Breastfeeding Should Be Discontinued When Restarting Cabergoline for Prolactinoma
A breastfeeding patient with prolactinoma should discontinue breastfeeding when restarting cabergoline treatment, as cabergoline interferes with lactation and is not recommended during breastfeeding. 1
Rationale for Discontinuing Breastfeeding
FDA Recommendations
- The FDA drug label explicitly states that cabergoline should not be given to women postpartum who are breastfeeding or planning to breastfeed 1
- The prolactin-lowering action of cabergoline directly interferes with lactation 1
- The drug label indicates that it is unknown whether cabergoline is excreted in human milk, but due to potential serious adverse reactions in nursing infants, a decision should be made to either discontinue nursing or discontinue the drug 1
Clinical Guidelines
- The European Society of Cardiology Working Group specifically advises against breastfeeding in patients with suspected peripartum cardiomyopathy who require prolactin-lowering medications, based on the postulated negative effects of prolactin subfragments 2
- While some guidelines acknowledge that certain medications (like ACE inhibitors) have been tested and can be used during breastfeeding, cabergoline is not among these medications 2
Cabergoline Treatment for Prolactinoma
Efficacy and Dosing
- Cabergoline is the dopamine agonist of choice for prolactinoma treatment due to:
- Superior effectiveness in normalizing prolactin levels (83% vs 59% for bromocriptine)
- Lower adverse event profile (52% vs 72% for bromocriptine) 3
- Standard initial dosage is 0.25-0.5 mg twice weekly, with gradual titration up to 2 mg/week for most patients 3
- For resistant cases, doses may be increased up to 3.5 mg/week, or in exceptional cases up to 7 mg/week 2, 3
Monitoring Requirements
- Baseline echocardiography is recommended before initiating cabergoline 3
- Follow-up echocardiography is suggested every 5 years for those receiving ≤2 mg/week and annually for those receiving >2 mg/week due to potential risk of cardiac valvulopathy 3
Clinical Considerations When Restarting Cabergoline
Tumor Response
- Cabergoline is highly effective in treating prolactinomas:
Potential Complications
- Medication-induced shrinkage of prolactinomas that have invaded sphenoid bone can cause cerebrospinal fluid leak, a serious but rare adverse event 2, 3
- Psychological intolerance including mood changes, depression, aggression, and hypersexuality may occur independent of dose 3
Alternative Approaches
If a patient strongly desires to continue breastfeeding, consider:
- Delaying cabergoline restart if clinically appropriate and safe
- Discussing surgical options for prolactinoma if medical therapy cannot be delayed and breastfeeding is a priority
- Close monitoring for tumor growth with periodic visual field assessments, especially for macroadenomas 5, 6
Follow-up After Treatment
- After achieving normal prolactin levels for 6 months, consider discontinuation with periodic monitoring 3
- If prolactin levels remain normal for at least 2 years and MRI shows no visible residual tumor, consider gradual dose reduction and eventual discontinuation 3
- Continue monitoring prolactin levels for at least 2 years after discontinuation 3
- Be aware that biochemical recurrence is common (68% in one study), but not all patients with recurrent hyperprolactinemia require restarting treatment 7
In conclusion, while cabergoline is highly effective for treating prolactinoma, its mechanism of action directly interferes with lactation, and the FDA explicitly recommends against its use during breastfeeding. The patient should be counseled to discontinue breastfeeding when restarting cabergoline treatment.