The Role of Kynmobi for Parkinson’s Disease

Kynmobi (apomorphine) sublingual film will be a new option for “off” episodes in Parkinson’s disease.

It’s a quick-acting dopamine agonist…for symptoms (tremor, etc) that return between carbidopa/levodopa doses, especially in advanced Parkinson’s disease.

Kynmobi will be used “on demand”…similar to Movapo (apomorphine) subcutaneous injection.

Expect some patients to prefer sublingual films over a subcutaneous injection…and the cost per dose is similar. However, the trade-off might be a slower onset in some patients.

But don’t jump to apomorphine “on demand.”

To minimize “off” episodes, recommend first optimizing carbidopa/levodopa therapy…such as with more frequent dosing or using controlled-release levodopa at bedtime for morning symptoms.

If that’s not enough, suggest adding a COMT inhibitor (entacapone), MAO-B inhibitor (rasagiline, etc), or oral dopamine agonist (pramipexole, etc) to prolong the effects of levodopa.

Reserve Kynmobi or Movapo for unpredictable “off” episodes…or to bridge patients to the next carbidopa/levodopa dose.

For patients starting Kynmobi, expect the first dose to be given in a prescriber’s office for BP and pulse monitoring.

Advise patients to drink water before taking a dose…to help the film dissolve more easily.

Explain that it may take up to 30 min, or possibly longer, before they are back “on.”

Instruct patients NOT to repeat the dose if the response isn’t optimal. They should only take one dose per “off” episode, with at least 2 hours between doses…up to 5 doses or 90 mg per day.

Tell patients and caregivers to monitor for side effects…such as nausea, impulse control disorders, and hallucinations.

To minimize nausea, suggest premedicating with an antiemetic, such as domperidone. But avoid using a 5-HT3 antagonist (ondansetron, etc)…since the combo can cause severe hypotension.