Should you get an under the skin dopamine pump to treat your Parkinson's symptoms?
By Michael S. Okun, M.D.
What are the emerging pump options in continuous dopamine delivery?
This is a picture by Antonini and colleagues that appeared in an excellent recent review article in the Journal of Neural Transmission about the emerging options when considering continuous dopamine delivery by pump.
Wouldn’t it be great if there were pumps which could deliver dopamine for Parkinson’s disease, and do it under the skin (subcutaneous)? The science underpinning the ‘magic’ for subcutaneous pumps has been a few decades in the making. Parkinson’s has joined the club of diabetes, pain, cancer and other diseases which utilize pumps to deliver drugs. Why are people with Parkinson’s so interested in under the skin (subcutaneous) pump therapy? What are the current options? What are the potential side effects? How do I know if I actually need an ‘under the skin’ dopamine pump? Will I be able to reduce the number of pills I must take everyday? In this month’s Parkinson’s Secrets blog, I will explore these questions and offer practical tips in case you are considering this type of therapy.
What kinds of under the skin pumps are commonly used in modern medicine?
Under the skin pumps are referred to as ‘subcutaneous drug pumps. They are generally used to deliver medications directly under the skin. The idea of such a pump is to provide continuous or controlled drug release. Here are a few pumps used in modern medicine that you may have heard of:
Insulin Pumps: These pumps deliver insulin to control blood sugars in diabetes.
Opioid and Pain Pumps: These pumps can be programmed to deliver opioids or other pain-relievers.
Continuous Glucose Monitors: These monitors can track blood sugar and some devices play a dual role to deliver insulin when needed.
Cancer Pumps: Chemotherapy can be delivered by continuous infusion pump.
Hormone Pumps: Believe it or not these pumps can be loaded for people with deficient hormones such as in cases of growth hormone (GH) deficiency.
Antibiotic/Antiviral Pumps: These pumps can deliver treatments to treat bacterial infections and viruses (such as HIV).
Why are folks with Parkinson’s interested in under the skin pump therapies?
Ray Chauduri and colleagues remind us in Nature Parkinson’s Disease (2016) that there can be all sorts of important pitfalls and challenges for absorbing Parkinson’s disease medications.
There are a number of reasons why folks are very interested in ‘under the skin’ pump therapies. Here are a few:
There is poor absorption of dopamine in the gastrointestinal tract.
Too many pills.
The frequency of taking pills every 2 to 3 hours during the waking day is challenging.
Swallowing pills can be difficult.
It is common to awaken in the middle of night with re-emergence of symptoms.
A pump placed inside the GI track requires a surgical or radiologically guided procedure, so an alternative is desirable.
A deep brain stimulation device requires brain surgery so an alternative is desirable.
A focused ultrasound or classical brain lesioning procedure requires surgery so an alternative is desirable.
What are the current options for subcutaneous Parkinson’s pump therapies?
Subcutaneous infusion pumps are an emerging option for continuous delivery of Parkinson’s medications and currently there are three to be watching.
Apomorphine Subcutaneous Pumps (Apo-Go Pen and Pump): Apomorphine is a dopamine agonist medication based subcutaneous continuous replacement therapy. This is owned by Supernus Pharmaceuticals and the company is working on feedback from the US FDA ,and has not received approval at the time of publication of this blog.
Foslevodopa/Foscarbidopa is a direct dopamine replacement subcutaneous pump. This is owned by Abbvie and received full FDA approval in October 2024.
Neuroderm (ND0612) is another subcutaneous carbidopa/levodopa subcutaneous infusion. This product is owned by Mitsubishi Tanabe Pharma Corporation and the company is working on feedback from the US FDA, but has not received approval.
What are the common side effects of subcutaneous pump therapies?
1. Skin and injection site reactions: Redness, swelling, and irritation at the infusion site. Can be pain or tenderness and also can be infection.
2. Allergic reactions: Rashes and itching may occur. There may be possible reactions to the medication in the pump itself or an allergy to the pump itself. Rarely anaphylaxis or a severe allergic reactions may occur.
3. Medication-side effect: Nausea, vomiting, dyskiensia, sleepiness, and low blood pressure when standing.
4. Device related side effects: The device can become clogged, the pump can malfunction or the pump may break. The alarms can malfunction and ‘go off’ unexpectedly.
What are the reported benefits for each dopamine pump option?
