• With advanced Parkinson’s disease (PD), oral medications often are less effective, leading to increased symptoms and a decreased quality of life.
• When oral medications stop working — or begin working less effectively — your doctor may recommend an injectable medication for the treatment of advanced PD.
• If you are nervous about using a needle on yourself, there are several steps you can take to overcome the fear of self-injecting your PD medications.

As Parkinson’s disease progresses, medications taken by mouth become less effective at controlling PD symptoms. This often leads to the return of symptoms such as tremor, stiffness, and slowed movement. The return of symptoms later on in PD can decrease quality of life.

Many people with advanced PD commonly report that their medications have lost effectiveness. “Recently I can tell when my PD medications are wearing off. I need them more often now, but I hate taking so many pills!” shared one MyParkinsonsTeam member.

Another member reported, “I’m having a hard time with meds wearing off too soon. The symptoms that return are extreme stiffness, balance, and posture issues. It really feels awful.”

Medications wear off over time in advanced Parkinson’s for the following reasons:

• The brain loses cells that make dopamine (the neurotransmitter involved in PD). In this case, the brain is unable to store as much of the drug as it once could, making the medication’s effect last for a shorter period of time.
• PD can cause delayed gastric emptying, meaning food can remain in a person’s stomach for extended periods of time. This delay can reduce the amount of medication absorbed into the bloodstream, diminishing its effect.

When people with advanced PD no longer respond well to oral medications, doctors may recommend injectable medications to manage the symptoms. Apomorphine is available as an injectable for PD, sold as Apokyn in the U.S. and Movapo in Canada. The U.S. Food and Drug Administration (FDA) has approved apomorphine specifically to treat the symptoms of advanced PD during “off” periods — the times that a person’s levodopa/carbidopa medication dose has worn off.

Why Are Some Medications Injected for Advanced PD?

Some medications lose their effectiveness when taken orally, as the body will metabolize almost all of the medication.

For instance, if someone takes apomorphine orally in pill form, their body will break down the medication, leaving less than 4 percent of the drug for the body to use. That is why many physicians instead prescribe injectable medication to people with advanced PD.

Different Types of Injections

There are two methods of injecting apomorphine into the body.

Intermittent Injection

When used as a rescue medication, a drug like apomorphine can be injected subcutaneously (under the skin) using a prefilled disposable pen.

This is similar to either an EpiPen or an insulin shot. The medication works quickly following the injection — usually within 15 minutes.

People with advanced PD can use intermittent self-injections as either a replacement for their oral medications, or in conjunction with oral drugs. If your doctor prescribes an injectable medication, get clear instructions on whether it should replace or supplement your other medications.

If you have advanced PD, you may need to use these injections multiple times per day. If your symptoms do not significantly improve with multiple injections, your prescribing health care provider will likely recommend a more constant way of injecting the medication.

Continuous Infusion

Continuous infusion involves a small, battery-operated pump called a syringe driver. This pump acts like an auto-injector and pushes a consistent amount of medication from a prefilled syringe into your body.

To use this type of device, a port is inserted under your skin, usually on the outside of your thighs or in the lower stomach. Infusion happens only during waking hours, so the device is removed completely at night.

Fear of Needles

Despite having the option of taking injectable medication, some people with advanced PD hesitate due to a fear of needles. For some, self-injection is particularly daunting.

Many people report needle phobia. One MyParkinsonsTeam member reported, “My PD is advanced. My neurologist wants to try me on Apokyn to be injected as needed by myself. I am nervous about it, as I am a baby about shots.”

Another member said, “In two days I am going into the hospital to start using an apomorphine infusion pump. I am feeling nervous about having to insert a needle into my stomach every morning and removing it at night.”

Overcoming Injection Anxiety

Since a fear of needles is common, there are several things a person with advanced PD can do before starting self-injection.

Receive Training for Self-Injection

A member of your health care team will train you and your family members on how to inject the medication at home.

Practice Safe Home Injection Techniques

The following techniques are helpful to remember when doing self-injections at home:

• Read the brochure that comes with the medication so you understand the specifics.
• Alternate the site of your injections from one injection to the next when using a prefilled pen. (Continuous infusion, however, typically goes in either the thigh or lower abdomen).
• Write down each injection site used. This helps to rotate injection sites on the body and prevent skin issues that can result from repeated injections.
• Check to see that the liquid in the pen is both colorless and clear. Do not use the medicine if it appears any differently.
• Avoid getting the liquid onto your skin or into your eyes. Rinse with water immediately if this happens.
• Prime the pen before using it. Consult instructions to do so correctly. If there are any doubts, call the prescribing doctor’s office.
• Never inject into a vein or a spot where the skin is abnormal in any way.

Tips for Overcoming Fear of Needles

Cedars-Sinai Hospital recommends these tips for overcoming the fear of needles:

• Relax — Breathing deeply or visualizing a peaceful scene can put you at ease. Deep breaths can lower heart rate and blood pressure, and can help you feel relaxed just prior to a needle stick.
• Numb the site — Use ice or over-the-counter numbing cream to create less pain and further reduce anxiety over self-injection.
• Expose yourself to needles — Exposure therapy, or intentionally subjecting yourself to things you’re afraid of, can reduce anxiety, including the fear of needles.
• Reframe your thoughts — Instead of focusing on the short-term discomfort of a needle stick, turn your thoughts to the positive effects of injectable PD medications. A therapist specializing in cognitive behavioral therapy can help.

Although responses to self-injected PD medications vary, MyParkinsonsTeam members often report how well the medications work for them.

One member said, “Sometimes I take 0.5 milligram of subcutaneous injectable Apokyn because I am frozen in one position and/or have twitching/cramping. I inject it two to three times a day. … It never disappoints, kicks in within minutes.”

Another member reported, “I use an apomorphine pump. … I inject the port daily. I find it easy to use and I don't fall down now or freeze. That was one of my biggest problems.”

Talk With Others Who Understand

MyParkinsonsTeam is the social network for people with Parkinson’s disease and their loved ones. On MyParkinsonsTeam, more than 81,000 members come together to ask questions, give advice, and share their stories with others who understand life with Parkinson’s disease.

Have you tried injectable medications for Parkinson’s disease? Share your experience in the comments below, or start a conversation by posting on your Activities page.