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<div class="pre-content"><div><div class="bk_prnt"><p class="small">NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.</p><p>LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012-. </p></div><div class="iconblock clearfix whole_rhythm no_top_margin bk_noprnt"><a class="img_link icnblk_img" title="All Drug Records" href="/books/n/livertox/"><img class="source-thumb" src="/corehtml/pmc/pmcgifs/bookshelf/thumbs/th-livertox-lrg.png" alt="Cover of LiverTox" height="100px" width="80px" /></a><div class="icnblk_cntnt eight_col"><h2>LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet].</h2><a data-jig="ncbitoggler" href="#__NBK548143_dtls__">Show details</a><div style="display:none" class="ui-widget" id="__NBK548143_dtls__"><div>Bethesda (MD): <a href="https://www.niddk.nih.gov/" ref="pagearea=page-banner&amp;targetsite=external&amp;targetcat=link&amp;targettype=publisher">National Institute of Diabetes and Digestive and Kidney Diseases</a>; 2012-.</div></div><div class="half_rhythm"><ul class="inline_list"><li style="margin-right:1em"><a class="bk_cntns" href="/books/n/livertox/">Drug Records</a></li></ul></div><div class="bk_noprnt"><form method="get" action="/books/n/livertox/" id="bk_srch"><div class="bk_search"><label for="bk_term" class="offscreen_noflow">Search term</label><input type="text" title="Search this book" id="bk_term" name="term" value="" data-jig="ncbiclearbutton" /> <input type="submit" class="jig-ncbibutton" value="Search this book" submit="false" style="padding: 0.1em 0.4em;" /></div></form></div></div><div class="icnblk_cntnt two_col"><div class="pagination bk_noprnt"><a class="active page_link prev" href="/books/n/livertox/Apoaequorin/" title="Previous page in this title">&lt; Prev</a><a class="active page_link next" href="/books/n/livertox/Apremilast/" title="Next page in this title">Next &gt;</a></div></div></div></div></div>
<div class="main-content lit-style" itemscope="itemscope" itemtype="http://schema.org/CreativeWork"><div class="meta-content fm-sec"><h1 id="_NBK548143_"><span class="title" itemprop="name">Apomorphine</span></h1><p class="small">Last Update: <span itemprop="dateModified">July 20, 2017</span>.</p></div><div class="body-content whole_rhythm" itemprop="text"><div id="Apomorphine.OVERVIEW"><h2 id="_Apomorphine_OVERVIEW_">OVERVIEW</h2><div id="Apomorphine.Introduction"><h3>Introduction</h3><p>Apomorphine is a subcutaneously administered dopamine receptor agonist used predominantly in the therapy of hypomobility of advanced Parkinson disease. The use of apomorphine has been limited, but it has not been associated with serum enzyme elevations during treatment nor has it been implicated in cases of acute liver injury.</p></div><div id="Apomorphine.Background"><h3>Background</h3><p>Apomorphine (a" poe mor' feen) is a subcutaneously administered dopamine receptor agonist which has moderate affinity for the D2, D3, and D5 class of dopamine receptors in the central nervous system and little activity against the D1 class. It also has some alpha adrenergic activity. Apomorphine was shown to improve motor function in animal models of Parkinson disease and in clinical trials, was shown to decrease hypomobility in patients with advanced Parkinsonism. Apomorphine was approved for use in the United States in 2004, but had been used in Europe for more than a decade. Current indications are for acute and intermittent treatment of hypomobility of advanced Parkinson disease. It is also used for acute dystonic reactions. Apomorphine is available in a liquid solution of 10 mg/mL under the brand name Apokyn. It is given in 0.2 to 0.6 mL doses subcutaneously as needed up to 3 times daily. Apomorphine injections usually cause nausea and vomiting requiring antiemetics. It can cause hypotension, gastrointestinal upset, anxiety, confusion, dizziness, headache, hallucinations, vivid dreams and insomnia, symptoms typical of dopaminergic stimulation.