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Liu T, Jia C, Li Y. Treatment of sexual dysfunction induced by hyperprolactinemia accompanied by reduced luteinizing hormone levels: A case report. Clin Case Rep 2024; 12:e8432. [PMID: 38435507 PMCID: PMC10901787 DOI: 10.1002/ccr3.8432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 12/20/2023] [Accepted: 12/24/2023] [Indexed: 03/05/2024] Open
Abstract
Key Clinical Message Sexual dysfunction induced by hyperprolactinemia accompanied by reduced luteinizing hormone (LH) is common in anrology clinics. A low dose of bromocriptine is helpful for restoring penile erectile function and libido in patients. Abstract Sexual dysfunction is closely related to hormonal disorders, of which prolactin (PRL) and luteinizing hormone (LH) disorders are common. How to treat sexual dysfunction induced by hyperprolactinemia accompanied by reduced LH levels is worth discussing. In this study, we aimed to present the case of a 35-year-old male patient with sexual dysfunction. The treatment process and physical and laboratory examination results were recorded. Before treatment, the PRL and LH levels in this patient were 31.27 ng/mL and 1.62 mIU/mL, respectively. The International Index of Erectile Function-5 (IIEF-5) score was initially 14 points. After regular treatment with low doses of bromocriptine and tadalafil, the hormonal disorder was corrected (PRL: 11.16 ng/mL and LH: 2.28 mIU/mL) and sexual function was recovered (IIEF-5: 23 points). This case report suggested a sufficient exposure to low-dose bromocriptine for such patients. Conversely, the exogenous supplementation of human chorionic gonadotropin may not be appropriate.
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Affiliation(s)
- Tao Liu
- Sexual Department, First Affiliated HospitalWannan Medical CollegeWuhuChina
| | - Chao Jia
- Sexual Department, First Affiliated HospitalWannan Medical CollegeWuhuChina
| | - Yan Li
- Sexual Department, First Affiliated HospitalWannan Medical CollegeWuhuChina
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2
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Saito N, Hirai N, Koyahara Y, Sato S, Hiramoto Y, Fujita S, Nakayama H, Hayashi M, Iwabuchi S. Evaluation of Treatment Strategies for Male Prolactin-Secreting Pituitary Neuroendocrine Tumors. Cureus 2024; 16:e54503. [PMID: 38516477 PMCID: PMC10955445 DOI: 10.7759/cureus.54503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2024] [Indexed: 03/23/2024] Open
Abstract
Prolactin-secreting pituitary neuroendocrine tumors (PitNETs) are more common in women. Male patients may also have few symptoms and have macroadenomas extending outside the sella turcica. This study aimed to report the results of cabergoline treatment in male patients with prolactin-secreting PitNET. The study included nine male patients aged 26-65 years (median, 46 years) diagnosed with prolactin-secreting PitNETs. The age at onset, prolactin values, tumor size, symptoms, and treatment were assessed. The mean prolactin value at the initial presentation was 2734.6 ng/mL, and the mean maximum tumor diameter was 40.4 mm. Visual field disturbance was the most common symptom (44.4%), followed by headaches (33.3%), asymptomatic symptoms (11.1%), and galactorrhea (11.1%). Eight patients responded to cabergoline treatment with normalization of prolactin levels and tumor shrinkage. One patient did not respond to the cabergoline treatment and required surgical intervention. There were no cases of cerebrospinal fluid leakage. Cabergoline was found to be an effective treatment for male prolactin-secreting PitNETs.
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Affiliation(s)
- Norihiko Saito
- Neurosurgery, Toho University Ohashi Medical Center, Tokyo, JPN
| | - Nozomi Hirai
- Neurosurgery, Toho University Ohashi Medical Center, Tokyo, JPN
| | - Yuki Koyahara
- Neurosurgery, Toho University Ohashi Medical Center, Tokyo, JPN
| | - Sho Sato
- Neurosurgery, Toho University Ohashi Medical Center, Tokyo, JPN
| | - Yu Hiramoto
- Neurosurgery, Toho University Ohashi Medical Center, Tokyo, JPN
| | - Satoshi Fujita
- Neurosurgery, Toho University Ohashi Medical Center, Tokyo, JPN
| | - Haruo Nakayama
- Neurosurgery, Toho University Ohashi Medical Center, Tokyo, JPN
| | - Morito Hayashi
- Neurosurgery, Toho University Ohashi Medical Center, Tokyo, JPN
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Stumpf MAM, Pinheiro FMM, Silva GO, Cescato VAS, Musolino NRC, Cunha-Neto MBC, Glezer A. How to manage intolerance to dopamine agonist in patients with prolactinoma. Pituitary 2023:10.1007/s11102-023-01313-8. [PMID: 37027090 DOI: 10.1007/s11102-023-01313-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2023] [Indexed: 04/08/2023]
Abstract
PURPOSE Dopamine agonists (DA) are the gold-standard for prolactinoma and hyperprolactinemia treatment. Intolerance to DA leading to drug drop out occurs in 3 to 12% of cases. We provide here a review of published data about DA intolerance and present a case report concerning the use of intravaginal cabergoline. METHODS We review the literature on the definition, the pathogenesis, frequency and management of DA intolerance. In addition, the review provides strategies to enhance tolerability and avoid precocious clinical treatment withdrawal. RESULTS Cabergoline is often cited as the most tolerable DA and its side effects tend to ameliorate within days to weeks. Restarting the same drug at a lower dose or switching to another DA can be used in cases of intolerance. The vaginal route can be tried specifically if there are gastrointestinal side effects in the oral administration. Symptomatic treatment could be attempted, although mainly based on a strategy used in other diseases. CONCLUSIONS Due to limited data, no guidelines have been developed for the management of intolerance in DA treatment. The most frequent management is to perform transsphenoidal surgery. Nevertheless, this manuscript provides data derived from published literature and expert opinion, suggesting new approaches to this clinical issue.
