Bromocriptine and psychosis: a literature review

Bi-directional and multi-modal effects of dexamphetamine on spatial binding windows in healthy individuals

OBJECTIVES

Stimuli that are separated by a short window of space or time, known as spatial and temporal binding windows (SBW/TBWs), may be perceived as separate. Widened TBWs are evidenced in schizophrenia, although it is unclear if the SBW is similarly affected. The current study aimed to assess if dexamphetamine (DEX) may increase SBWs in a multimodal visuo-tactile illusion, potentially validating usefulness as an experimental model for multimodal visuo-tactile hallucinations in schizophrenia, and to examine a possible association between altered binding windows (BWs) and working memory (WM) suggested by previous research.

METHODS

A placebo-controlled, double-blinded, and counter-balanced crossover design was employed. Permuted block randomisation was used for drug order. Healthy participants received DEX (0.45 mg/kg, PO, b.i.d.) or placebo (glucose powder) in capsules. The Rubber Hand Illusion (RHI) and Wechsler Adult Intelligence Scale Spatial Span was employed to determine whether DEX would alter SBWs and WM, respectively. Schizotypy was assessed with a variety of psychological scales.

RESULTS

Most participants did not experience the RHI even under normal circumstances. Bi-directional and multimodal effects of DEX on individual SBWs and schizotypy were observed, but not on WM.

CONCLUSIONS

Bidirectional multimodal effects of DEX on the RHI and SBWs were observed in individuals, although not associated with alterations in WM.

Treatment of Prolactinoma

Prolactinomas are the commonest form of pituitary neuroendocrine tumor (PitNET), representing approximately half of such tumors. Dopamine agonists (DAs) have traditionally been the primary treatment for the majority of prolactinomas, with surgery considered the second line. The aim of this review is to examine the historical and modern management of prolactinomas, including medical therapy with DAs, transsphenoidal surgery, and multimodality therapy for the treatment of aggressive prolactinomas and metastatic PitNETs, with an emphasis on the efficacy, safety, and future directions of current therapeutic modalities. DAs have been the mainstay of prolactinoma management since the 1970s, initially with bromocriptine and more recently with cabergoline. Cabergoline normalizes prolactin in up to 85% of patients and causes tumor shrinkage in up to 80%. Primary surgical resection of microprolactinomas and enclosed macroprolactinomas performed by experienced pituitary neurosurgeons have similar remission rates to cabergoline. Aggressive prolactinomas and metastatic PitNETS should receive multimodality therapy including high dose cabergoline, surgery, radiation therapy (preferably using stereotactic radiosurgery where suitable), and temozolomide. DAs remain a reliable mode of therapy for most prolactinomas but results from transsphenoidal surgery in expert hands have improved considerably over the last one to two decades. Surgery should be strongly considered as primary therapy, particularly in the setting of microprolactinomas, non-invasive macroprolactinomas, or prior to attempting pregnancy, and has an important role in the management of DA resistant and aggressive prolactinomas.

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.

Liposomes: Novel Drug Delivery Approach for Targeting Parkinson's Disease

Parkinson's disease is one of the most severe progressive neurodegenerative disorders, having a mortifying effect on the health of millions of people around the globe. The neural cells producing dopamine in the substantia nigra of the brain die out. This leads to symptoms like hypokinesia, rigidity, bradykinesia, and rest tremor. Parkinsonism cannot be cured, but the symptoms can be reduced with the intervention of medicinal drugs, surgical treatments, and physical therapies. Delivering drugs to the brain for treating Parkinson's disease is very challenging. The blood-brain barrier acts as a highly selective semi-permeable barrier, which refrains the drug from reaching the brain. Conventional drug delivery systems used for Parkinson's disease do not readily cross the blood barrier and further lead to several side-effects. Recent advancements in drug delivery technologies have facilitated drug delivery to the brain without flooding the bloodstream and by directly targeting the neurons. In the era of Nanotherapeutics, liposomes are an efficient drug delivery option for brain targeting. Liposomes facilitate the passage of drugs across the blood-brain barrier, enhances the efficacy of the drugs, and minimize the side effects related to it. The review aims at providing a broad updated view of the liposomes, which can be used for targeting Parkinson's disease.

