Webinar with EURO-INF Project Leader Professor K Ray Chaudhuri discloses significant benefits of apomorphine and intrajejunal levodopa infusion in advanced Parkinson's disease.

In an exclusive interactive webinar held on Wednesday 20th June at 14:30 BST, Professor K Ray Chaudhuri  (King’s College Hospital, London and Clinical Director of the National  Parkinson Foundation), discussed the emerging and preliminary results of the  ongoing EUROINF (1) comparative real life holistic (motor, non motor and quality of life) survey of  the effects of conventional therapies in advanced Parkinson’s disease. The  survey is endorsed by the European patient group, EPDA and is currently being  carried out across Europe in 8 countries. Central to this is the significant  benefit seen with both apomorphine  and intrajejunal levodopa infusion, on motor aspects of non motor symptoms (sleep, mood and fatigue) and  overall quality of life (QOL) that mirrors the effects of deep brain stimulation (DBS), even in patients who would otherwise be unsuitable for  surgical therapy. Some improvements appeared to be specific for infusional  therapies and while such data is as yet unavailable  for DBS therapy, the available evidence suggests that DBS may  worsen issues such as restless legs syndrome and mood related symptoms. The  survey also includes DBS cases for future comparative analysis. This survey was  first presented and highlighted as a key contribution in the Movement Disorder  Society's 16th International Congress of Parkinson's Disease and Movement  Disorders on Sunday June 17th.   

Professor Chaudhuri began by explaining the rationale  behind the observational survey methodology and how it represented the best way  to compare the two treatment strategies in real life scenarios. Focussing on  patient QOL, the survey looked at the cumulative effects of both motor  and non motor symptoms, as non motor factors are widely recognised as having a primary  impact on a patient’s QOL. While acknowledging that the survey is non-randomised,  something he believes would be almost impossible to conduct, he commented that it  does represent, “a set of patients all GPs will have to deal with in real life.”  The survey also uses outcome measures that are “good guides to good clinical  practice … with validated motor and non motor scales in addition to validated measures of QOL.” The  other strength of the survey lies in the numbers involved – over 40 patients on  levodopa and 37 patients on apomorphine  – which makes it the largest cohort yet studied.   

When it comes to analysing the current results, while motor  and non motor effects are appreciably affected by both therapies  leading to a robust improvement in QOL there are subtle differences. One of the  most noticeable of these is with reference to UPDRS III where both treatments  work very well but where apomorphine in particular has a very strong effect on  motor benefit. Professor Chaudhuri again, “Apomorphine also has an improvement  on aspects of non  motor symptoms but perhaps not as good  an effect on dyskinesia as one would expect.” This however may be because  apomorphine was used concomitantly with oral treatment in most treatment centres.  Further  investigation into specific non motor effects of both treatments  is one direction that the survey is likely to take.   

A number of questions touched on  the comparison between both treatments and deep brain stimulation. Professor  Chaudhuri notes that the evidence base for each had pro’s and con’s but  asserted that a key consideration was the unsuitability of DBS for patients  over a certain age or with certain cognitive issues. “So the real question arises, ‘what  do we offer these patients?’ In this situation apomorphine infusion as well as  levodopa infusion offers a valid treatment option, another therapeutic option which  may be available. And in that sense, this piece of work has some real life  practical importance.”   

Professor Chaudhuri also  commented on the need for all three treatments to ideally be made accessible to  all patients based on informed choice. This is not the case in practice, for  example, in the US, where deep brain stimulation remains the main pathway to  advanced therapies while apomorphine infusion has not yet been licensed apart  from in its intermittent injection form and levodopa infusion is still going  through the licensing process. Only when patients and clinicians have access to  all options can there be the best outcome for the patient.         

To watch the  interview in full please visit

1. The ‘real life’ observational study is the work of EUROPAR, an academic multi-disciplinary group  of movement disorders specialists, supported by the European Parkinson's  Disease Association and the PD Non Motor Group and is the largest cohort  study so far. Typically this involves a  comparative look at the "infusion" therapies but will also be  extended to include deep brain stimulation of the subthalamic nucleus.  Furthermore, ‘old’ patients, usually excluded in clinical trials are included  with the study also aiming to ‘audit’ a comparison of clinical practice across  these centres.