Brom-ergocryptine in the treatment of phenothiazine-induced galactorrhoea

Dopamine agonist therapy for prolactinomas: do we need to rethink the place of surgery in prolactinoma management?

The current treatment paradigm for prolactinomas involves dopamine agonist (DA) therapy as the first-line treatment, with surgical resection reserved for cases where there is DA failure due to resistance or intolerance. This review highlights how DA therapy can be optimised to overcome its increasingly recognised pitfalls, whilst also addressing the potential for expanding the use of surgery in the management of prolactinomas. The first part of the review discusses the limitations of DA therapy, namely: DA resistance; common DA side effects; and the rare but serious DA-induced risks of cardiac valvulopathy, impulse control disorders, psychosis, CSF rhinorrhoea and tumour fibrosis. The second part of the review explores the role of surgery in prolactinoma management with reference to its current second-line position and recent calls for surgery to be considered as an alternative first-line treatment alongside DA therapy. Randomised trials comparing medical vs surgical therapy for prolactinomas are currently underway. Pending these results, a low surgical threshold approach is herein proposed, whereby DA therapy remains the default treatment for prolactinomas unless there are specific triggers to consider surgery, including concern regarding DA side effects or risks in vulnerable patients, persistent and bothersome DA side effects, emergence of any serious risks of DA therapy, expected need for long-term DA therapy, as well as the traditional indications for surgery. This approach should optimise the use of DA therapy for those who will most benefit from it, whilst instituting surgery early in others in order to minimise the cumulative burden of prolonged DA therapy.

Treatment of psychotropic-induced hyperprolactinaemia

Prolactin, a protein hormone synthesised and released by the anterior pituitary, promotes mammary tissue development and lactation and suppresses gonadotrophin secretion. Dopamine is the natural inhibitor of prolactin release and so standard antipsychotics, which block dopamine receptors, will cause prolactin levels to rise. This hyperprolactinaemia can lead to gynaecomastia, galactorrhoea, menstrual disturbances, a reduction in sperm count, erectile dysfunction, failure of ejaculation and reduced libido. Prolactin-related adverse effects are frequently encountered in patients on antipsychotics and are a cause of substantial morbidity.

Hyperprolactinemia associated with psychotropics--a review

INTRODUCTION

Different classes of psychotropics can cause hyperprolactinemia to varying degrees. Among antipsychotics, typical agents and risperidone are the most frequent and significant offenders. In this review we discuss the pathophysiology, offending medications, assessment and management of hyperprolactinemia.

METHODS

We did a literature review between 1976 and 2008 using PubMed, MEDLINE, PsychINFO and Cochrane database. Search terms used were prolactin, hyperprolactinemia, psychotropics, antipsychotics, typical antipsychotics, atypical antipsychotics, antidepressants and SSRIs.

RESULTS

Prolactin elevation is more common with antipsychotics than with other classes of drugs. Typical antipsychotics are more prone to cause hyperprolactinemia than atypical agents. Management options include discontinuation of offending medication, switching to another psychotropic, supplementing concurrent hormonal deficiencies and adding a dopamine agonist or aripiprazole.

CONCLUSION

Clinicians need to be alert about the potential for hyperprolactinemia and its manifestations with these medications. Prolactin levels need to be monitored and other causes of hyperprolactinemia ruled out in suspected cases.

Drugs and prolactin

Medications commonly cause hyperprolactinemia and their use must be differentiated from pathologic causes. The most common medications to cause hyperprolactinemia are the antipsychotic agents, although some of the newer atypical antipsychotics do not do so. Other medications causing hyperprolactinemia include antidepressants, antihypertensive agents, and drugs which increase bowel motility. Often, the medication-induced hyperprolactinemia is symptomatic, causing galactorrhea, menstrual disturbance, and erectile dysfunction. In the individual patient, it is important differentiate hyperprolactinemia due to a medication from a structural lesion in the hypothalamic-pituitary area. This can be done by stopping the medication temporarily to determine if the prolactin (PRL) levels return to normal, switching to another medication in the same class which does not cause hyperprolactinemia (in consultation with the patient's physician and/or psychiatrist), or by performing an MRI or CT scan. If the hyperprolactinemia is symptomatic, management strategies include switching to an alternative medication which does not cause hyperprolactinemia, using estrogen/testosterone replacement, or cautiously adding a dopamine agonist.

