Foslevodopa infusion in the real world has shown promise for Parkinson's, however we must pay attention to any emergent neuropsychiatric symptoms. Continuous subcutaneous infusion refers to medication delivered under the skin at a steady rate to smooth out motor fluctuations. This research letter provides important insights into safety signals that may emerge when folks start and adjust this therapy at home. Maeve Bradley and colleagues describe in Movement Disorders Clinical Practice their extended real world experience w/ foslevodopa foscarbidopa using an outpatient titration protocol. Key Points: - Outpatient initiation was feasible, however dose optimization still required several weeks and infusion rates increased by an average of 35% from baseline. -Neuropsychiatric complications were more frequent w/ hallucinations emerging in 21 percent of patients and frequently appearing weeks after initiation. - Discontinuation rates were similar to inpatient programs, however reasons differed and included neuropsychiatric symptoms, infusion site issues and lack of effectiveness. My take: We will need to provide guidance on when to employ pump therapies in Parkinson's and what to do if neuropsychiatric symptoms emerge. Real-world data is really important to this effort. Here are 5 points that resonated w/ me: 1- Expect individualized dosing because stable infusion rates usually take weeks to achieve and will require close follow up. 2- Watch for delayed hallucinations because these symptoms may appear long after the first few days of treatment and require rapid adjustment. 3- Understand the role of past psychosis since a history of hallucinations may increase risk, however does not perfectly predict who will struggle. 4- Rely on your care team because trained nurses visiting at home can safely guide adjustments and keep therapy on track. 5- Recognize when to stop because some folks will discontinue due to neuropsychiatric issues or skin reactions, and switching therapies may be the best option for some folks. movementdisorders.onlinelibr… @ParkinsonDotOrg @FixelInstitute @PdAvengers @ACPIMPhysicians @movedisorder