From the Guidelines
Treatment of prolactinoma should begin with dopamine agonist medications, with cabergoline being the first-line choice due to its superior efficacy and fewer side effects, as recommended by the most recent consensus guideline for the diagnosis and management of pituitary adenomas in childhood and adolescence 1.
Key Considerations
- Dopamine agonists reduce tumor size and normalize prolactin levels in most patients, with cabergoline being the preferred agent due to its longer half-life and greater affinity for the dopamine receptor 1.
- Treatment duration varies, but typically continues for at least 2 years with normal prolactin levels and significant tumor shrinkage before considering medication withdrawal.
- Regular monitoring of prolactin levels and periodic MRI scans are essential to track treatment response.
- Surgery is generally reserved for patients who don't respond to or cannot tolerate medication, or for those with large tumors causing significant visual impairment.
- Side effects of dopamine agonists may include nausea, dizziness, and headache, which often improve with continued use.
Special Considerations
- In patients with visual disturbances or pituitary apoplexy, cabergoline can still be offered as first-line therapy while carefully monitoring for any deterioration in vision, pituitary function, or general status 1.
- Radiotherapy may be considered in exceptional cases where other treatment modalities are not available or have been exhausted, with the main indication being control of tumor growth rather than normalization of prolactin levels 1.
- Echocardiography should be performed at the start of treatment with a dopamine agonist and yearly surveillance echocardiography for patients receiving high-dose cabergoline 1.
Potential Complications
- Cerebrospinal fluid leak can occur due to medication-induced shrinkage of prolactinomas that have invaded the sphenoid bone, requiring urgent intervention 1.
- Apoplexy has been described during cabergoline therapy, both in adults and children 1.
From the FDA Drug Label
Bromocriptine mesylate tablets, USP treatment is indicated in patients with prolactin-secreting adenomas, which may be the basic underlying endocrinopathy contributing to the above clinical presentations. Reduction in tumor size has been demonstrated in both male and female patients with macroadenomas
- Prolactinoma treatment: Bromocriptine mesylate is indicated for the treatment of prolactin-secreting adenomas.
- Reduction in tumor size: The drug has been shown to reduce tumor size in both male and female patients with macroadenomas 2.
- Key consideration: The use of bromocriptine for prolactinoma treatment is supported by evidence from well-controlled trials in adults, with additional data in a limited number of children and adolescents 2.
From the Research
Treatment Options for Prolactinoma
- Medical treatment of hyperprolactinemia is based on the use of dopamine agonists (DA): bromocriptine, lisuride, quinagolide, and cabergoline 3
- Dopamine agonists can induce normal prolactinemia and ovulatory cycles in over 80% of cases 3
- In cases of macroprolactinoma, MRI monitoring should be carried out after 3 months of treatment to verify tumor size reduction 3
Efficacy of Dopamine Agonists
- Cabergoline is very effective and well-tolerated in more than 90% of patients with either microprolactinomas or macroprolactinomas 4
- Bromocriptine induces normalization of prolactin levels in 80-90% of patients with microprolactinomas and approximately 70% of those with macroprolactinomas 4
- Cabergoline treatment also induces tumor shrinkage in the majority of patients with macroprolactinomas 4
Resistance to Dopamine Agonists
- Dopamine agonist (DA)-resistant prolactinomas are rare but constitute a real challenge, since there are few therapeutic alternatives left for these patients 5
- The addition of a somatostatin analog to ongoing cabergoline treatment may be effective in some patients with DA-resistant macroprolactinomas 5
Surgical Treatment
- Surgical removal can also be considered in selected cases, such as patients with macroadenomas with local complications or those not responding to medical treatment 6
- Surgically treated patients had a greater reduction in tumor size than non-surgically treated ones 6
Outcome and Follow-up
- A significant reduction in PRL levels was seen within six to 12 months of treatment, and a notable decrease in tumor size was seen with medical management 7
- The prolactin level at diagnosis was positively correlated with maximum tumor diameter 7
- Median follow-up duration was 40 (12-288) months, and complete resolution of adenoma was seen in 13 patients 7