Apomorphine and levodopa infusion therapies for advanced Parkinson's disease: selection criteria and patient management

The continuous infusion of levodopa or apomorphine represents a good therapeutic option for advanced Parkinson's disease as this approach provides constant dopaminergic stimulations and is a good alternative to deep brain stimulation. While apomorphine provides a similar level of motor benefit to levodopa, its long-term use is limited by compliance and injection site skin reactions. The administration of levodopa/carbidopa by continuous duodenal infusion allows replacement of all oral medications and permits achievement of a satisfactory therapeutic response paralleled by a reduction in motor complication severity. However, compared with apomorphine, it is more invasive as it requires a percutaneous endoscopic gastrostomy. In this review we discuss the advantages and limitations of these procedures and how they compare to deep brain stimulation. We also address the issue of selection criteria and propose clinical characteristics of candidates to help the clinician choose the most suitable option for their patients.