A systematic review on clinical management of antipsychotic-induced sexual dysfunction in schizophrenia

INTRODUCTION

Sexual dysfunction frequently occurs in patients with schizophrenia under antipsychotic therapy, and the presence of sexual side effects may affect compliance. The aim of this study was to review and describe clinical findings relating to the appropriate management of such dysfunctions.

MATERIAL AND METHODS

The research was carried out through Medline (from 1966 to March 2005), PsycInfo (from 1974 to March 2005), and Cochrane Library (from 1965 to March 2005) and included any kind of study, from case reports to randomized trials.

RESULTS

The most common sexual dysfunctions found in the literature were libido decrease, difficulties in achieving and maintaining erection, ejaculatory dysfunction, orgasmic dysfunction, and menstrual irregularities. Thirteen papers were found: eight of them were open-label studies, four were descriptions of cases, and only one was a randomized clinical trial. All of them were short-term and had small sample sizes. The agents used were: bromocriptine, cabergoline, cyproheptadine, amantadine, shakuyaku-kanzo-to, sildenafil and selegiline.

DISCUSSION

There was no evidence that those agents had proper efficacy in treating the antipsychotic-induced sexual dysfunction. An algorithm for managing sexual dysfunction induced by antipsychotics is suggested as a support for clinical decisions. Since the outcome from schizophrenia treatment is strongly related to compliance with the antipsychotics, prevention of sexual dysfunction is better than its treatment, since there is a scarcity of data available regarding the efficacy of intervention to deal with these problems.

Medication-induced hyperprolactinemia

Medication use is a common cause of hyperprolactinemia, and it is important to differentiate this cause from pathologic causes, such as prolactinomas. To ascertain the frequency of this clinical problem and to develop treatment guidelines, the medical literature was searched by using PubMed and the reference lists of other articles dealing with hyperprolactinemia due to specific types of medications. The medications that most commonly cause hyperprolactinemia are antipsychotic agents; however, some newer atypical antipsychotics do not cause this condition. Other classes of medications that cause hyperprolactinemia include antidepressants, antihypertensive agents, and drugs that increase bowel motility. Hyperprolactinemia caused by medications is commonly symptomatic, causing galactorrhea, menstrual disturbance, and impotence. It is Important to ensure that hyperprolactinemia in an Individual patient is due to medication and not to a structural lesion in the hypothalamic/pituitary area; this can be accomplished by (1) stopping the medication temporarily to determine whether prolactin levels return to normal, (2) switching to a medication that does not cause hyperprolactinemia (in consultation with the patient's psychiatrist for psychoactive medications), or (3) performing magnetic resonance imaging or computed tomography of the hypothalamic/pituitary area. If the patient's hyperprolactinemia is symptomatic, treatment strategies include switching to an alternative medication that does not cause hyperprolactinemia, using estrogen or testosterone replacement, or, rarely, cautiously adding a dopamine agonist.

Antipsychotic-induced hyperprolactinaemia: mechanisms, clinical features and management

