What is the management of hyperprolactinemia according to National Institute for Health and Care Excellence (NICE) guidelines in the United Kingdom (UK)?

From the Guidelines

The management of hyperprolactinemia according to UK NICE guidelines involves offering cabergoline as first-line therapy, even in the presence of visual disturbance and pituitary apoplexy, while carefully monitoring for any deterioration in vision, pituitary function, or general status. This approach is based on the most recent and highest quality evidence available, including a study published in Nature Reviews Endocrinology in 2024 1, which recommends cabergoline as the dopamine agonist of choice due to its superior effectiveness and lower adverse effect profile.

Key Considerations

• Identify and address any reversible causes of hyperprolactinemia, such as medications, hypothyroidism, or renal failure.
• For symptomatic patients with microadenomas or idiopathic hyperprolactinemia, dopamine agonists are first-line treatment, with cabergoline preferred due to better efficacy and tolerability compared to bromocriptine.
• For macroprolactinomas, higher doses of cabergoline may be required, and treatment aims to normalize prolactin levels, restore gonadal function, and reduce tumor size.
• Monitor prolactin levels every 4-8 weeks initially, then every 6-12 months once stable, and consider surgery or radiotherapy for patients with resistance or intolerance to medical therapy, or those with acute complications.

Treatment Approach

• Start cabergoline at a dose of 0.25mg twice weekly, gradually increasing to 0.5-1mg twice weekly if needed.
• For pregnant patients, dopamine agonists are typically discontinued unless the tumor threatens vision.
• Treatment duration varies, and some patients with microadenomas may attempt medication withdrawal after 2-3 years of normal prolactin levels and significant tumor shrinkage, while others require lifelong therapy, as suggested by a study published in Nature Reviews Endocrinology in 2024 1.

Additional Considerations

• Careful multidisciplinary discussion is needed for patients who express a preference for surgery rather than long-term medication or are non-adherent to medical therapy.
• Radiotherapy should be reserved for exceptional patients with a growing prolactinoma and where other treatment modalities are not available or have been exhausted, as recommended by a study published in Nature Reviews Endocrinology in 2024 1.
• Surgery is a viable option for patients with microprolactinomas or intrasellar macroprolactinomas, especially in high-volume surgical centers, and is certainly an alternative to long-term cabergoline therapy, as suggested by a study published in Nature Reviews Endocrinology in 2024 1.

From the Research

Management of Hyperprolactinemia

The management of hyperprolactinemia involves several steps, including diagnosis, treatment, and follow-up.

• Diagnosis: The diagnostic evaluation first requires exclusion of other causes of hyperprolactinemia, such as pregnancy, primary hypothyroidism, numerous medications, and miscellaneous causes 2.
• Treatment: The treatment of choice for nearly all patients with hyperprolactinemic disorders is medical, with dopamine agonists (bromocriptine, pergolide, cabergoline) being extremely effective in lowering serum prolactin, restoring gonadal function, decreasing tumor size, and improving visual fields 2, 3, 4.
• Dopamine Agonists: Dopamine agonists such as bromocriptine and cabergoline have been found to be an effective treatment for hyperprolactinemia, not only inducing adenoma shrinkage but also lowering serum prolactin levels 5.
• Follow-up: For patients with macroprolactinoma treated with dopamine agonists, MRI monitoring should be carried out after 3 months of treatment to verify tumor size reduction, then after 1 year, yearly for the next 5 years and once every 5 years if adenoma size is stable 3.

National Institute for Health and Care Excellence (NICE) Guidelines

There are no research papers provided to assist in answering this question regarding the management of hyperprolactinemia according to National Institute for Health and Care Excellence (NICE) guidelines in the United Kingdom (UK).

Treatment Options

• Medical Therapy: Medical therapy is recommended initially, with neurosurgical evaluation reserved for specific clinical situations, such as failure of medical therapy and evidence of mass effect despite medical therapy 4.
• Surgery: Surgery should be considered only in certain circumstances, and for the majority of patients, dopamine agonists will be sufficient to alleviate symptoms and restore normal prolactin levels 6.
• Combination Therapy: Surgical intervention may resurface as an alternative first-line treatment, and when used in combination with cabergoline, surgery offers a higher disease remission rate than either drug or operation alone 5.