From the Guidelines
To address high prolactin levels that have persisted for over 15 years, you should consult with an endocrinologist who can prescribe cabergoline (Dostinex) as the first-line therapy, given its superior effectiveness and lower adverse effect profile, as recommended by the most recent guidelines 1.
Key Considerations
- The primary goal of treatment is to reduce serum prolactin concentrations and induce tumor shrinkage, if a prolactinoma is present.
- Cabergoline is the preferred dopamine agonist due to its superior effectiveness and lower adverse effect profile, as stated in the consensus guideline for the diagnosis and management of pituitary adenomas in childhood and adolescence: part 2, specific diseases 1.
- Treatment typically continues until prolactin levels normalize, which may take weeks to months, and some patients require long-term therapy.
- Before starting medication, an MRI should be ordered to check for a pituitary tumor (prolactinoma), which is a common cause of elevated prolactin.
- Regular follow-up appointments are essential to monitor response to treatment and adjust medication as needed.
Additional Recommendations
- Lifestyle modifications such as stress reduction and avoiding excessive breast stimulation may help as complementary approaches.
- Review of current medications is necessary, as some drugs like antipsychotics, certain antidepressants, and some blood pressure medications can raise prolactin levels.
- Consideration of gradual cabergoline dose reduction to maintain normoprolactinaemia and eventual treatment discontinuation may be possible if serum prolactin levels have been normalized for at least 2 years on medical therapy and there is no visible residual prolactinoma on MRI, as suggested by the guideline 1.
Monitoring and Follow-up
- Clinical monitoring, including assessment of growth, puberty, galactorrhoea, menstrual history, gynaecomastia or loss of libido in puberty, and biochemical monitoring by measurement of serum prolactin, are essential.
- MRI should be repeated 3–6 months after starting cabergoline treatment for macroprolactinomas, and re-imaging depends on clinical and biochemical follow-up for microprolactinomas.
- Longer-term imaging frequency depends on symptoms, biochemical control, and the closeness of the pituitary mass to the optic chiasm.
From the FDA Drug Label
CLINICAL PHARMACOLOGY Bromocriptine mesylate is a dopamine receptor agonist, which activates post-synaptic dopamine receptors The dopaminergic neurons in the tuberoinfundibular process modulate the secretion of prolactin from the anterior pituitary by secreting a prolactin inhibitory factor (thought to be dopamine); in the corpus striatum the dopaminergic neurons are involved in the control of motor function Clinically, bromocriptine mesylate significantly reduces plasma levels of prolactin in patients with physiologically elevated prolactin as well as in patients with hyperprolactinemia. To get rid of high prolactin levels that have been present for over 15 years, bromocriptine mesylate can be used as it significantly reduces plasma levels of prolactin in patients with hyperprolactinemia 2.
- Key points:
- Bromocriptine mesylate is a dopamine receptor agonist.
- It reduces plasma levels of prolactin in patients with hyperprolactinemia.
- It should be taken with food to minimize side effects.
- Regular monitoring of blood pressure and other potential side effects is necessary. It is essential to consult a healthcare professional to determine the best course of treatment and to discuss potential side effects and interactions with other medications.
From the Research
Treatment Options for High Prolactin Levels
To address high prolactin levels that have been present for over 15 years, several treatment options are available:
- Dopamine agonists, such as bromocriptine, pergolide, quinagolide, and cabergoline, are the primary treatment for prolactinomas, with cabergoline showing a favorable profile in terms of efficacy and tolerability 3.
- Surgical resection of the prolactinoma is an option for patients who do not respond to or refuse long-term pharmacological therapy 3, 4.
- Radiotherapy may be considered if surgery fails or is not feasible 3, 4.
Diagnosis and Monitoring
- Pituitary imaging, such as MRI, is essential for evaluating hyperprolactinemia and detecting pituitary tumors 5.
- Regular monitoring of prolactin levels and pituitary imaging is necessary to assess the effectiveness of treatment and detect any potential tumor growth 6.
- However, for patients with macroprolactinomas and long-term normal prolactin levels on dopamine agonist treatment, MRI follow-up may be unnecessary 6.
Important Considerations
- Hyperprolactinemia can be caused by various factors, including pituitary tumors, drug intake, hypothyroidism, renal failure, and cirrhosis, and a thorough diagnosis is necessary to determine the underlying cause 3, 7.
- The presence of a pituitary macroadenoma may require surgical or radiological management, and dopamine agonist therapy may need to be adjusted or discontinued in certain cases 7, 4.