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Affiliation(s)
- Matheo Augusto Morandi Stumpf
- Unidade de Neuroendocrinologia, Disciplina de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Ovídio Pires de Campos, 225 - Cerqueira César, São Paulo, 05403- 010, SP, Brazil.
| | - Felipe Moura Maia Pinheiro
- Unidade de Neuroendocrinologia, Disciplina de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Ovídio Pires de Campos, 225 - Cerqueira César, São Paulo, 05403- 010, SP, Brazil
| | - Gilberto Ochman Silva
- Grupo de Neuroendocrinologia, Divisão de Neurocirurgia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brasil
| | - Valter Angelo Sperling Cescato
- Grupo de Neuroendocrinologia, Divisão de Neurocirurgia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brasil
| | - Nina Rosa Castro Musolino
- Grupo de Neuroendocrinologia, Divisão de Neurocirurgia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brasil
| | - Malebranche Berardo Carneiro Cunha-Neto
- Grupo de Neuroendocrinologia, Divisão de Neurocirurgia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brasil
| | - Andrea Glezer
- Unidade de Neuroendocrinologia, Disciplina de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Ovídio Pires de Campos, 225 - Cerqueira César, São Paulo, 05403- 010, SP, Brazil
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Tng EL, Teo AED, Aung AT. Macroprolactinoma with secondary resistance to dopamine agonists: a case report and review of the literature. J Med Case Rep 2023; 17:96. [PMID: 36927797 PMCID: PMC10021939 DOI: 10.1186/s13256-023-03820-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 02/14/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND Resistance to dopamine agonists is not uncommonly seen in prolactinomas. However, development of resistance to dopamine agonists after an initial period of robust treatment response is rare, and only 39 cases have been reported in the past four decades. We describe a Chinese man with this rare condition and explored the postulated mechanisms that may explain this phenomenon. We compiled similar cases that were previously reported and compared their etiology, progress, and response to treatment. On the basis of these cases, we derived a list of differential diagnoses to consider in patients with secondary resistance to dopamine agonists. CASE PRESENTATION A 63-year-old Chinese man presented with blurred vision and was subsequently diagnosed with a macroprolactinoma. He had initial response to cabergoline but developed secondary resistance to it after 5 years. The prolactinoma continued to grow, and his serum prolactin remained markedly elevated despite adherence to escalating dosages of cabergoline up to 6 mg/week. The patient finally underwent transsphenoidal surgery and was found to have a sparsely granulated lactotroph tumor with Ki-67 index of 5%. Postoperatively, there was improvement in his serum prolactin level, although he still required treatment with cabergoline at 6 mg/week. CONCLUSIONS Surgery can facilitate disease control in patients with prolactinomas that develop secondary resistance to dopamine agonists. Malignant prolactinoma is an important differential diagnosis in this group of patients, especially when serum prolactin remains markedly elevated despite resolution or stability of the primary pituitary lesion, suggesting a metastatic source of prolactin secretion.
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Affiliation(s)
- Eng-Loon Tng
- Department of Medicine, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Tower A Level 8, Singapore, 609606, Singapore.
| | - Ada Ee Der Teo
- Department of Medicine, Division of Endocrinology, National University Health System, 1E Kent Ridge Road, NUHS Tower Block Level 10, Singapore, 119228, Singapore
| | - Aye Thida Aung
- Ministry of Health Holdings, 1 Maritime Square, #11-25 HarbourFront Centre, Singapore, 099253, Singapore
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Shibuya Y, Shiba M, Hayashi T, Iwai S, Mitake A, Mori N, Ichibori Y, Minamiguchi H, Makino N, Hirayama A, Higuchi Y. Peripartum Cardiomyopathy with the Cardiac Function Restored by Cabergoline. Intern Med 2022. [PMID: 36418104 PMCID: PMC10400386 DOI: 10.2169/internalmedicine.0988-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Peripartum cardiomyopathy (PPCM) is a left ventricular systolic dysfunction associated with heart failure (HF) in late-term pregnancy or peripartum. A 29-year-old pregnant woman with no history of cardiac disease noted lower extremity edema around 34 weeks' gestation with significant weight gain. She delivered twins via caesarean section, and the edema regressed postpartum. On postpartum day 4, however, she experienced difficulty breathing at night and was diagnosed with HF owing to PPCM. HF treatment along with cabergoline was initiated. With low prolactin blood levels, her symptoms and cardiac function improved over time. This case demonstrated the usefulness of anti-prolactin therapy with cabergoline in PPCM.
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Affiliation(s)
- Yuki Shibuya
- Cardiovascular Division, Osaka Police Hospital, Japan
| | - Mikio Shiba
- Cardiovascular Division, Osaka Police Hospital, Japan
| | | | - Sayuri Iwai
- Department of Obstetrics and Gynecology, Osaka Police Hospital, Japan
| | - Amane Mitake
- Department of Obstetrics and Gynecology, Aizenbashi Hospital, Japan
| | - Naoki Mori
- Cardiovascular Division, Osaka Police Hospital, Japan
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Naz F, Malik A, Riaz M, Mahmood Q, Mehmood MH, Rasool G, Mahmood Z, Abbas M. Bromocriptine Therapy: Review of mechanism of action, safety and tolerability. Clin Exp Pharmacol Physiol 2022; 49:903-922. [DOI: 10.1111/1440-1681.13678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 05/24/2022] [Accepted: 05/25/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Faiza Naz
- Punjab University College of Pharmacy University of the Punjab Lahore Pakistan
| | - Abdul Malik
- College of Pharmacy University of Sargodha Sargodha Pakistan
| | - Muhammad Riaz
- Department of Allied Health Sciences University of Sargodha Sargodha Pakistan
| | - Qaisar Mahmood
- College of Pharmacy University of Sargodha Sargodha Pakistan
| | - Malik Hassan Mehmood
- Department of Pharmacology, Faculty of Pharmaceutical Sciences Government College University Faisalabad Pakistan
| | - Ghulam Rasool
- Department of Allied Health Sciences University of Sargodha Sargodha Pakistan
| | - Zahed Mahmood
- Department of Biochemistry Government College University Faisalabad Pakistan
| | - Mazhar Abbas
- Department of Biochemistry College of Veterinary and Animal Sciences, University of Veterinary and Animal Sciences (Jhang Campus) Lahore Pakistan
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Cai X, Zhu J, Yang J, Tang C, Cong Z, Ma C. Are dopamine agonists still the first-choice treatment for prolactinoma in the era of endoscopy? A systematic review and meta-analysis. Chin Neurosurg J 2022; 8:9. [PMID: 35395837 PMCID: PMC8994364 DOI: 10.1186/s41016-022-00277-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 03/21/2022] [Indexed: 11/16/2022] Open
Abstract
Background For prolactinoma patients, dopamine agonists (DAs) are indicated as the first-line treatment and surgery is an adjunctive choice. However, with the development of surgical technique and equipment, the effect of surgery has improved. The aim of this study was to assess the efficacy and safety of surgery versus DAs in patients with different types of prolactinomas. Methods A systematic search of literature using Web of Science, PubMed, Cochrane Library, and Clinical Trial databases was conducted until July 12, 2019. Prolactinoma patients treated with DAs (bromocriptine or cabergoline) or surgery (microscopic or endoscopic surgery) were included. Outcomes included the biochemical cure rate, recurrence rate, prolactin level, improvement rates of symptoms, and incidence rates of complications. A random-effects model was used to pool the extracted data. Qualitative comparisons were conducted instead of quantitative comparison. Results DAs were better than surgery in terms of the biochemical cure rate (0.78 versus 0.66), but surgery had a much lower recurrence rate (0.19 versus 0.57). Full advantages were not demonstrated in improvement rates of symptoms and incidence rates of complications with both treatment options. In microprolactinoma patients, the biochemical cure rate of endoscopic surgery was equal to the average cure rate of DAs (0.86 versus 0.86) and it surpassed the biochemical cure rate of bromocriptine (0.86 versus 0.76). In macroprolactinoma patients, endoscopic surgery was slightly higher than bromocriptine (0.66 versus 0.64) in terms of the biochemical cure rate. Conclusion For patients with clear indications or contraindications for surgery, choosing surgery or DAs accordingly is unequivocal. However, for patients with clinical equipoise, such as surgery, especially endoscopic surgery, in microprolactinoma and macroprolactinoma patients, we suggest that neurosurgeons and endocrinologists conduct high-quality clinical trials to address the clinical equipoise quantitatively. Supplementary Information The online version contains supplementary material available at 10.1186/s41016-022-00277-1.