</p></div><div id="Apomorphine.Hepatotoxicity"><h3>Hepatotoxicity</h3><p>Apomorphine has not been reported to cause serum aminotransferase elevations or clinically apparent acute liver injury, but its use has been limited and is typically given in low doses for a limited period of time. Thus, if apomorphine causes liver injury it must be rare.</p><p><a class="def" href="/books/n/livertox/glossary/def-item/glossary.likelihood-score/">Likelihood score</a>: E (unlikely cause of clinically apparent liver injury).</p></div><div id="Apomorphine.Mechanism_of_Injury"><h3>Mechanism of Injury</h3><p>The metabolism of apomorphine has not been well defined; it appears to be minimally metabolized in the liver.</p><p>Drug Class: <a href="/books/n/livertox/AntiparkinsonAgents/">Antiparkinson Agents</a></p><p>Other Drugs in the Subclass, Dopamine Receptor Agonists: <a href="/books/n/livertox/Bromocriptine/">Bromocriptine</a>, <a href="/books/n/livertox/Pergolide/">Pergolide</a>, <a href="/books/n/livertox/Pramipexole/">Pramipexole</a>, <a href="/books/n/livertox/Ropinirole/">Ropinirole</a>, <a href="/books/n/livertox/Rotigotine/">Rotigotine</a></p></div></div><div id="Apomorphine.PRODUCT_INFORMATION"><h2 id="_Apomorphine_PRODUCT_INFORMATION_">PRODUCT INFORMATION</h2><div id="Apomorphine.BPI" class="box"><p>
<b>REPRESENTATIVE TRADE NAMES</b>
</p><p>Apomorphine &#x02013; Apokyn&#x000ae;</p><p>
<b>DRUG CLASS</b>
</p><p>Antiparkinson Agents</p><p>
<a href="https://dailymed.nlm.nih.gov/dailymed/search.cfm?labeltype=all&#x00026;query=Apomorphine" ref="pagearea=body&amp;targetsite=external&amp;targetcat=link&amp;targettype=uri">COMPLETE LABELING</a>
</p><p>Product labeling at DailyMed, National Library of Medicine, NIH</p></div></div><div id="Apomorphine.CHEMICAL_FORMULA_AND_STRUCTU"><h2 id="_Apomorphine_CHEMICAL_FORMULA_AND_STRUCTU_">CHEMICAL FORMULA AND STRUCTURE</h2><div id="Apomorphine.T1" class="table"><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK548143/table/Apomorphine.T1/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__Apomorphine.T1_lrgtbl__"><table><thead><tr><th id="hd_h_Apomorphine.T1_1_1_1_1" rowspan="1" colspan="1" style="vertical-align:top;">DRUG</th><th id="hd_h_Apomorphine.T1_1_1_1_2" rowspan="1" colspan="1" style="vertical-align:top;">CAS REGISTRY NUMBER</th><th id="hd_h_Apomorphine.T1_1_1_1_3" rowspan="1" colspan="1" style="vertical-align:top;">MOLECULAR FORMULA</th><th id="hd_h_Apomorphine.T1_1_1_1_4" rowspan="1" colspan="1" style="vertical-align:top;">STRUCTURE</th></tr></thead><tbody><tr><td headers="hd_h_Apomorphine.T1_1_1_1_1" rowspan="1" colspan="1" style="vertical-align:top;">Apomorphine</td><td headers="hd_h_Apomorphine.T1_1_1_1_2" rowspan="1" colspan="1" style="vertical-align:top;">
<a href="https://pubchem.ncbi.nlm.nih.gov/substance/134971357" ref="pagearea=body&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubchem">58-00-4</a>
</td><td headers="hd_h_Apomorphine.T1_1_1_1_3" rowspan="1" colspan="1" style="vertical-align:top;">C17-H17-N-O2</td><td headers="hd_h_Apomorphine.T1_1_1_1_4" rowspan="1" colspan="1" style="vertical-align:top;">
<div class="graphic"><img src="/books/NBK548143/bin/Apomorphine_Structure.jpg" alt="Apomorphine Chemical Structure" /></div>
</td></tr></tbody></table></div></div></div><div id="Apomorphine.REFERENCES"><h2 id="_Apomorphine_REFERENCES_">REFERENCES</h2><p>References updated: 20 July 2017</p><ul class="first-line-outdent"><li><div class="bk_ref" id="Apomorphine.R1">Zimmerman HJ. Antiparkinsonism drugs. In, Zimmerman HJ. Hepatotoxicity: the adverse effects of drugs and other chemicals on the liver. 2nd ed. Philadelphia: Lippincott, 1999, pp. 715-7.<div><i>(Expert review of hepatotoxicity published in 1999; among anticholinergic agents, "only trihexyphenidyl has been incriminated in hepatic injury"; other antiparkinsonism drugs discussed include levodopa, lergotrile [no longer available], pergolide and bromocriptine).