Hyperprolactinaemia is an important but neglected adverse effect of antipsychotic medication. It occurs frequently with conventional antipsychotics and some atypical antipsychotics (risperidone and amisulpride) but is rare with other atypical antipsychotics (aripiprazole, clozapine, olanzapine, quetiapine, ziprasidone). For this reason the terms 'prolactin-sparing' and 'prolactin-raising' are more useful than 'atypical' and 'conventional' when considering the effect of antipsychotic drugs on serum prolactin. During antipsychotic treatment prolactin levels can rise 10-fold or more above pretreatment values. In a recent study approximately 60% of women and 40% of men treated with a prolactin-raising antipsychotic had a prolactin level above the upper limit of the normal range. The distinction between asymptomatic and symptomatic hyperprolactinaemia is important but is often not made in the literature. Some symptoms of hyperprolactinaemia result from a direct effect of prolactin on target tissues but others result from hypogonadism caused by prolactin disrupting the normal functioning of the hypothalamic-pituitary-gonadal axis. Symptoms of hyperprolactinaemia include gynaecomastia, galactorrhoea, sexual dysfunction, infertility, oligomenorrhoea and amenorrhoea. These symptoms are little researched in psychiatric patients. Existing data suggest that they are common but that clinicians underestimate their prevalence. For example, well conducted studies of women treated with conventional antipsychotics have reported prevalence rates of approximately 45% for oligomenorrhoea/amenorrhoea and 19% for galactorrhoea. An illness-related under-function of the hypothalamic-pituitary-gonadal axis in female patients with schizophrenia may also contribute to menstrual irregularities. Long-term consequences of antipsychotic-related hypogonadism require further research but are likely and include premature bone loss in men and women. There are conflicting data on whether hyperprolactinaemia is associated with an increased risk of breast cancer in women. In patients prescribed antipsychotics who have biochemically confirmed hyperprolactinaemia it is important to exclude other causes of prolactin elevation, in particular tumours in the hypothalamic-pituitary area. If a patient has been amenorrhoeic for 1 year or more, investigations should include bone mineral density measurements. Management should be tailored to the individual patient. Options include reducing the dose of the antipsychotic, switching to a prolactin-sparing agent, prescribing a dopamine receptor agonist and prescribing estrogen replacement in hypoestrogenic female patients. The efficacy and risks of the last two treatment options have not been systematically examined. Antipsychotic-induced hyperprolactinaemia should become a focus of interest in the drug treatment of psychiatric patients, particularly given the recent introduction of prolactin-sparing antipsychotics. Appropriate investigations and effective management should reduce the burden of adverse effects and prevent long-term consequences.

Use of the dopamine agonists bromocriptine and cabergoline in the management of risperidone-induced hyperprolactinemia in patients with psychotic disorders

Risperidone is a novel antipsychotic agent that blocks both dopaminergic and serotonergic receptors. In several reports, clinically significant hyperprolactinemia has been reported in patients on this agent. However, the optimal management of risperidone-induced hyperprolactinemia has not been clarified. We reviewed the records of 5 patients with psychotic disorders who were evaluated for risperidone-induced hyperprolactinemia. There were 4 females and 1 male patient, aged 30-45 yr. All patients had significant hyperprolactinemia, with prolactin (PRL) levels ranging from 65.5 to 209 microg/l. All but 1 of these patients had manifestations of hypogonadism. In these 4 patients, risperidone therapy was continued and the dopamine agonists bromocriptine or cabergoline were added. In 3 out of 4 patients, such additional therapy reduced the PRL level and alleviated hypogonadism. None of the patients treated with these agents had a worsening of psychosis. We conclude that risperidone can cause clinically significant hyperprolactinemia in patients treated with this drug. If risperidone therapy must be continued in such patients, addition of the dopamine agonists bromocriptine or cabergoline may successfully alleviate hyperprolactinemia and the associated manifestations without worsening psychotic symptoms.

Bromocriptine and psychosis: a literature review

Bromocriptine is an ergot-derived dopamine agonist. Its current uses include the treatment of Parkinson's disease, postpartum ablaction, prolactinomas, acromegaly, and amenorrhea and galactorrhea secondary to neuroleptic use. It is often reported to produce psychiatric side effects such as confusion, hallucinations, and delusions. The literature is reviewed and supports a strong anecdotal relationship between bromocriptine use and psychosis.

Bone density and reproductive hormones in patients with neuroleptic-induced hyperprolactinemia

