie Meneret, MD, Marie Vidailhet, MD, PhD, Anne Doe, MD, PhD, Sophie Drapier, MD, PhD, David Maltete, MD, PhD, Christine Tranchant, MD, PhD, Christine Brefel‐Courbon, MD, PhD, Margherita Fabbri, MD, PhD, Fabienne Ory‐Magne, MD, PhD, Olivier Rascol, MD, PhD, and Jeremie Belin, MD
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