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Affiliation(s)
- Xiangming Cai
- School of Medicine, Southeast University, Nanjing, China
| | - Junhao Zhu
- School of Medicine, Nanjing Medical University, Nanjing, China
| | - Jin Yang
- School of Medicine, Nanjing Medical University, Nanjing, China
| | - Chao Tang
- Department of Neurosurgery, Jinling Hospital, Nanjing, China
| | - Zixiang Cong
- Department of Neurosurgery, Jinling Hospital, Nanjing, China
| | - Chiyuan Ma
- School of Medicine, Southeast University, Nanjing, China. .,School of Medicine, Nanjing Medical University, Nanjing, China. .,Department of Neurosurgery, Jinling Hospital, Nanjing, China. .,School of Medicine, Nanjing University, Nanjing, China.
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Fachi MM, de Deus Bueno L, de Oliveira DC, da Silva LL, Bonetti AF. Efficacy and safety in the treatment of hyperprolactinemia: A systematic review and network meta-analysis. J Clin Pharm Ther 2021; 46:1549-1556. [PMID: 34137053 DOI: 10.1111/jcpt.13460] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/11/2021] [Accepted: 05/22/2021] [Indexed: 01/29/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Hyperprolactinemia is a neuroendocrine disease that is responsible for a quarter of cases of secondary amenorrhea, which can lead to infertility in women. Dopaminergic agonists (bromocriptine, cabergoline, quinagolide) can be used in the treatment. However, there is a lack of secondary studies that compare their efficacy and safety, especially through a network meta-analysis. Thus, to contribute to the decision-making, a systematic review and network meta-analyses (NMA) were performed to evaluate the efficacy and safety of dopaminergic agonists in the treatment of hyperprolactinemia. METHODS Randomized clinical trials (RCT) were retrieved through PubMed, Web of Science and Scopus databases. The efficacy and safety of the drugs were compared, considering the following outcomes: prolactin (PRL) levels, number of patients with galactorrhoea, menstrual irregularities and adverse drug reactions. NMA was built for each outcome. Results were reported as odds ratios (OR) with 95% credibility intervals. Ranking probabilities were calculated by surface under the cumulative ranking analysis (SUCRA) and Stochastic multicriteria acceptability analysis (SMAA). RESULTS AND DISCUSSION Seventeen RCTs were included in the systematic review and fifteen in the meta-analyses. The drugs had similar efficacy, considering the PRL levels. The SUCRA analysis showed that quinagolide (0.075 and 0.05 mg/day) was superior for reducing irregular menstruation, whereas bromocriptine was the best (97%) for galactorrhoea. Cabergoline proved to be the safest drug, except for abdominal pain at a dose of 1 mg/week. The SMAA demonstrated similar results to SUCRA. WHAT IS NEW AND CONCLUSION This is the first network meta-analysis that evaluated the efficacy and safety of dopaminergic agonists in the treatment of hyperprolactinemia. The results of this review revealed that these drugs have similar efficacy, but cabergoline has a better safety profile.
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Yi N, Ji L, Zhang Q, Zhang S, Liu X, Shou X, Lu B. Long-term follow-up of female prolactinoma patients at child-bearing age after transsphenoidal surgery. Endocrine 2018; 62:76-82. [PMID: 29934876 DOI: 10.1007/s12020-018-1652-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 06/12/2018] [Indexed: 10/28/2022]
Abstract
CONTEXT Prolactinoma is the most common subtype of functional pituitary adenoma. Effective therapy is required for women of child-bearing age to achieve remission at serum prolactin level and regain reproductive function. PURPOSE To evaluate long-term outcomes, including menstrual recovery, after transsphenoidal surgery on female prolactinoma patients by experienced neurosurgeons. DESIGN Observational study. PATIENTS Consecutive female prolactinoma patients aged from 16 to 45 years were included. Histological analysis after surgery revealed adenoma with positive staining for prolactin. Plurihormonal cell adenomas were excluded. MAIN MEASUREMENTS Clinical manifestations, surgical indications, serum prolactin level before and after surgery, surgical complications, pituitary fuctions, drug maintenance, the status of menstruation, and pregnancy. RESULTS Sixty-three consecutive female patients with a mean age of 29.5 ± 1.1 years were included. Based on magnetic resonance imaging findings before surgery, 31 (49.2%) patients had microadenoma, and the remaining 32 (50.8%) had macroadenoma. The median follow-up after transsphenoidal surgery was 53 (33-74) months, and long-term surgical remission was achieved in 50 (79.37%) patients with 28 (90.32%) microadenomas and 22 (68.75%) macroadenomas. No meningitis or persistent cerebrospinal fluid leaks occurred. Only one case suffered from persistent diabetes insipidus at follow-up. No severe pituitary dysfunction was observed in microprolactinoma patients. Of patients with menstrual disorders, 85% regained regular menstrual cycles after surgery. Nineteen patients in this cohort desired pregnancy and 15 of them successfully gave birth after surgery. All 17 microadenoma patients with modern surgical indications achieved normal prolactin levels and regular menstrual cycles with only one patient on drug therapy at follow-up. CONCLUSION Long-term follow-up showed a high remission rate in female prolactinoma patients, especially in microadenoma patients, after surgery. Transsphenoidal surgery performed by experienced neurosurgeons may offer a valuable approach to treat female microprolactinoma patients of child-bearing age with modern indications for surgery.