To study the prevalence of osteoporosis and hyperandrogenism in neuroleptic-induced hyperprolactinemia, the authors evaluated 10 patients. Three were amenorrheic, while seven had oligomenorrhea. Nine patients had galactorrhea. The Ferriman-Gallway hirsutism score was 12 +/- 2. Vaginal smear maturation value was 53 +/- 8. Bone density, measured by dual photon absorptionometry in the spine, femoral neck, Ward's triangle, and trochanteric region, was 98 +/- 1.5, 92.7 +/- 3, 88.5 +/- 4.2, and 92.6 +/- 3.3 percentile of controls matched for age, sex, weight, and ethnicity, respectively. Serum prolactin, follicle-stimulating hormone (FSH), luteinizing hormone (LH), dehydroepiandrosterone sulfate (DHEAS), total testosterone, and free testosterone were 82 +/- 10 ng/ml, 8.5 +/- 1.1 mIU/ml, 11.1 +/- 2.6 mIU/ml, 4695 +/- 594 ng/ml, 90 +/- 17 ng%, and 2.36% +/- 0.3%, respectively. Serum thyroid-stimulating hormone (TSH) and free thyroxine index were normal. Bone density strongly correlated with vaginal maturation value (r = 0.904, P less than 0.01). It is concluded that (1) neuroleptic-induced hyperprolactinemia is associated with hirsutism and androgen excess primarily of adrenal origin and (2) a subset of these patients is at an increased risk of developing osteoporosis. It may be possible to identify patients at risk of osteoporosis by examining vaginal smears for maturation value. Early detection and management are imperative in this group of patients.

Effects of bromocriptine on neuroleptic-induced amenorrhea, galactorrhea and impotence

The effects of bromocriptine on neuroleptic-induced endocrinological disturbances (amenorrhea, galactorrhea and impotence) were investigated. Bromocriptine (5.0-7.5 mg/day) was administered to psychiatric patients receiving neuroleptics and developing hyperprolactinemia. The following results were obtained. Menses recurred in 7 of 10 patients with amenorrhea. A decrease in lactation appeared in 5 of 6 patients with galactorrhea. A significant increase in the serum levels of testosterone was observed after 8 weeks of the treatment in male patients. (N = 6). There was no remarkable deterioration in regard to the psychotic symptoms in schizophrenic patients. (N = 7). In non-schizophrenic patients (N = 9), a significant improvement was observed in regard to "somatic concern" (in Brief Psychiatric Rating Scale).

Effects of intravenous and subcutaneous administration of apomorphine on the clinical symptoms of chronic schizophrenics

The effects of apomorphine, a stimulant of dopamine autoreceptors, were studied in 12 chronic schizophrenics on neuroleptic treatment; both subcutaneous and intravenous administration were used. Apomorphine has been reported to have therapeutic effects in previous studies but, we were not able to confirm any significant and specific differences in psychotic symptoms or tardive dyskinesia scores with apomorphine administration, compared with placebo. These results do not support the importance of dopamine autoreceptors in the regulation of schizophrenic and dyskinetic symptoms in chronic neuroleptic-treated patients.

Hyperprolactinaemic amenorrhoea in Hong Kong

In a retrospective study of 595 patients attending the Menstrual Disorder Clinic from January, 1978 to December, 1981, 92 patients (15.5%) had raised serum prolactin (PRL) levels (greater than 25 ng/ml) on 2 or more separate occasions with a mean (+/- S.E.M.) value of 67.1 +/- 2.5 ng/ml. Galactorrhoea was found in 27.2% of the hyperprolactinaemic patients. Primary amenorrhoea was observed in 1 patient (1.1%) with serum PRL level of 68 ng/ml. Secondary amenorrhoea of longer than 6 months' duration occurred in 61 patients (66.3%) with mean PRL level 84.2 +/- 3.3 ng/ml. The 30 patients (32.6%) with irregular menstruation had a mean PRL level of 47.2 +/- 3.3 ng/ml. Investigations revealed that 43 patients (46.7%) had idiopathic hyperprolactinaemia, 14 patients (15.4%) had drug induced hyperprolactinaemia and 1 patient (1.1%) had hypothyroidism; 18 patients (19.5%) had suspected pituitary microadenoma and 16 patients (17.2%) had abnormal radiographic findings. Bromocriptine treatment was given to 38 patients, 13 with abnormal tomographic findings (mean serum PRL greater than 100ng/ml); 18 with suspected pituitary microadenoma (mean serum PRL 94 +/- 2.7 ng/ml) and 7 with idiopathic hyperprolactinaemia (mean serum PRL 65 +/- 4.7 ng/ml). All patients (38/38) responded to treatment with restoration of menstruation and cessation of galactorrhoea within 1 to 3 months. Mean PRL level was 21.6 +/- 5.2 ng/ml at the time of response. Thirteen patients subsequently became pregnant and all delivered healthy babies.