</i></div></div></li><li><div class="bk_ref" id="Apomorphine.R2">Larrey D, Ripault MP. Hepatotoxicity of psychotropic drugs and drugs of abuse. In, Kaplowitz N, DeLeve LD, eds. Drug-induced liver disease. 3rd ed. Amsterdam: Elsevier Inc, 2013, pp. 443-62.<div><i>(Review of hepatotoxicity of agents acting on the central nervous system).</i></div></div></li><li><div class="bk_ref" id="Apomorphine.R3">Standaert DG, Roberson ED. Treatment of central nervous system degenerative disorders. In, Brunton LL, Chabner BA, Knollman BC, eds. Goodman &#x00026; Gilman&#x02019;s the pharmacological basis of therapeutics. 12th ed. New York: McGraw-Hill, 2011, pp. 609-28.<div><i>(Textbook of pharmacology and therapeutics).</i></div></div></li><li><div class="bk_ref" id="Apomorphine.R4">McDowell F. Symposium on levodopa in Parkinson's disease. Clinical and pharmacological aspects. Clinical laboratory abnormalities. Clin Pharmacol Ther 1971; 12: 335-9. [<a href="https://pubmed.ncbi.nlm.nih.gov/4102803" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 4102803</span></a>]<div><i>(Retrospective analysis of laboratory abnormalities arising in 974 patients with Parkinson disease treated with levodopa; AST elevations occurred in 9% of 5427 determinations, but were usually mild and transient returning to normal in 1-2 months without dose adjustment; AST levels rose to 1600 U/L in one patient who later died of complications of diabetes).</i></div></div></li><li><div class="bk_ref" id="Apomorphine.R5">Pinter MM, Helscher RJ, Mundsperger N, Binder H. Transient increase of pancreatic enzymes evoked by apomorphine in Parkinson's disease. J Neural Transm 1998; 105: 1237-44. [<a href="https://pubmed.ncbi.nlm.nih.gov/9928892" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 9928892</span></a>]<div><i>(Among 29 patients with Parkinson disease treated with apomorphine, transient asymptomatic elevations in amylase and lipase elevations occurred in 5; liver enzymes remained normal).</i></div></div></li><li><div class="bk_ref" id="Apomorphine.R6">Lambert D, Waters CH. Comparative tolerability of the newer generation antiparkinsonian agents. Drugs Aging 2000; 16: 55-65. [<a href="https://pubmed.ncbi.nlm.nih.gov/10733264" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 10733264</span></a>]<div><i>(Review of mechanism of action, tolerability and safety of selegiline, pramipexole, ropinirole, tolcapone and entacapone in Parkinson disease).</i></div></div></li><li><div class="bk_ref" id="Apomorphine.R7">Reuben A, Koch DG, Lee WM; Acute Liver Failure Study Group. Drug-induced acute liver failure: results of a U.S. multicenter, prospective study. Hepatology 2010; 52: 2065-76. [<a href="/pmc/articles/PMC3992250/" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pmc">PMC free article<span class="bk_prnt">: PMC3992250</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/20949552" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 20949552</span></a>]<div><i>(Among 1198 patients with acute liver failure enrolled in a US prospective study between 1998 and 2007, 133 were attributed to drug induced liver injury, but none were attributed to agents used for Parkinson disease).</i></div></div></li><li><div class="bk_ref" id="Apomorphine.R8">Bj&#x000f6;rnsson ES, Bergmann OM, Bj&#x000f6;rnsson HK, Kvaran RB, Olafsson S. Incidence, presentation, and outcomes in patients with drug-induced liver injury in the general population of Iceland. Gastroenterology 2013; 144: 1419-25,1425. [<a href="https://pubmed.ncbi.nlm.nih.gov/23419359" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 23419359</span></a>]<div><i>(In a population based study of drug induced liver injury from Iceland, 96 cases were identified over a 2 year period, but none of the 96 were attributed to an agent used to treat Parkinson disease).