Commentary
Video
Patient Perspectives and Expert Tips on Managing CSAI Challenges in PD
Author(s):
Pagan shared insights from InfusON patient interviews on the challenges and benefits of initiating CSAI therapy and discussed how expert roundtable recommendations can guide neurologists in managing skin nodules associated with treatment.
At the 2025 American Academy of Neurology Annual Meeting, held April 5-9, in San Diego, California, movement disorder expert Fernando L. Pagan, MD, sat down with NeurologyLive® to share some updates on therapeutics for managing motor fluctuations in Parkinson disease (PD) based presentations from meeting. Pagan highlighted real-world findings related to treatment use, including patient experiences, adherence strategies, and adverse effect management with these therapies.
In this segment, Pagan discussed the clinical considerations and practical aspects of initiating continuous subcutaneous apomorphine infusion therapy for patients with PD. He highlighted the learning curve associated with device placement, skin site rotation to manage nodules, and gradual dose titration tailored to individual tolerability. Pagan emphasized the importance of leveraging European clinical experience, particularly in managing skin-related adverse effects and titration protocols. He also outlined strategies for adjusting concurrent dopaminergic therapies during initiation.
Transcript below edited for clarity.
Fernando L. Pagan, MD: So, when you're initiating these subcutaneous pumps—continuous subcutaneous infusions—there's a learning curve for our patients. Firstly, how to place the pump, how to properly place the application. With these treatments, you want to make sure that you're going through the dermis, because it's absorbed through the subcutaneous fat. If you inject it into the dermis, it can cause some irritation and skin reactions. So, it could be a little uncomfortable, cause a little bit of redness for patients. Just learning how to apply it—it's a device, so there is a bit of a learning curve in how to properly adjust it. It's about learning how to use the device.
But I think once the patients get used to it, they see the difference between these therapies and the oral therapies. That’s a big change that happens over time. Some of the challenges with this one—specifically with apomorphine—is that you need to slowly increase it to get to the ultimate therapeutic benefit for our patients. And there can be some skin nodules, so you do want to continue to move the device daily to different locations. But we have a lot of real estate in our bodies—not only around the belly button, but also the flanks, thighs, even the triceps. So, there are a lot of different areas that can be used, and we’ve learned that over 30 years of experience.
My European colleagues state that if you do some massaging where the skin nodules occur, that will help reduce them. They sometimes use spiky balls to massage those nodules away. Again, these are things we're going to learn as neurologists now treating these patients who are having significant motor fluctuations. But I think it’s so exciting that we have all these new therapies for patients with movement disorders that we’ve really been waiting a long time for.
Definitely, learning from our European colleagues—who have such great experience with these subcutaneous, continuous infusions—is important. It's important to get those pearls on how to deal with these challenges when we see our patients. So definitely listening to our colleagues who’ve been doing this for many, many years, and getting the best practices on how to start these patients up as well.
You see the diversity in Europe—some centers always start these infusions in the inpatient setting. Here in the US, with the InfusON study, we did it as an outpatient. And the company that is rolling out the apomorphine continuous subcutaneous infusion does have a Circle of Care program that will allow patients to be titrated at home. But important communication needs to happen between the provider and the patient as you’re slowly increasing the dose to the therapeutic effect.
You know, taking it slow for certain patients—other patients, you may be able to go every 3 to 5days; others, maybe every week that you're able to increase that dose depending on tolerability. Because here in the United States, we don’t have antiemetics. In Europe, there is a drug called domperidone that’s used prior to initiation, but we don’t have that here in the United States.
But we saw in the clinical trials—both in the InfusON study—that not all patients needed the antiemetic. And we’ve also seen with titrations of apomorphine on demand for "OFF" periods, that we can start patients and slowly titrate up without an antiemetic. So, learning from the experts, you can really get some good pearls of wisdom on how to slowly titrate these patients up to therapeutic benefit.
Which medicines do you want to first taper off or begin to titrate down? My recommendation is definitely to begin with the dopamine agonist, started adjunctively first. And then, as you're titrating up this dopamine agonist, start to remove the previous oral dopamine agonist. Then you can take a look at the rest of the medication regimen, see how the patient is doing—you may even be able to slowly titrate down the amount of levodopa.
And for some patients, you may be able to switch the formulation of levodopa—maybe start to use some of the extended-release formulations that are now available as well. So, there are a lot of therapeutic options available for our patients. Listening to our colleagues in Europe, seeing what they’ve done in the past—and here in the US, we have a little bit of an advantage with some of the new formulations of carbidopa/levodopa—that may give us an edge that our European colleagues didn’t have over the last 30 years.