The epidemiology, diagnosis and treatment of Prolactinomas: The old and the new

Prevalence and incidence of prolactinomas are approximately 50 per 100,000 and 3-5 new cases/100,000/year. The pathophysiological mechanism of hyperprolactinemia-induced gonadotropic failure involves kisspeptin neurons. Prolactinomas in males are larger, more invasive and less sensitive to dopamine agonists (DAs). Macroprolactin, responsible for pseudohyperprolactinemia is a frequent pitfall of prolactin assay. DAs still represent the primary therapy for most prolactinomas, but neurosurgery has regained interest, due to progress in surgical techniques and a high success rate in microprolactinoma, as well as to some underestimated side effects of long-term DA treatment, such as impulse control disorders or impaired quality of life. Recent data show that the suspected effects of DAs on cardiac valves in patients with prolactinomas are reassuring. Finally, temozolomide has emerged as a valuable treatment for rare cases of aggressive and malignant prolactinomas that do not respond to all other conventional treatments.

Cabergoline in acromegaly

Acromegaly, a rare disease due to growth hormone (GH) hypersecretion by a pituitary adenoma, is associated with severe comorbidity and premature death if not adequately treated. The usual first-line treatment is surgery. Various drugs, including somatostatin receptor ligands, dopamine agonists and GH receptor antagonists, are now available for use if surgery fails to suppress GH/IGF-I hypersecretion. Cabergoline, now the preferred dopamine agonist for treating hyperprolactinemia, is also used off-label for treating acromegaly. Cabergoline monotherapy is reported to normalize IGF-I levels in more than one-third of patients with acromegaly. When a somatostatin receptor ligand proves ineffective, cabergoline add-on therapy normalizes the IGF-I level in 40-50% of patients. Finally, when combined with the GH receptor antagonist pegvisomant in patients with mild uncontrolled disease, cabergoline helps to achieve normal IGF-I levels while avoiding the need for high-dose pegvisomant. Cabergoline is also inexpensive and well tolerated; in particular, it does not appear to promote heart valve disease.

Cabergoline-induced manic episode: case report

Cabergoline is an orally administered synthetic dopamine agonist that is used for the treatment of hyperprolactinemia, Parkinson's disease and antipsychotic-induced prolactin elevation. One of the main characteristics of cabergoline is its long duration of effect. It is highly effective in suppressing prolactin levels up to 21 days after a single 1 mg oral dose. The prolonged elimination half-life offers an advantage of once-daily dosing, but it might be a handicap in terms of washout of adverse effects such as psychosis. Cabergoline has been associated with adverse reactions consistent with other dopaminergic agonists including cardiovascular, gastrointestinal and neuropsychiatric effects. It is known that dopaminergic treatment is a remarkable risk factor for psychosis. A number of reports implicate dopamine agonists in the development of psychosis, but there is no knowledge in the literature of dopamine agonist-induced mania. In this case, we report the first manic episode occurring after cabergoline use for hyperprolactinemia treatment. In susceptible individuals, cabergoline can cause manic episodes and cabergoline should be used more carefully considering the risk-benefit ratio.

Effect of bromocriptine alginate nanocomposite (BANC) on a transgenic Drosophila model of Parkinson's disease

The effect of bromocriptine, a dopamine agonist, administered in the form of bromocriptine alginate nanocomposite (BANC) was studied on Parkinson's disease (PD) model flies. The synthesized BANC was subject to characterization and, at a final concentration of 0.5, 1.0 and 1.5 µM, was mixed in diet. The PD flies were allowed to feed on it for 24 days. A significant dose-dependent delay in the loss of climbing activity and activity pattern was observed in PD flies exposed to 0.5, 1.0 and 1.5 µM BANC. The PD flies exposed to BANC also showed a significant reduction in lipid peroxidation and glutathione-S-transferase activity, and an increase in glutathione content. However, no gross morphological changes were observed in the brains of PD flies compared with controls. The results suggest that BANC is effective in reducing the PD symptoms in these transgenic flies.