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Affiliation(s)
- Na Yi
- Department of Endocrinology and Metabolism, Huashan Hospital, Fudan University, Shanghai, China
| | - Lijin Ji
- Department of Endocrinology and Metabolism, Huashan Hospital, Fudan University, Shanghai, China
| | - Qi Zhang
- Department of Endocrinology and Metabolism, Huashan Hospital, Fudan University, Shanghai, China
| | - Shuo Zhang
- Department of Endocrinology and Metabolism, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaoxia Liu
- Department of Endocrinology and Metabolism, Huashan Hospital, Fudan University, Shanghai, China
| | - Xuefei Shou
- Department of Neurosurgery, Huashan Hospital Fudan University, No. 12 Wulumuqi Middle Road, Jing'an District, Shanghai, 200040, China.
| | - Bin Lu
- Department of Endocrinology and Metabolism, Huashan Hospital, Fudan University, Shanghai, China.
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Huang HY, Lin SJ, Zhao WG, Wu ZB. Cabergoline versus bromocriptine for the treatment of giant prolactinomas: A quantitative and systematic review. Metab Brain Dis 2018; 33:969-976. [PMID: 29546691 DOI: 10.1007/s11011-018-0217-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 03/09/2018] [Indexed: 10/17/2022]
Abstract
The aim of this study is to compare the efficacy of bromocriptine (BRC) versus cabergoline (CAB) in patients with giant prolactinomas. We searched MEDLINE, EMBASE, CENTRAL and Clinical Trials.gov for studies dated before March 1st, 2016, that used BRC or CAB for the treatment of patients with giant prolactinomas. Specific eligibility criteria were set to identify articles and cases. The selected articles were reviewed, and the data were extracted for analysis. The compared outcomes included tumor shrinkage, tumor response, normalization of prolactin (PRL) level, and visual field defect (VFD) improvement. Gender differences were also considered. Differences between the groups were assessed using Student's t test and the chi-square test. Two hundred and forty-five records were identified, and 10 articles and 104 cases met the inclusion criteria. Based on our analysis, CAB is significantly better than BRC in normalizing PRL levels in patients, especially males, with giant prolactinomas (69.4% versus 31.7%, p = 0.01). However, there was no significant difference between the two drugs in terms of tumor shrinkage, tumor response and VFD improvement (p > 0.05) in male or female patients. CAB exhibits significantly better efficacy than BRC in the normalization of PRL levels in male patients with giant prolactinomas. Regarding tumor reduction and VFD improvement, both drugs are comparably effective for patients of both genders. This quantitative and systematic review provides preliminary evidence in favor of CAB as a medical therapy for treating giant prolactinomas in male patients, especially those with extremely high PRL levels.
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Affiliation(s)
- Hai Yan Huang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197# Ruijin Er Road, Shanghai, 200025, China
| | - Shao Jian Lin
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197# Ruijin Er Road, Shanghai, 200025, China
| | - Wei Guo Zhao
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197# Ruijin Er Road, Shanghai, 200025, China
| | - Zhe Bao Wu
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197# Ruijin Er Road, Shanghai, 200025, China.
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Triantafilo N, Castro-Gutiérrez V, Rada G. Cabergoline or bromocriptine for prolactinoma? Medwave 2016; 16:e6545. [PMID: 27689434 DOI: 10.5867/medwave.2016.6545] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Cabergoline and bromocriptine are among the most commonly used drugs to treat prolactinoma. Cabergoline is a long-acting dopamine receptor agonist which might offer advantages over bromocriptine. However, it is not clear if this translates into clinical benefits. Searching in Epistemonikos database, which is maintained by screening 30 databases, we identified two systematic reviews including 12 studies addressing the question of this article, including five randomized controlled trials. We combined the evidence using meta-analysis and generated a summary of findings following the GRADE approach. We concluded cabergoline is more effective than bromocriptine in resolution of amenorrhea/oligomenorrhea and galactorrhea, it probably increases pregnancy rate, and it is associated to less adverse effects. It is not clear whether cabergoline is also more effective with respect to tumor growth because the certainty of the evidence is very low.
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Affiliation(s)
- Nicolás Triantafilo
- Departamento de Medicina Interna, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Proyecto Epistemonikos, Santiago, Chile. Address: Facultad de Medicina, Pontificia Universidad Católica de Chile, Lira 63, Santiago Centro, Chile.
| | - Victoria Castro-Gutiérrez
- Proyecto Epistemonikos, Santiago, Chile; Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Gabriel Rada
- Departamento de Medicina Interna, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Proyecto Epistemonikos, Santiago, Chile; Programa de Salud Basada en Evidencia, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; GRADE working group; The Cochrane Collaboration
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12
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Jethwa PR, Patel TD, Hajart AF, Eloy JA, Couldwell WT, Liu JK. Cost-Effectiveness Analysis of Microscopic and Endoscopic Transsphenoidal Surgery Versus Medical Therapy in the Management of Microprolactinoma in the United States. World Neurosurg 2015; 87:65-76. [PMID: 26548828 DOI: 10.1016/j.wneu.2015.10.090] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 10/22/2015] [Accepted: 10/24/2015] [Indexed: 01/20/2023]
Abstract
BACKGROUND Although prolactinomas are treated effectively with dopamine agonists, some have proposed curative surgical resection for select cases of microprolactinomas to avoid life-long medical therapy. We performed a cost-effectiveness analysis comparing transsphenoidal surgery (either microsurgical or endoscopic) and medical therapy (either bromocriptine or cabergoline) with decision analysis modeling. METHODS A 2-armed decision tree was created with TreeAge Pro Suite 2012 to compare upfront transsphenoidal surgery versus medical therapy. The economic perspective was that of the health care third-party payer. On the basis of a literature review, we assigned plausible distributions for costs and utilities to each potential outcome, taking into account medical and surgical costs and complications. Base-case analysis, sensitivity analysis, and Monte Carlo simulations were performed to determine the cost-effectiveness of each strategy at 5-year and 10-year time horizons. RESULTS In the base-case scenario, microscopic transsphenoidal surgery was the most cost-effective option at 5 years from the time of diagnosis; however, by the 10-year time horizon, endoscopic transsphenoidal surgery became the most cost-effective option. At both time horizons, medical therapy (both bromocriptine and cabergoline) were found to be more costly and less effective than transsphenoidal surgery (i.e., the medical arm was dominated by the surgical arm in this model). Two-way sensitivity analysis demonstrated that endoscopic resection would be the most cost-effective strategy if the cure rate from endoscopic surgery was greater than 90% and the complication rate was less than 1%. Monte Carlo simulation was performed for endoscopic surgery versus microscopic surgery at both time horizons. This analysis produced an incremental cost-effectiveness ratio of $80,235 per quality-adjusted life years at 5 years and $40,737 per quality-adjusted life years at 10 years, implying that with increasing time intervals, endoscopic transsphenoidal surgery is the more cost-effective treatment strategy. CONCLUSIONS On the basis of the results of our model, transsphenoidal surgical resection of microprolactinomas, either microsurgical or endoscopic, appears to be more cost-effective than life-long medical therapy in young patients with life expectancy greater than 10 years. We caution that surgical resection for microprolactinomas be performed only in select cases by experienced pituitary surgeons at high-volume centers with high biochemical cure rates and low complication rates.
