Does quetiapine (Quetiapine) cause hyperprolactinemia?

From the Guidelines

Quetiapine can cause elevated prolactin levels, but the risk is relatively low compared to other antipsychotic medications. The evidence from the study published in the BMJ in 2020 1 shows that quetiapine has a relatively weak and transient D2 blockade, resulting in minimal or temporary prolactin elevation in most patients. According to the study, quetiapine has a NMA estimate of 6.75 (1.20 to 38.05) for abstinence, and the corresponding absolute probability of abstinence is 69% (29 to 93%), which is relatively high compared to other medications. However, this study does not directly address the risk of elevated prolactin levels.

Further evidence from the study published in Nature Reviews Endocrinology in 2024 1 suggests that medications, including antipsychotics like quetiapine, can cause hyperprolactinemia through direct prolactin stimulatory pathways or by antagonizing inhibitory dopaminergic tone. The study also notes that the role of synthetic oral oestrogens, such as contraceptive pills, in causing mild elevation of prolactin is controversial.

Another study published in Nature Reviews Endocrinology in 2024 1 recommends performing serial dilutions of serum for prolactin measurement in patients with large pituitary lesions and normal or mildly elevated prolactin levels. This study highlights the importance of accurate prolactin measurement and the potential for anomalous results due to the "high-dose hook effect".

Some key points to consider:

• Quetiapine has a relatively low risk of causing elevated prolactin levels compared to other antipsychotic medications.
• Elevated prolactin can lead to symptoms like menstrual irregularities, decreased libido, erectile dysfunction, or galactorrhea (breast milk production).
• Patients taking quetiapine and experiencing these symptoms should have their prolactin levels checked with a simple blood test.
• For patients concerned about prolactin-related side effects, quetiapine is often considered one of the safer antipsychotic options, along with aripiprazole and clozapine.
• Medications like risperidone, paliperidone, and haloperidol carry a much higher risk of significant prolactin elevation.

In terms of morbidity, mortality, and quality of life, it is essential to monitor prolactin levels and adjust treatment accordingly to minimize the risk of hyperprolactinemia and its associated symptoms. This can be achieved through regular blood tests and clinical evaluations. Additionally, patients should be informed about the potential risks and benefits of quetiapine and other antipsychotic medications to make informed decisions about their treatment.

From the FDA Drug Label

Like other drugs that antagonize dopamine D2 receptors, quetiapine elevates prolactin levels in some patients and the elevation may persist during chronic administration. During clinical trials with quetiapine, the incidence of shifts in prolactin levels to a clinically significant value occurred in 3.6% (158/4416) of patients treated with quetiapine compared to 2.6% (51/1968) on placebo. In acute placebo-controlled trials in children and adolescent patients with bipolar mania (3-week duration) or schizophrenia (6-week duration), the incidence of shifts in prolactin levels to a value (>20 µg/L males; > 26 µg/L females at any time) was 13.4% (18/134) for quetiapine compared to 4% (3/75) for placebo in males and 8.7% (9/104) for quetiapine compared to 0% (0/39) for placebo in females.

Quetiapine can cause high prolactin levels in some patients, with an incidence of 3.6% in adults and up to 13.4% in children and adolescents, compared to placebo 2.

From the Research

Quetiapine and Prolactin Levels

• Quetiapine is considered a prolactin-sparing antipsychotic, meaning it is less likely to cause an increase in prolactin levels compared to other antipsychotics 3.
• A study found that quetiapine did not increase prolactin secretion, in contrast to haloperidol, a typical antipsychotic 4.
• Another study compared the effects of quetiapine, aripiprazole, and ziprasidone on prolactin levels and found that quetiapine had a lower risk of hyperprolactinemia compared to ziprasidone, but a higher risk compared to aripiprazole 5.
• The available evidence suggests that quetiapine is not typically associated with high prolactin levels, but individual results may vary.

Comparison to Other Antipsychotics

• Risperidone and amisulpride are more likely to cause hyperprolactinemia compared to quetiapine 3.
• Aripiprazole, another atypical antipsychotic, has been shown to have a lower risk of hyperprolactinemia compared to quetiapine in some studies 5, 6.
• The choice of antipsychotic should be based on individual patient needs and medical history, taking into account the potential risks and benefits of each medication.

Management of Hyperprolactinemia

• If hyperprolactinemia does occur, management options may include reducing the dose of the antipsychotic, switching to a different antipsychotic, or adding a dopamine receptor agonist 3, 7.
• Aripiprazole has been shown to be effective in reducing prolactin levels in patients with antipsychotic-induced hyperprolactinemia 7, 6.