Summary: The results suggest that the bromocriptine alginate nanocomposite is potent in reducing the symptoms of Parkinson's disease in a transgenic fly model of the disease.

Transient psychosis in women on clomiphene, bromocriptine, domperidone and related endocrine drugs

BACKGROUND

There have been reports of transient psychosis in women medicated for gynecologic conditions.

OBJECTIVE

The aim of this paper was to explore this literature.

METHOD

The PubMed and Google Scholar databases were searched for relevant case reports Results: The following reports were found: psychosis induced by gonadotropin-releasing hormone in the treatment of endometriosis, by clomiphene treatment for infertility, by bromocriptine treatment for milk suppression and by the withdrawal of domperidone prescribed as a galactologue as well as by the withdrawal of estrogen replacement therapy.

CONCLUSION

In susceptible women, psychotic symptoms can result from treatments that reduce estrogen levels, such as leuprolide acetate or clomiphene, or treatments that increase dopamine levels (bromocriptine). Psychosis can also be caused indirectly when estrogen treatment is discontinued or dopamine antagonism (e.g. domperidone) withdrawn. Estrogen-reducing and dopamine-increasing treatments used in gynecology need to be carefully monitored.

Ergotism in Norway. Part 2: The symptoms and their interpretation from the eighteenth century onwards

Ergotism, the disease caused by consuming Claviceps purpurea, a highly poisonous, grain-infecting fungus, occurred at various places scattered throughout Norway during the eighteenth and nineteenth centuries. By focusing on these cases we chart the changing interpretations of the peculiar disease, frequently understood within a religious context or considered as a supernatural (e.g. ghostly) experience. However, there was a growing awareness of the disease ergotism, and from the late eighteenth century onwards it was often correctly interpreted as being due to a fungus consumed via bread or porridge. Also, nineteenth-century fairy-tales and regional legends reveal that people were increasingly aware and fearful of the effects of consuming infected grain.

Endocrinological outcomes of pure endoscopic transsphenoidal surgery: a Croatian Referral Pituitary Center experience

AIM

To analyze early remission, complications, and pituitary function recovery after pure endoscopic endonasal transsphenoidal surgery (PEETS), a novel method in pituitary adenoma treatment.

METHODS

Testing of all basal hormone values and magnetic resonance imaging (MRI) were performed preoperatively and postoperatively (postoperative MRI only in nonfunctioning adenomas) in 117 consecutive patients who underwent PEETS in the period between 2007 and 2010. The series consisted of 21 somatotroph adenomas, 61 prolactinomas, and 4 corticotroph and 31 nonfunctioning adenomas. Sixty-three were macroadenomas and 54 were microadenomas. Remission was defined as hormonal excess normalization on the seventh postoperative day in functioning adenomas and as normal MRI findings approximately four months postoperatively in nonfunctioning adenomas. The presence of hypogonadism, growth hormone deficiency, and hypothyroidism was assessed on the seventh postoperative day. Hypocortisolism was assessed through necessity for replacement therapy within 18 months postoperatively.

RESULTS

Remission was achieved in 84% of patients: in 100% of microadenoma and 70% of macroadenoma patients (P<0.001, odds ratio [OR], 28.16, 95% confidence interval [CI], 1.61-491.36), respectively. Endocrinological complications occurred in 17.1% of patients: in 9% of microadenoma and 24% of macroadenoma patients (P=0.049, OR, 3.06; 95% CI, 1.03-9.08). Duration of empirical hydrocortisone replacement therapy was significantly shorter in microadenoma patients (P<0.001). Thirty-five percent of preoperatively present hormonal deficiencies improved after the surgery. Between tumor types there were no significant differences in remission, complications, and normal pituitary function recovery.