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Affiliation(s)
- Pinakin R Jethwa
- Department of Neurological Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA
| | - Tapan D Patel
- Department of Neurological Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA
| | - Aaron F Hajart
- Department of Neurological Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA; Department of Otolaryngology-Head and Neck Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA
| | - Jean Anderson Eloy
- Department of Neurological Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA; Department of Otolaryngology-Head and Neck Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA; Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Newark, New Jersey, USA
| | - William T Couldwell
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - James K Liu
- Department of Neurological Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA; Department of Otolaryngology-Head and Neck Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA; Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Newark, New Jersey, USA.
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Zang Q, Liu Y, He J, Yue X, Zhang R, Wang R, Abliz Z. A sensitive and rapid HPLC–MS/MS method for the quantitative determination of trace amount of bromocriptine in small clinical prolactinoma tissue. J Chromatogr B Analyt Technol Biomed Life Sci 2015; 989:91-7. [DOI: 10.1016/j.jchromb.2015.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 02/28/2015] [Accepted: 03/06/2015] [Indexed: 11/30/2022]
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Arduc A, Gokay F, Isik S, Ozuguz U, Akbaba G, Tutuncu Y, Berker D, Kucukler FK, Aydin Y, Guler S. Retrospective comparison of cabergoline and bromocriptine effects in hyperprolactinemia: a single center experience. J Endocrinol Invest 2015; 38:447-53. [PMID: 25421155 DOI: 10.1007/s40618-014-0212-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 11/12/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Patients with hyperprolactinemia who require medical therapy are typically treated with dopamine agonists (DAs). In most cases, DAs normalize prolactin levels, control symptoms, and substantially decrease tumor size. Here, we aimed to compare the efficacy of cabergoline (CAB) and bromocriptine (BRC) in patients with hyperprolactinemia at a single center. METHODS Retrospective analysis of the clinical records of 498 patients with hyperprolactinemia [mean age 33.3 ± 10.8 years (range 16-66), 450 women, and 48 men] who had received either CAB (n = 450) or BRC (n = 48) was performed. RESULTS The mean age, gender distribution, and treatment duration were similar between the CAB and BRC groups (33.2 ± 11 vs. 34.1 ± 9.6 years, male/female 44/406 vs. 4/44, 18.7 ± 12.1 vs. 17.8 ± 6.0 months, respectively; p > 0.05 for all). Mean dosage was 1.5 ± 1.6 mg/week for CAB and 3.8 ± 2.7 mg/day for BRC. Baseline prolactin levels, frequency of galactorrhea, amenorrhea, oligomenorrhea, erectile dysfunction, infertility, and visual impairment were similar between the two groups, whereas the baseline tumor volume was higher in the CAB group. The prolactin normalization rate (87.4 vs. 41.4 %, p = 0.029) and tumor volume shrinkage (79.8 ± 39.1 vs. 54.1 ± 55.3 %, p = 0.015) were significantly higher in the CAB-treated patients than in the BRC-treated patients, while the tumor cure rates were similar. Symptom relief was higher in the CAB group than in the BRC group. More side effects were recorded in patients who took BRC (29.1 vs. 5.3 %, p < 0.001). CONCLUSION Our data revealed that CAB was more effective than BRC in controlling symptoms associated with hormone excess, normalizing serum prolactin levels, and shrinking prolactinomas.
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Affiliation(s)
- A Arduc
- National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Diabetes, Endocrine and Obesity Branch, Bethesda, MD, USA.
- , 1778 Dawson Street, Vienna, VA, 22182, USA.
| | - F Gokay
- Ministry Of Health, Endocrinology and Metabolism Clinic, Kayseri Research and Training Hospital, Kayseri, Turkey
| | - S Isik
- Ministry Of Health, Endocrinology and Metabolism Clinic, Ankara Numune Research and Training Hospital, Ankara, Turkey
| | - U Ozuguz
- Department of Endocrinology and Metabolism, Faculty of Medicine, Afyon Kocatepe University, Ankara, Turkey
| | - G Akbaba
- Ministry Of Health, Endocrinology and Metabolism Clinic, Ankara Numune Research and Training Hospital, Ankara, Turkey
| | - Y Tutuncu
- Ministry Of Health, Endocrinology and Metabolism Clinic, Ankara Numune Research and Training Hospital, Ankara, Turkey
| | - D Berker
- Ministry Of Health, Endocrinology and Metabolism Clinic, Ankara Numune Research and Training Hospital, Ankara, Turkey
| | - F K Kucukler
- Department of Endocrinology and Metabolism, Faculty of Medicine, Hitit University, Corum, Turkey
| | - Y Aydin
- Department of Endocrinology and Metabolism, Duzce University Medical School, Duzce, Turkey
| | - S Guler
- Department of Endocrinology and Metabolism, Faculty of Medicine, Hitit University, Corum, Turkey
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Successful management of a giant pituitary lactosomatotroph adenoma only with cabergoline. Case Rep Endocrinol 2013; 2013:134241. [PMID: 23762662 PMCID: PMC3665222 DOI: 10.1155/2013/134241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 04/20/2013] [Indexed: 11/18/2022] Open
Abstract
Although advances in endocrinologic and neuroradiologic research allow easier recognition of pituitary adenomas, giant pituitary tumours are relatively rare. In the literature, the term “giant” is generally used when a pituitary tumour becomes larger than 4 cm in diameter. Cabergoline is a potent and long-acting inhibitor of prolactin secretion, which exhibits high specificity and affinity for dopamine D2 receptor. Herein, we report a 46-year-old woman with a giant lactosomatotroph pituitary adenoma, sized 6 × 5 × 5.5 cm, who is treated successfully only with cabergoline. The patient showed dramatic response to cabergoline treatment by means of clinical, biochemical and radiological imaging findings. Cabergoline seems to be safe and effective in the treatment of prolactin and growth hormone cosecreting pituitary adenomas as well as prolactinomas. However, surgical or more aggressive approach must be considered where indicated.
