What is the treatment for elevated prolactin levels?

Treatment for Elevated Prolactin Levels

The first-line treatment for symptomatic hyperprolactinemia is dopamine agonist therapy, with cabergoline at an initial dose of 0.25 mg twice weekly being the preferred agent due to superior efficacy and tolerability. 1

Initial Assessment and Diagnosis

Before initiating treatment, it's essential to:

• Determine the cause of hyperprolactinemia:

  • Medication-induced (antipsychotics, antidepressants, antihypertensives)
  • Physiologic (pregnancy, breastfeeding)
  • Pathologic (prolactinoma, hypothyroidism, renal failure)
  • Idiopathic

• Obtain MRI imaging if prolactin levels are significantly elevated (>200 ng/mL strongly suggests prolactinoma) 2

• Check for symptoms requiring treatment:

  • Hypogonadism (amenorrhea, infertility, decreased libido)
  • Galactorrhea
  • Headaches or visual disturbances (with macroadenomas)
  • Risk of osteoporosis due to estrogen/testosterone deficiency

Treatment Algorithm

1. Dopamine Agonist Therapy

First-line: Cabergoline

• Initial dosing: 0.25 mg twice weekly 1
• Titration: Increase by 0.25 mg twice weekly at 4-week intervals
• Maximum dose: Typically up to 1 mg twice weekly 1
• Advantages: Better tolerated, more effective, longer half-life (once/twice weekly dosing)

Alternative: Bromocriptine

• Consider for women planning pregnancy (more safety data in pregnancy) 2
• Less well-tolerated than cabergoline (more nausea, dizziness) 3
• Requires multiple daily dosing

2. Monitoring

• Prolactin levels should be checked after initiating therapy:

  • Initially at 4-week intervals during dose titration
  • Once stabilized, every 3-6 months

• For prolactinomas:

  • MRI after 3 months of treatment to verify tumor shrinkage
  • Then after 1 year, yearly for 5 years, and every 5 years if stable 3
  • For microprolactinomas, MRI after 1 year and then after 5 years 3

• Cardiac monitoring:

  • Baseline echocardiogram before starting treatment
  • Yearly echocardiography if dose >2 mg/week
  • Every 5 years if dose ≤2 mg/week 1, 4

3. Treatment Duration and Discontinuation

For patients with normal prolactin levels maintained for ≥6 months, consider tapering:

• Reduce to 0.25 mg once weekly for 4-8 weeks
• If prolactin remains normal, further reduce to 0.25 mg every 2 weeks for 8 weeks
• Then discontinue completely 1

After discontinuation, monitor:

• Prolactin levels every 3 months for the first year
• Every 6 months for the second year
• Reduced frequency if levels remain normal for 2 years 1

4. Special Situations

Medication-induced Hyperprolactinemia

• If possible, discontinue the causative medication
• If medication cannot be withdrawn:
  • Consider switching to an alternative medication in the same class that doesn't cause hyperprolactinemia
  • Hormone replacement therapy (estrogen/testosterone) to prevent osteoporosis 5
  • Dopamine agonists generally not recommended unless adenoma present 3

Surgical Management

Consider surgical referral for:

• Resistance to dopamine agonist therapy
• Intolerance to medical therapy
• Patient preference for definitive treatment
• Deteriorating vision despite cabergoline therapy 1

Pregnancy Considerations

• Discontinue dopamine agonists once pregnancy is confirmed
• Exception: If there's risk of tumor expansion (large macroadenomas)
• Bromocriptine has more safety data in pregnancy than cabergoline 2

Potential Pitfalls and Side Effects

Side Effects of Dopamine Agonists

• Common (13% of patients): Nausea, dizziness, headache 1
• Management: Start with lower doses, titrate slowly, consider nighttime dosing

Cardiac Valvulopathy Risk

• Higher risk with doses >2 mg/week of cabergoline 4
• Regular echocardiographic monitoring is essential
• Discontinue if valvular regurgitation, restriction, or thickening develops 4

Fibrotic Complications

• Monitor for symptoms of:
  • Pleuro-pulmonary disease (dyspnea, cough, chest pain)
  • Retroperitoneal fibrosis (flank pain, edema)
  • Cardiac fibrosis 4, 6

Dopamine Agonist Resistance

• Defined as failure to normalize prolactin or achieve tumor shrinkage after 3-6 months at maximum tolerated doses
• Options: Increase dose if tolerated or consider surgical intervention 1

Recurrence After Discontinuation

• Occurs in 20-30% of cases, particularly with residual adenoma 3
• Continue monitoring prolactin levels after discontinuation

By following this treatment algorithm and monitoring protocol, most patients with hyperprolactinemia can achieve normalization of prolactin levels, resolution of symptoms, and in cases of prolactinomas, significant tumor shrinkage.