CONCLUSION

Patients with microadenomas had higher remission and lower complication rates following PEETS, emphasizing the necessity for early detection and treatment of pituitary adenomas. PEETS is a discussion-worthy method for microprolactinoma treatment.

Psychiatric side effects of medications prescribed in internal medicine

Several pharmacological treatments used in internal medicine can induce psychiatric side effects (PSEs) that mimic diagnoses seen in psychiatry. PSEs may occur upon withdrawal or intoxication, and also at usual therapeutic doses. Drugs that may lead to depressive, anxious, or psychotic syndromes include corticosteroids, isotretinoin, levo-dopar mefloquine, interferon-a, and anabolic steroids, as well as some over-the-counter medications. PSEs are often difficult to diagnose and can be very harmful to patients. PSEs are discussed in this review, as well as diagnostic clues to facilitate their identification.

Aripiprazole use combined with depot antipsychotic medication: two cases demonstrating its ability to reduce prolactin levels in an adolescent forensic hospital

Many patients maintained on depot medication have raised prolactin levels, which can lead to a range of long-term medical problems. The addition of aripiprazole can reduce prolactin levels and restore sexual function in these patients. The cases described demonstrate the potential role of aripiprazole in a forensic setting.

Working memory span capacity improved by a D2 but not D1 receptor family agonist

Patients with schizophrenia exhibit poor working memory (WM). Although several subcomponents of WM can be measured, evidence suggests the primary subcomponent affected in schizophrenia is span capacity (WMC). Indeed, the NIMH-funded MATRICS initiative recommended assaying the WMC when assessing the efficacy of a putative therapeutic for FDA approval. Although dopamine D1 receptor agonists improve delay-dependent memory in animals, evidence for improvements in WMC due to dopamine D1 receptor activation is limited. In contrast, the dopamine D2-family agonist bromocriptine improves WMC in humans. The radial arm maze (RAM) can be used to assess WMC, although complications due to ceiling effects or strategy confounds have limited its use. We describe a 12-arm RAM protocol designed to assess whether the dopamine D1-family agonist SKF 38393 (0, 1, 3, and 10 mg/kg) or bromocriptine (0, 1, 3, and 10 mg/kg) could improve WMC in C57BL/6N mice (n=12) in cross-over designs. WMC increased and strategy usage decreased with training. The dopamine D1 agonist SKF 38393 had no effect on WMC or long-term memory. Bromocriptine decreased WMC errors, without affecting long-term memory, consistent with human studies. These data confirm that WMC can be measured in mice and reveal drug effects that are consistent with reported effects in humans. Future research is warranted to identify the subtype of the D2-family of receptors responsible for the observed improvement in WMC. Finally, this RAM procedure may prove useful in developing animal models of deficient WMC to further assess putative treatments for the cognitive deficits in schizophrenia.

Treatment complexities of a young woman suffering psychosis and pituitary adenoma

This paper is a clinical description of the presentation, therapy, and pharmacological management of a 28-year-old woman who had nine admissions to a psychiatry ward, the last four within one year. It became clear that the treatments, which the patient had received concurrently for ten years for a pituitary adenoma and for psychotic symptoms, were counteractive. The case highlights the importance of the role of prolactin in psychosis and of an interdisciplinary team approach when patients present with complex symptoms.

The role of dopamine in symptoms and treatment of apathy in Alzheimer's disease

BACKGROUND

Alzheimer's disease (AD) is characterized by a number of serious and debilitating behavioral and psychological symptoms of dementia (BPSD). The most common of these BPSD is apathy, which represents a major source of morbidity and premature institutionalization in the AD population. Many studies have identified discrete changes to the dopaminergic (DAergic) system in patients with AD. The DAergic system is closely related to the brain reward system (BRS) and some studies have suggested that dysfunction in the DAergic system may account for symptoms of apathy in the AD population.