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Mayer J, Sato A, Kiupel M, DeCubellis J, Donnelly T. Extralabel use of cabergoline in the treatment of a pituitary adenoma in a rat. J Am Vet Med Assoc 2011; 239:656-60. [PMID: 21879967 DOI: 10.2460/javma.239.5.656] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
CASE DESCRIPTION A 0.65-kg (1.43-lb) 24-month-old sexually intact male albino pet rat was examined because of a 3-week history of hypodipsia, apparent blindness, and sudden change in behavior. CLINICAL FINDINGS The rat was able to move around its cage but appeared unaware of its surroundings, was visually unresponsive, and seemed unusually aggressive. The rat's hind limbs appeared mildly paretic, and it had sporadic difficulty placing its hind limbs on a flat surface. Given the rat's age, history, and physical examination findings, the primary differential diagnosis was a pituitary tumor. Magnetic resonance imaging (MRI) of the rat's brain was performed and revealed a large pituitary mass, which was indicative of a tumor. TREATMENT AND OUTCOME Cabergoline (0.6 mg/kg [0.27 mg/lb], PO, q 72 h) was administered. On follow-up MRI 2 months later, the pituitary mass had substantially decreased in size. For 6 months following the second MRI study, the rat continued to receive the same dosage of cabergoline and had no clinical signs of disease or unusual behavior. However, at 8.5 months after the start of the treatment, the rat was in poor condition and had clinical signs similar to those initially. A third MRI study was performed and revealed substantial regrowth of the mass. The rat was euthanized and a necropsy was performed; a histopathologic diagnosis of pituitary adenoma was made. CLINICAL RELEVANCE Pituitary adenomas have long been recognized as a common finding in geriatric rats (> 18 months old). Affected rats may respond favorably to oral administration of cabergoline.
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Affiliation(s)
- Jörg Mayer
- Department of Clinical Sciences, Foster Hospital for Small Animals, Cummings School of Veterinary Medicine, Tufts University, North Grafton, MA 01536, USA.
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dos Santos Nunes V, El Dib R, Boguszewski CL, Nogueira CR. Cabergoline versus bromocriptine in the treatment of hyperprolactinemia: a systematic review of randomized controlled trials and meta-analysis. Pituitary 2011; 14:259-65. [PMID: 21221817 DOI: 10.1007/s11102-010-0290-z] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Cabergoline and bromocriptine are the most used drugs in the treatment of hyperprolactinemia, they are able to normalize the prolactin levels, restore gonadal function and promote tumor reduction in the majority of patients. We undertake a systematic review and meta-analysis of randomized controlled trials to compare cabergoline versus bromocriptine in the treatment of patients with idiopathic hyperprolactinemia and prolactinomas. The data sources were: Embase, Pubmed, Lilacs and Cochrane Central. The outcome measures were: normalization of prolactin secretion, restoration of gonadal function, reduction of tumoral volume, quality of life and adverse drug effects. Were identified 418 references and after screening by title and abstract, we obtained complete copies of 34 articles potentially eligible for inclusion in the review. From this total, 19 were selected to be included, but fifteen of them were excluded due to the following reasons: one randomized study compared cabergoline versus placebo and other randomized study compared different doses of cabergoline; five references were cases series; four were only controlled studies; three were retrospectives series and; one was a cohort study. Therefore, four publications were included in the review and in the final analysis. The meta-analysis of normalization of serum prolactin levels and menstruation with return of ovulatory cycle showed a significant difference in favor of cabergoline group (RR 0.67 [CI 95% 0.57, 0.80]) e (RR 0.74 [CI 95% 0.67, 0.83]), respectively. The number of adverse effects was significantly higher in the bromocriptine number than in cabergoline group (RR 1.43 [CI 95% 1.03, 1.98]). The meta-analysis showed new evidence favoring the use of cabergoline in comparison with bromocriptine for the treatment of prolactinomas and idiopathic hyperprolactinemia.
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Affiliation(s)
- Vania dos Santos Nunes
- Department of Internal Medicine, Botucatu Medical School, Sao Paulo, State University/Unesp, Sao Paulo, Brazil.
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18
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Abstract
Prolactinomas, the most prevalent type of neuroendocrine disease, account for approximately 40% of all pituitary adenomas. The most important clinical problems associated with prolactinomas are hypogonadism, infertility and hyposexuality. In patients with macroprolactinomas, mass effects, including visual field defects, headaches and neurological disturbances, can also occur. The objectives of therapy are normalization of prolactin levels, to restore eugonadism, and reduction of tumor mass, both of which can be achieved in the majority of patients by treatment with dopamine agonists. Given their association with minimal morbidity, these drugs currently represent the mainstay of treatment for prolactinomas. Novel data indicate that these agents can be successfully withdrawn in a subset of patients after normalization of prolactin levels and tumor disappearance, which suggests the possibility that medical therapy may not be required throughout life. Nevertheless, multimodal therapy that involves surgery, radiotherapy or both may be necessary in some cases, such as patients who are resistant to the effects of dopamine agonists or for those with atypical prolactinomas. This Review reports on efficacy and safety of pharmacotherapy in patients with prolactinomas.
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Affiliation(s)
- Annamaria Colao
- Department of Molecular and Clinical Endocrinology and Oncology, University Federico II of Naples, Italy, Via Sergio Pansini 5, I-80131 Naples, Italy.