</i></div></div></li><li><div class="bk_ref" id="Apomorphine.R9">Drugs for Parkinson's disease. Treat Guidel Med Lett 2013; 11 (135): 101-6. [<a href="https://pubmed.ncbi.nlm.nih.gov/24165688" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 24165688</span></a>]<div><i>(Concise review of recommendations for therapy of Parkinson disease with description of mechanisms of action, efficacy and adverse events). </i></div></div></li><li><div class="bk_ref" id="Apomorphine.R10">Hern&#x000e1;ndez N, Bessone F, S&#x000e1;nchez A, di Pace M, Brahm J, Zapata R, A Chirino R, et al. Profile of idiosyncratic drug induced liver injury in Latin America: an analysis of published reports. Ann Hepatol 2014; 13: 231-9. [<a href="https://pubmed.ncbi.nlm.nih.gov/24552865" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 24552865</span></a>]<div><i>(Among 176 reports of drug induced liver injury from Latin America published between 1996 and 2012, none were attributed to an agent to treat Parkinson disease).</i></div></div></li><li><div class="bk_ref" id="Apomorphine.R11">Chalasani N, Bonkovsky HL, Fontana R, Lee W, Stolz A, Talwalkar J, Reddy KR, et al.; United States Drug Induced Liver Injury Network. Features and outcomes of 899 patients with drug-induced liver injury: The DILIN Prospective Study. Gastroenterology 2015; 148: 1340-52. [<a href="/pmc/articles/PMC4446235/" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pmc">PMC free article<span class="bk_prnt">: PMC4446235</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/25754159" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 25754159</span></a>]<div><i>(Among 899 cases of drug induced liver injury from the US enrolled in a prospective database between 2004 and 2012, none were attributed to an agent used to treat Parkinson disease).</i></div></div></li></ul></div><div id="bk_toc_contnr"></div></div></div>
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<a href="https://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&amp;db=pubmed&amp;pubmedfilters=true&amp;term=(Apomorphine/AE)+AND+Human%5BMH%5D+AND+(drug+induced+liver+injury+OR+jaundice/CI+OR+bile+duct+diseases/CI+OR+liver/DE+OR+liver+diseases/CI)+AND+(%221900/1/1%22%5BEDat%5D%3A%222999/12/31%22%5BEDat%5D)" ref="pagearea=document-links&amp;targetsite=external&amp;targetcat=link&amp;targettype=uri">Recent References on Apomorphine: from PubMed.gov</a>
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26(6):840-52. </em></div></div></li><li class="brieflinkpopper two_line"><a class="brieflinkpopperctrl" href="/pubmed/15592807" ref="ordinalpos=1&amp;linkpos=2&amp;log$=relatedreviews&amp;logdbfrom=pubmed"><span xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="invert">Review</span> [Apomorphine in the treatment of Parkinson's Disease].</a><span class="source">[Nervenarzt. 2005]</span><div class="brieflinkpop offscreen_noflow"><span xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="invert">Review</span> [Apomorphine in the treatment of Parkinson's Disease].<div class="brieflinkpopdesc"><em xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="author">Dressler D. </em><em xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="cit">Nervenarzt. 2005 Jun; 76(6):681-9. </em></div></div></li><li class="brieflinkpopper two_line"><a class="brieflinkpopperctrl" href="/pubmed/10707193" ref="ordinalpos=1&amp;linkpos=3&amp;log$=relatedreviews&amp;logdbfrom=pubmed"><span xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="invert">Review</span> Use of apomorphine in Parkinson's disease.</a><span class="source">[Hosp Med. 1999]</span><div class="brieflinkpop offscreen_noflow"><span xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="invert">Review</span> Use of apomorphine in Parkinson's disease.<div class="brieflinkpopdesc"><em xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="author">O'Sullivan JD, Lees AJ. </em><em xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="cit">Hosp Med. 1999 Nov; 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