Dopamine autoreceptor stimulation: clinical significance

Recent studies of the effects of low doses of dopamine agonists, designed to stimulate dopamine autoreceptors and hence diminish the synthesis and release of dopamine, were based on a series of basic research studies which demonstrated the existence of autoreceptors on dopamine neurones of the nigrostriatal, mesolimbic and mesocortical dopaminergic neurones. Evidence for autoreceptors on the tuberoinfundibular dopamine neurones which participate in the regulation of prolactin and growth hormone secretion is lacking. Some recent reports have questioned the existence of dopamine autoreceptors on the mesolimbic and nigrostriatal dopamine neurones. Specificity of various dopamine agonists and antagonists for the dopamine autoreceptor will be reviewed. The sedative, anxiolytic, antipsychotic, antidyskinetic and neuroendocrine effects of low dose dopamine agonists in man will be described. Low dose apomorphine, N-propylapomorphine and bromocriptine have been reported to have antipsychotic effects in the major psychoses, to diminish tardive dyskinesia and to enhance extrapyramidal insufficiency. A unique depressive state which developed in a small proportion of psychiatric patients after low dose apomorphine will be described. Further evidence for the lack of dopamine autoreceptors on the tuberoinfundibular dopamine neurones in man will be presented. Strategies for further study of the dopamine autoreceptor concept in man will be discussed.

Effects of chronic neuroleptic therapy on human PRL secretion and testicular function

Correlation between secretion of testicular steroids and plasma prolactin (PRL) levels, before and during bromocriptin treatment, was studied in 20 psychiatric patients under neuroleptic therapy for two years or longer. Eleven of them were under additional treatment with antiparkinson drugs (AP group). Plasma PRL, testosterone (T), 5 alpha dihydrotestostérone (DHT), 17 beta-estradiol (E2), 17 alpha OH-progestérone (17 alpha OHP), and dehydroepiandrosterone-sulfate (D-S) were measured by specific RIA both at basal level and in response to testicular stimulation by hCG. Mean basal PRL levels were normal in the patients under neuroleptic treatment along (Ne group), and slightly elevated in the AP group. In the Ne group, an unexpected, significant increase occurred in mean plasma PRL during the hCG stimulation, before bromocriptine treatment. Mean basal steroid levels were normal in both groups. The testicular responses to hCG, as reflected by the T, E2, 17 alpha OHP, and DHT mean plasma levels, were within the normal ranges in the AP group; in the Ne group, however, T and DHT displayed a subnormal mean increase, while E2 and 17 alpha OHP responses were within the normal range. These results suggest that some modifications of the enzymatic activity for testicular steroidogenesis could be induced in the patients under neuroleptic treatment alone. Moreover, a significant reverse correlation was found between PRL and T basal in both group; this correlation disappeared during the bromocriptine treatment.

Management of hyperprolactinaemic amenorrhoea

Results of treatment of 52 patients with amenorrhoea associated with hyperprolactinaemia are presented. All patients had a detailed radiological examination of the pituitary fossa, including lateral tomography in every patient and air encephalography in those in whom a pituitary tumour was suspected. There were 17 patients with untreated pituitary tumours, 5 patients with previously treated pituitary tumours and persisting hyperprolactinaemia, and 30 patients with normal pituitary radiology. Patients with pituitary tumours were treated either by transsphenoidal or transfrontal surgical extirpation of the tumour, followed, if necessary, by external irradiation and/or bromocriptine, Four patients were treated with external irradiation as primary therapy, and three patients who did not wish to conceive were treated with bromocriptine as primary therapy. Patients with normal radiological appearances were treated with bromocriptine as primary treatment. Ovulatory menstrual cycles developed in 42 patients and there were 19 pregnancies. Those ovulating but not conceiving had adequate nonendocrine factors to account for the disparity. Failure of response was seen in 10 patients and was due to inadequate fall of prolactin in response to surgery (2 patients), external irradiation (3 patients) and bromocriptine (1 patient), and gonadotrophin deficiency which developed after surgery in 3 patients but was present pre-operatively in 1. The relative merits of treatment by surgery, external irradiation and bromocriptine are discussed and a policy of treatment outlined.