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Bronstein MD. Long-term control of macroprolactinomas. Expert Rev Endocrinol Metab 2008; 3:361-376. [PMID: 30754204 DOI: 10.1586/17446651.3.3.361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Hyperprolactinemia is the most prevalent hypothalamic-pituitary dysfunction, with prolactinomas being its main cause. Microprolactinomas (diameter < 10 mm) represent approximately 60% of the prolactin-secreting adenomas, and are far more common in women than in men, whereas macroadenomas have roughly the same prevalence in both genders. The treatment of patients harboring macroprolactinomas is highly gratifying, with more than 80% of them adequately controlled by dopamine-agonist (DA) drugs: cabergoline being the most efficacious to date. Emerging evidence points to remission of the disease after long-term DA therapy in a significant number of patients. The remaining cases, mainly those with enclosed tumors, may be treated successfully by pituitary surgery. Radiotherapy is reserved for cases with dopaminergic drug resistance not surgically cured. The development of new therapeutic approaches may turn the control of the subset of macroprolactinomas refractory to both DA and surgery into reality.
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Affiliation(s)
- Marcello D Bronstein
- a Professor of Endocrinology, Chief, Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clinicas, University of Sao Paulo Medical School, Av. Dr. Eneas de Carvalho Aguiar 155-Predio dos Ambulatorios-8o andar-bloco3. CEP: 05403-900, Sao Paulo, SP, Brazil.
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Remarkable effects of cabergoline in a patient with huge prolactinoma resistant to high-dose bromocriptine: case report. ACTA ACUST UNITED AC 2007; 69:85-8; discussion 88. [PMID: 17967478 DOI: 10.1016/j.surneu.2006.11.060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2006] [Accepted: 11/21/2006] [Indexed: 11/22/2022]
Abstract
BACKGROUND Cabergoline (CAB) has been proposed as the first-line treatment in the management of prolactin (PRL)-secreting tumors (prolactinoma [PRLoma]), including those resistant to standard dopamine agonist (DAA) therapy. The authors report remarkable effects of CAB in a case of huge PRLoma that had been resistant to a long-term, high-dose treatment with bromocriptine (BRC). CASE DESCRIPTION A 28-year-old man was originally presented with oculomotor paresis when he was 9 years old. After 2 partial resections, he was treated with a maximum 60-mg/d dose of BRC for 18 years. Nonetheless, the tumor grew up to more than 8 cm in diameter, serum PRL increased over 60000 ng/mL, and his visual acuity deteriorated. Cabergoline normalized serum PRL level, shrank the tumor mass remarkably, and caused marked improvement of visual acuity. CONCLUSION Prolactin normalization and significant tumor shrinkage could be achieved with CAB even in extremely BRC-resistant PRLomas. Surgical resection should be reserved only for patients who are resistant to cabergoline or who require urgent decompression in such emergency as massive intratumoral hemorrhage.
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Abstract
Although the objective of the urologist is to correct the factors of male infertility and to favour natural procreation, the strategy must consider also the couple and the female aspects of infertility. Some types of male infertility require specific treatment. In severe cases, recent advances in medical assistance to procreation have changed the prognosis of male infertility. Pregnancy can be obtained by the means of gamet manipulation and spermatozoid selection. Nevertheless, such techniques expose to genetic disorders transmission. Subsequently, genetic assessment is required during male infertility management, especially for difficult cases.
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Affiliation(s)
- J Schlosser
- Service d'urologie et d'andrologie, Hôpital Robert Debré, Reims, France.
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22
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Olafsdottir A, Schlechte J. Management of resistant prolactinomas. ACTA ACUST UNITED AC 2006; 2:552-61. [PMID: 17024154 DOI: 10.1038/ncpendmet0290] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2006] [Accepted: 04/27/2006] [Indexed: 11/08/2022]
Abstract
Resistance to dopamine agonists occurs in a subset of patients with prolactin-secreting pituitary tumors. The resistance is mediated by loss of pituitary D2 receptors and occurs in both microadenomas and macroadenomas. Cabergoline is the most effective dopamine agonist and tumors that do not respond to bromocriptine or quinagolide frequently respond to cabergoline. Treatment options include maximizing the dose of the dopamine agonist, changing agonists, trans-sphenoidal surgery and radiation therapy. The goal of therapy is to restore and maintain gonadal and neurologic function, and this might occur in the absence of a normal prolactin level or a significant change in tumor size. Trans-sphenoidal pituitary surgery should be reserved for patients who are intolerant of medical therapy, or in whom this has failed. Radiation therapy has a limited role in treatment of resistant prolactinomas and should be reserved for patients in whom medical and surgical therapy has failed.
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Affiliation(s)
- Agusta Olafsdottir
- Division of Endocrinology and Metabolism, Department of Internal Medicine at the University of Iowa in Iowa City, IA 52242, USA
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Gomez R, Gonzalez-Izquierdo M, Zimmermann RC, Novella-Maestre E, Alonso-Muriel I, Sanchez-Criado J, Remohi J, Simon C, Pellicer A. Low-dose dopamine agonist administration blocks vascular endothelial growth factor (VEGF)-mediated vascular hyperpermeability without altering VEGF receptor 2-dependent luteal angiogenesis in a rat ovarian hyperstimulation model. Endocrinology 2006; 147:5400-11. [PMID: 16901966 DOI: 10.1210/en.2006-0657] [Citation(s) in RCA: 120] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
No specific treatment is available for ovarian hyperstimulation syndrome (OHSS), the most important complication in infertile women treated with gonadotropins. OHSS is caused by increased vascular permeability (VP) through ovarian hypersecretion of vascular endothelial growth factor (VEGF)-activating VEGF receptor 2 (VEGFR-2). We previously demonstrated in an OHSS rodent model that increased VP was prevented by inactivating VEGFR-2 with a receptor antagonist (SU5416). However, due to its toxicity (thromboembolism) and disruption of VEGFR-2-dependent angiogenic processes critical for pregnancy, this kind of compound cannot be used clinically to prevent OHSS. Dopamine receptor 2 (Dp-r2) agonists, used in the treatment of human hyperprolactinemia including pregnancy, inhibit VEGFR-2-dependent VP and angiogenesis when administered at high doses in animal cancer models. To test whether VEGFR-2-dependent VP and angiogenesis could be segregated in a dose-dependent fashion with the Dp-r2 agonist cabergoline, a well-established OHSS rat model supplemented with prolactin was used. A 100 microg/kg low-dose Dp-r2 agonist cabergoline reversed VEGFR-2-dependent VP without affecting luteal angiogenesis through partial inhibition of ovarian VEGFR-2 phosphorylation levels. No luteolytic effects (serum progesterone levels and luteal apoptosis unaffected) were observed. Cabergoline administration also did not affect VEGF/VEGFR-2 ovarian mRNA levels. Results in the animal model and the safe clinical profile of Dp-r2 agonists encouraged us to administer cabergoline to oocyte donors at high risk for developing the syndrome. Prophylactic administration of cabergoline (5-10 microg/kg x d) decreased the occurrence of OHSS from 65% (controls) to 25% (treatment). Therefore, a specific, safe treatment for OHSS is now available.