The foslevodopa/carbidopa subcutaneous pump (sold as Vyalev in the U.S.): This pump recently received FDA approval. The pump features a continuous 24-hour infusion. Trials have revealed 1.7 hours of increased on time. Local skin reactions were the most common side effect.
This is one of the recent Lancet Neurology papers on foslevodopa/foscarbidopa therapy.
The NeuroDerm ND0612 pump is another subcutaneous dopamine replacement option which revealed ~1.7 hours additional hours of “good ON” time compared to those on pills. Similar to other options, skin reactions were the most commonly reported adverse event.
This is a summary of recent data on Neuroderm that has been made publicly available.
A example picture of the apomorphine pump.
Apomorphine subcutaneous infusion pumps: Continuous apomorphine infusion reduced "off" time by ~1.9 hours a day. Skin nodules, nausea, and drowsiness were reported as potential side effects.
This is a summary of the data from the TOLEDO trial which was published by Regina Katzenschlager and colleagues in Lancet Neurology.
How do I know if I really need an under the skin pump for my Parkinson’s disease?
The most important question to ask when pondering whether to try an under the skin dopamine pump is simply what are the symptoms you seek to improve.
The following symptoms will likely have an ‘excellent chance of improving’ with a subcutaneous pump:
Wearing off of medications: This can lead to motor (stiffness, slowness, tremor) or non-motor symptoms (depressive symptoms, anxiety).
Motor and non-motor fluctuations: Your symptoms are bouncing up and down like a yo-yo between feeling ‘on’ with improved symptoms and feeling ‘off’ like the medications are not working.
Many health care practitioners will simply tell you that adding a pump therapy may improve the amount of good ‘on’ time, when you feel like your medication has kicked in and is working optimally. This increased ‘on time’ has the potential to relieve many but not all bothersome symptoms.
In some cases a pump therapy may improve the dance like movements called dyskinesia.
What symptoms may ‘not improve’ with a subcutaneous dopamine pump? The following symptoms are unlikely to improve:
Balance and falling
Walking and freezing, especially if they are not improving during your best ‘on’ times.
Moderate to severe anxiety and depression.
The loudness and clearness of the voice.
If I get a pump, will I be able to reduce the number of pills I take everyday?
Reducing the pill burden is a top priority for many persons with Parkinson’s disease. Reducing the pill burden includes decreasing the total number of pills per day, but also may include the reduction of the frequency you must take pills. Ideally, pump therapies should reduce or eliminate the need for Parkinson’s disease pills such as levodopa, dopamine agonists and other medications. However, in reality you may over time need to complement pump therapies with medications; especially to address any emergent symptoms. Additionally, if your pump does not continue to dispense medication during the night, you may have to supplement therapy with ‘some pills.’
This is a great picture from the Hospice and Pallimed blog which reminds us that pill burden is a ‘real-thing.’
If you add an ‘under the skin’ pump can you later also receive DBS therapy, focused ultrasound, Duopa pump therapy and/or classical brain lesioning therapies?
The answer is YES. If you receive subcutaneous pump therapy, all of your surgical options remain open. In fact you can combine options to maximize benefit, meaning that you may start with an under the skin pump, and later add DBS therapy. Alternatively you could start with DBS therapy or focused ultrasound, and add a subcutaneous pump therapy.
What are the top take home tips about ‘under the skin’ pump therapies for Parkinson’s?
Subcutaneous pumps are not for everyone. Remember, the benefits are ‘real’ however they are only ~2 hours of extra good ‘on’ time per day.
If you are experiencing wearing off of your medication doses or emergence of dance-like dyskinesia movements, before considering pump therapy, it is worthwhile to try to optimize medications. One example of optimization, would be a trial of making dosages smaller and moving them closer together or perhaps adding amantadine for dyskinesia suppression.
Following a trial or trials of medication optimization, if you still have bothersome wearing off, motor fluctuations or dyskinesia you may consider adding a subcutaneous pump.
If you have already undergone DBS therapy or a classical lesion therapy (pallidotomy, thalamotomy) or focused ultrasound therapy a subcutaneous pump can be added.
Jonny Acheson is our blog’s artist for parkinsonsecrets.com and he also is a doctor and a person with Parkinson’s disease.
Michael Okun and Indu Subramanian are the blog writers and editors for parkinsonsecrets.com.