From the Guidelines
Cabergoline can be stopped in patients with pituitary adenoma after at least 2 years of medical therapy, if the serum level of prolactin has been normalized and there is no visible residual prolactinoma on MRI, with a gradual dose reduction to maintain normoprolactinaemia and eventual treatment discontinuation. This approach is based on the most recent guideline from the Nature Reviews Endocrinology 1, which suggests considering gradual cabergoline dose reduction to maintain normoprolactinaemia and eventual treatment discontinuation, with continued serum prolactin monitoring for at least 2 more years. Some key points to consider when stopping cabergoline include:
- The patient should have normalized prolactin levels for at least 2 years on medical therapy
- There should be no visible residual prolactinoma on MRI
- A gradual dose reduction should be implemented to maintain normoprolactinaemia
- The patient should be monitored for at least 2 more years after treatment discontinuation
- The use of cabergoline and treatment for more than 2 years are associated with a decreased relapse rate, as reported in a meta-analysis 1
- Tapering doses prior to withdrawal reduces the risk of relapse, but treatment beyond 2 years has no further beneficial effect, as found in another meta-analysis 1. It is essential to note that the relapse rates of prolactinomas after treatment withdrawal can be variable, ranging from 26-89%, largely within the first 2 years of treatment withdrawal 1. Therefore, regular monitoring is crucial after stopping cabergoline, with prolactin measurements and periodic MRI imaging.
From the FDA Drug Label
After a normal serum prolactin level has been maintained for 6 months, cabergoline may be discontinued, with periodic monitoring of the serum prolactin level to determine whether or when treatment with cabergoline should be reinstituted.
Cabergoline discontinuation in patients with pituitary adenoma can be considered after 6 months of maintaining a normal serum prolactin level, with periodic monitoring of the serum prolactin level to assess the need for reinstituting treatment 2.
From the Research
Cabergoline Withdrawal in Pituitary Adenoma
- Cabergoline treatment is an effective approach for hyperprolactinemia, and its withdrawal can be considered in certain cases 3.
- A study found that cabergoline withdrawal was followed by serum prolactin increase in 22 cases, but 5 patients showed normoprolactinemia with negative MRI after one year 3.
- Another study suggested that cabergoline withdrawal can be attempted in patients with normal prolactin levels on low doses of medication and evidence of radiographic tumor involution 4.
- However, the presence of cavernous sinus invasion at diagnosis may be an unfavorable predictor for biochemical remission after cabergoline discontinuation 5.
Factors Influencing Cabergoline Withdrawal
- The initial prolactin level and chances of cavernous sinus invasion were higher in the recurrence group after cabergoline withdrawal 5.
- Age, sex, maximal and remnant tumor size, and treatment duration were similar between the groups with and without recurrence after cabergoline withdrawal 5.
- A significant decrease in T2 intensity ratio after 6 months of cabergoline therapy was observed in the remission group 5.
General Guidelines for Pituitary Adenoma Treatment
- First-line therapy for prolactinomas consists of bromocriptine or cabergoline, while transsphenoidal pituitary surgery is first-line therapy for other pituitary adenomas requiring treatment 6, 7.
- Medical therapy with somatostatin analogues, cabergoline, and pegvisomant is often used in addition to surgery for growth hormone-secreting tumors 7.
- Dopamine agonist therapy is the primary therapy for prolactin-secreting adenomas and usually results in normoprolactinemia, eugonadism, and tumor reduction 4.