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Affiliation(s)
- Raul Gomez
- Department of Obstetrics and Gynecology, Columbia University, 630 West 168th Street, P&S Building 16-438, New York, New York 10032, USA.
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Biswas M, Smith J, Jadon D, McEwan P, Rees DA, Evans LM, Scanlon MF, Davies JS. Long-term remission following withdrawal of dopamine agonist therapy in subjects with microprolactinomas. Clin Endocrinol (Oxf) 2005; 63:26-31. [PMID: 15963057 DOI: 10.1111/j.1365-2265.2005.02293.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Reports suggest that up to 70% of patients with microprolactinomas treated with dopamine agonist therapy may achieve long-term normoprolactinaemic remission following drug withdrawal. Yet, there is no consensus on the duration of therapy nor is therapeutic interruption universally practised. We have assessed remission rates in a large cohort of treatment-naive subjects with microprolactinomas. Subjects received dopamine agonist (DA) therapy with either cabergoline or bromocriptine for a period of 2 to 3 years in the majority of cases, followed by a trial of treatment withdrawal. DESIGN Retrospective analysis of clinic records of 89 patients (mean age 32.7 +/- 8.4 years, 84 women and 5 men) who had received either cabergoline (n = 67) (0.5-3 mg weekly) or bromocriptine (n = 22) (2.5-10 mg daily) for a mean duration of 3.1 years. RESULTS Following withdrawal of therapy, 57 subjects developed recurrence (64%) and the mean time to recurrence was 9.6 months (range 1-44 months), while 32 subjects (36%) remained in remission beyond 1 year (mean 3.6 years, range 1-7 years). There was no difference in remission rates between subjects treated with cabergoline (n = 21) and bromocriptine (n = 11), but a direct relationship between pretreatment prolactin concentration and risk of recurrent symptomatic hyperprolactinaemia was observed. No subjects developed clinical features to suggest tumour expansion following therapeutic discontinuation. CONCLUSIONS This study confirms that abrupt withdrawal of chronic dopamine agonist therapy, following 2 to 3 years of treatment is safe and associated with long-term remission in 30-40% of subjects with microprolactinomas. This therapeutic strategy is convenient and applicable in clinical practice.
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Affiliation(s)
- M Biswas
- Department of Endocrinology, University Hospital of Wales, Heath Park, Cardiff, Wales, UK
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Abstract
Pharmacologic resistance to dopamine agonists is defined here as failure to normalize PRL levels and failure to decrease macroprolactinoma size by >or=50%. Failure to normalize PRL levels is found in about one-quarter of patients treated with bromocriptine and 10-15% of those treated with pergolide or cabergoline. Failure to achieve at least a 50% reduction in tumor size occurs in about one-third of those treated with bromocriptine and 10-15% of those treated with pergolide or cabergoline. The cause of dopamine resistance is primarily a decrease in D(2) receptors but the receptors have normal affinity for dopamine. Treatment approaches for patients resistant to dopamine agonists include changing to another dopamine agonist and increasing the dose of the drug as long as there is continued response to the dose increases and no adverse effects with higher doses. Transsphenoidal surgery is also an option. Clomiphene, gonadotropins, and GnRH can be used if fertility is desired. For those not desiring fertility, estrogen replacement may be used unless there is a macroadenoma, in which case control of tumor growth is also an issue and dopamine agonists are generally necessary. In many patients modest or even no reduction in tumor size may be acceptable as long as there is not tumor growth. Hormone replacement (estrogen or testosterone) may cause a decrease in efficacy of the dopamine agonist so that it must be carried out cautiously. Reduction of endogenous estrogen, use of selective estrogen receptor modulators, and aromatase inhibitors are potential experimental approaches.
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Affiliation(s)
- Mark E Molitch
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, 303 E. Chicago Avenue, Tarry 15-731, Chicago, IL 60611, USA.
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Abstract
Although endocrinopathies are not often seen in infertile men, these disorders are clinically significant; they often have potentially serious medical significance, regardless of fertility issues. Correction of these disorders represents a possible way to restore normal fertility for the male partner. Male fertility is critically dependent upon a normal hormonal milieu. The hypothalamic-pituitary-gonadal axis is quite sensitive to disruption by endocrine disorders and other generalized medical disorders. Thus, male infertility is occasionally the presenting sign for significant underlying medical disease; it is important to properly evaluate these patients.
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Affiliation(s)
- Jonathan P Jarow
- Department of Urology, Johns Hopkins University School of Medicine, 601 North Caroline Street, Baltimore, MD 21287-0850, USA.
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Abstract
Resistance to dopamine agonists can be defined with respect to failure to normalize PRL levels and failure to decrease tumor size by > or = 50%. Using these definitions, failure to normalize PRL levels is seen in 24% of those treated with bromocriptine, 13% of those treated with pergolide and 11% of those treated with cabergoline. Failure to achieve at least a 50% reduction in tumor size occurs in about one-third of those treated with bromocriptine and 10-15% of those treated with pergolide or cabergoline. Studies of in vitro cell preparations show that the D2 receptors of resistant tumors are decreased in number but have normal affinity. Treatment approaches for resistant patients include switching to another dopamine agonist and raising the dose of the drug as long as there is continued response to the dose increases and no adverse effects. Transsphenoidal surgery can also be done. If fertility is desired, clomiphene, gonadotropins, and GnRH are also options. If fertility is not desired, estrogen replacement may be used unless there is a macroadenoma, in which case control of tumor growth is also an issue and dopamine agonists are generally necessary. However, in many cases modest or even no reduction may be acceptable long-term as long as there is not tumor growth. Hormone replacement (estrogen or testosterone) may cause a decrease in efficacy of the dopamine agonist so that it must be carried out cautiously. Reduction of endogenous estrogen, use of selective estrogen receptor modulators, and aromatase inhibitors are potential experimental approaches.
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Affiliation(s)
- Mark E Molitch
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
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