METHOD

Changes to the dopamine (DA) system in AD will be reviewed, and evidence supporting the involvement of the DAergic system in the development of apathy will be examined. Additionally, some pharmacological interventions with DA activity have been identified. The utility of these treatments in the AD population will be reviewed, with a focus on apathy as an outcome.

RESULTS

Evidence presented in this review suggests that DA dysfunction in discrete brain areas is an important correlate of apathy in AD and that the DAergic system may be a rational target for pharmacological treatment of apathy.

Dopamine Agonists and their risk to induce psychotic episodes in Parkinson's disease: a case-control study

BACKGROUND

Psychosis is rare in untreated patients with Parkinson's disease (PD) but the prevalence rises to 40% during dopaminergic treatment. So far, no systematic comparison of the psychogenic potential of different dopaminergic drugs had been performed.

METHODS

Eighty PD patients with psychotic episodes were compared to an age-matched control group of PD patients without psychotic episodes (n = 120) in a cross-sectional retrospective study.

RESULTS

We found a positive correlation between psychotic episodes and dementia, number of concomitant medication, and pergolide intake. Odds ratio calculation confirmed the association with dementia. With respect to dopaminergic treatment, pergolide showed the highest odds ratio, levodopa the lowest. An adjusted logistic regression model confirmed the strong association with psychotic episodes and pergolide and no association with levodopa (adjusted odds ratio 2.01 and 0.11, respectively).

CONCLUSION

The analysis indicates that dementia and concomitant medication are factors in PD associated with psychotic symptoms. Furthermore, different dopaminergic drugs showed markedly different associations with psychotic symptoms.

Medical causes and consequences of hyperprolactinaemia. A context for psychiatrists

Hyperprolactinaemia is the commonest endocrine disorder of the hypothalamic-pituitary axis and can lead to both short-term sexual dysfunction and galactorrhoea, and long-term loss of bone mineral density. Prolactin is secreted from the anterior pituitary gland under the influence of dopamine, which exerts a tonic inhibitory effect on prolactin secretion. Physiological regulators of prolactin secretion include many different types of 'stress' and sleep. Disruption of the normal control of prolactin secretion results in hyperprolactinaemia from pathological and pharmacological causes. The administration of antipsychotic medication is responsible for the high prevalence of hyperprolactinaemia in people with severe mental illness. Physiological hyperprolactinaemia, such as pregnancy and lactation, should be distinguished from pathological causes to prevent unnecessary investigation and treatment. The causes, consequences and management of hyperprolactinaemia are discussed in this article.

Operative treatment of prolactinomas: indications and results in a current consecutive series of 212 patients

OBJECTIVE

Medical therapy with dopamine agonists (DA) is the primary treatment of choice in most patients with prolactinomas. 'Classical' surgical indications are intolerance or lack of efficiency of DA therapy. Focusing on a possible shift of recent indications, we retrospectively analyzed our results of surgical treatment in prolactinomas.

PATIENTS AND METHODS

Between 1990 and 2005, we have operated on 212 consecutive patients with prolactinomas. Surgical indications were divided into 'classical' indications and 'modern' indications defined as cystic prolactinomas or patients with microprolactinomas who individually decided on a primary surgical treatment.

RESULTS

Initial overall remission was accomplished in 53.2% including giant prolactinomas. However, in microadenomas, the remission rate was significantly higher with 91.3%. Overall remission at the latest follow-up was 42.7%, but 72.5% in intrasellar tumors, 80% in cystic prolactinomas, and 84.8% in microprolactinomas. The overall recurrence rate was 18.7%. Relapse of hyperprolactinemia in microprolactinomas was 7.1%. In our series, continually less patients were surgically treated for 'classical' indications. By contrast, the number of patients who individually decided on a primary surgical therapy has increased considerably.

