What is the recommended dose of cabergoline (dopamine receptor agonist) for adults?

Recommended Dose of Cabergoline for Adults

For adults with hyperprolactinemia, initiate cabergoline at 0.25 mg twice weekly and titrate by 0.25 mg increments every 4 weeks up to a standard maximum of 1-2 mg per week, with resistant cases potentially requiring 3.5 mg per week or exceptionally up to 7 mg per week. 1, 2

Initial Dosing and Titration

• Start with 0.25 mg twice weekly (0.5 mg total per week) as the recommended initial dose 1
• Increase by 0.25 mg twice weekly (0.5 mg total per week increments) based on serum prolactin response 1
• Do not increase doses more rapidly than every 4 weeks to allow adequate assessment of response at each dose level 1
• The standard therapeutic range for most patients is 1-2 mg per week divided into twice-weekly dosing 2, 1

Standard Dosing for Different Presentations

• Microprolactinomas and idiopathic hyperprolactinemia: Most patients achieve normalization with 0.5-1 mg per week 3
• Macroprolactinomas: Typically require higher doses, with a median of 1 mg per week, though significant overlap exists with smaller tumors 3
• Once prolactin control is achieved, the dose can often be reduced to a lower maintenance level (frequently to 0.5 mg per week) 3

High-Dose Therapy for Resistant Cases

For patients who fail to respond to standard doses (up to 2 mg per week), consider graduated dose escalation:

• Increase to 3.5 mg per week for resistant cases 4, 2
• In exceptional circumstances, doses up to 7 mg per week may be used 4, 2
• Some adult patients have received doses up to 12 mg per week, though this remains well below the 21 mg per week used for Parkinson's disease 4, 2
• Important caveat: Evidence suggests limited additional benefit from doses above 3.5 mg per week in many adults 4, 2

Resistance Definition and Timing

Dopamine agonist resistance is defined as:

• Failure to achieve normal prolactin levels (biochemical resistance) AND/OR
• Less than 50% reduction in tumor area or less than 30% reduction in longest tumor diameter after 3-6 months of maximally tolerated doses (at least 2 mg per week) 4

Minimizing Side Effects

• Administer doses at night with small incremental increases to reduce gastrointestinal intolerance and postural hypotension 4, 2
• This strategy helps avoid switching to less effective dopamine agonists like bromocriptine 4
• Psychological side effects (mood changes, depression, aggression, hypersexuality, impulse control disorders) are dose-independent and related to dopaminergic effects 4, 2

Monitoring Requirements

Cardiac surveillance is dose-dependent:

• For doses ≤2 mg per week: Echocardiography every 5 years 2
• For doses >2 mg per week: Annual echocardiography with cardiac auscultation 2
• Baseline cardiovascular evaluation and echocardiography should be performed before initiating therapy 1

Treatment Duration and Discontinuation

• After maintaining normal prolactin levels for 6 months, cabergoline may be discontinued with periodic prolactin monitoring 1
• Efficacy data beyond 24 months of continuous therapy is limited 1
• Many patients maintain normal or reduced prolactin levels for several months after withdrawal 5

Common Pitfalls to Avoid

• Do not escalate doses too rapidly: The 4-week interval between increases is critical for assessing true response 1
• Do not automatically increase beyond 3.5 mg per week: Many patients who don't respond to this dose won't benefit from higher doses and should be considered for surgery or radiotherapy 4, 2
• Do not ignore cardiac monitoring: Higher doses carry increased valvulopathy risk, particularly above 2 mg per week 2
• Watch for cerebrospinal fluid leak: Tumor shrinkage can cause rhinorrhea (mean 3.3 months after starting treatment), requiring urgent intervention 4