Protocol for Skin Nodule Management Related to Continuous Subcutaneous Infusion in Parkinson Disease Proposed by Expert Panel

Stuart H. Isaacson, MD, FAAN

An expert roundtable of movement disorder specialists and dermatologists has produced a protocol for the management of skin nodules, the most commonly reported infusion-site reaction associated with the use of continuous subcutaneous infusions, such as those related to continuous apomorphine infusion (SPN-830; Supernus), in patients with Parkinson disease (PD).

All told, the panel suggested that most of these reactions are self-limited, resolve spontaneously, do not limit the successful continuation of treatment, and importantly, can be managed by a treating neurologist without any referral to dermatology or other medical professional. The protocol was presented in a poster 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 (ATMRD) Congress, held by the PMD Alliance from June 8 to 11, 2023, in Washington, DC.

“[Infusion-site reactions] are thought to reflect an inflammatory response to infused medication, its metabolites, and/or infusion excipients,” Isaacson and colleagues wrote. “Experts reviewed current knowledge of [infusion-site reactions] and discussed their clinical experience with [continuous subcutaneous apomorphine infusion]-related [infusion-site reactions], including guidance for people with Parkinson disease and clinician education and training.”

Ultimately, the group noted that the majority of these nodules can be managed conservatively, with Isaacson et al suggesting that patients report any infusion-site reactions that do not improve, expand, or are associated with systemic symptoms to their clinicians. As infections are uncommon in the instance of infusion-site reactions/nodules, the group suggested that empiric antibiotics “were not felt to be necessary in most circumstances.”

READ MORE: Patients With Parkinson Disease Might Benefit From Social Participation Education, Resources

The presence of a variety of select signs and symptoms—specifically, the timing following the infusion, pruritus, size, erythema, fluctuance, and drainage—were suggested as the key factors to include in the classification of infusion-site reactions. These classifications of these symptoms included asymptomatic, symptomatic but mild, symptomatic but moderate, and symptomatic and severe.

The clinical framework that was proposed for managing continuous subcutaneous apomorphine infusion-related infusion-site reactions went as such:

• Primary Intervention: Physician should provide education for the patient and care partner on proper insertion technique, skin hygiene, site rotation, and the cleaning of residual medication from skin.
• Evaluation:
  • History (patient and care provider): Clarification of the timing after infusion; the location; and presence of pruritus, pain, and redness.
  • Examination (neurologist): Determination of the size, presence of erythema, presence of tenderness, and state of drainage or fluctuance.
• Classification and Initial Management:
  • Asymptomatic ——> Provider should provide reeducation on proper insertion technique, site rotation, skin hygiene, and avoidance of problem skin areas.
  • Symptomatic, Mild ——> Patient should call if symptoms increase, or new symptoms appear.
  • Symptomatic, Moderate ——> Physician should monitor the reaction for a resolution.
  • Symptomatic, Severe ——> Physician should consider taking a culture and/or utilizing empiric antibiotics.
• Secondary Prevention: Physician should provide reeducation on proper insertion technique, site rotation, skin hygiene, and avoidance of problem skin areas.

The roundtable was convened in June 2022 to develop the proposed framework, when they 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 ultimately concluded that further research will help to elucidate the underlying causes of these infusion-site reactions, but that simple steps can be taken to try to minimize their occurrence. The full group included Isaacson, as well as 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.

Click here for more coverage of ATMRD 2023.

REFERENCE
Isaacson SH, Grall MS, Gupta F, et al. Protocol to Help Neurologists Manage Subcutaneous Apomorphine Therapy Skin Nodules: Expert Roundtable Recommendations. Presented at: ATMRD; June 9-11, 2023; Washington, DC.