CONCLUSION

Remission rates after surgical treatment of prolactinomas remain excellent, particularly in microadenoma and intrasellar macroadenomas, whereas morbidity of transsphenoidal surgery is low in the hands of experienced pituitary surgeons. Our remission rates not only confirm the already interdisciplinarily accepted surgical indications, but also emphasize the value of primary transsphenoidal surgery as a discussion-worthy alternative to dopaminergic therapy in young patients with microprolactinomas or cystic tumors.

Épisode maniaque induit par la Bromocriptine en post-partum

The postpartum period is a high-risk period for occurrence of mood disorders (depression, mania) particularly for women with a history of bipolar disorder. We report the case of a woman with a postpartum mania episode with psychotic features induced by bromocriptine. This case report highlights the need to systematically explore the personal history of pregnant women in search of mood disorder which may proscribe use of bromocriptine.

Periodic limb movements and other movement disorders in sleep: neuropsychiatric dimensions

Movement disorders such as Parkinson's disease and Tourette's syndrome, primarily manifest during wakefulness, intrude into sleep. There are some disorders, however, such as periodic limb movements in sleep, restless legs syndrome, paroxysmal nocturnal dystonia, bruxism, and somnambulism, which occur primarily during sleep. The diagnosis and management of these disorders pose a challenge to neuropsychiatric practice, not only because they may be difficult to distinguish from other neuropsychiatric disorders, but also because psychiatric disorders are often co-morbid with them. Study of these disorders is necessary for an understanding of the interaction of sleep and movement, and how disturbance in one may affect the other.

Understanding the new and evolving profile of adverse drug effects in schizophrenia

This article has reviewed the emerging side-effect profiles of second-generation antipsychotic medications. Although these medications have favorable extrapyramidal side-effect profiles, clinicians must be aware of their propensity to cause weight gain, glucose and lipid abnormalities, and cardiac and sexual side effects. If clinicians are proactive about warning patients about these side effects and appropriately monitoring them, further morbidity and mortality may be prevented in this patient population. Initial choices of medication should be made based on the relative side-effect profiles in light of a particular patient's medical status. In the future, new treatments may be developed, with even fewer side effects.

Risperidone-associated hyperprolactinemia

OBJECTIVE

To compare the prolactogenic effects of risperidone, clozapine, and typical antipsychotic agents in an outpatient community-based psychiatric population.

METHODS

Prolactin and thyroid-stimulating hormone (TSH) concentrations were measured in 68 outpatients with schizophrenia who were receiving antipsychotic medications and were recruited from a community mental health clinic.

RESULTS

The percentage of women with increased prolactin concentrations was significantly greater in the risperidone group (100%, 12 of 12 patients) than in the clozapine group (25%, 1 of 4) (P = 0.0071) but not in comparison with the typical antipsychotic agent group (83%, 5 of 6) (P = 0.333). The percentage of men with increased prolactin concentrations was significantly greater in the risperidone group (94%, 17 of 18) than in the clozapine group (18%, 3 of 17) (P<0.0001) and in comparison with the typical antipsychotic agent group (27%, 3 of 11) (P = 0.0003). The mean prolactin concentration (all ng/mL +/- standard deviation) was also significantly higher in patients taking risperidone (women, 125.0 +/- 56.6; men, 37.3 +/- 23.9) than clozapine (women, 22.0 +/- 25.9; men, 13.3 +/- 22.4) (female patients, P = 0.0004; male patients, P<0.0001) or typical antipsychotic agents (women, 69.0 +/- 59.8; men, 13. 3 +/- 9.1) (female patients, P = 0.036; male patients, P = 0.0003). In the risperidone group, gender affected prolactin level, with women having higher concentrations than men, but the duration of therapy did not. In this group, prolactin was inversely dependent on age. No difference was noted in TSH concentrations between medication groups.

CONCLUSION

Risperidone is a potent inducer of hyperprolactinemia in outpatients with schizophrenia in a community population. The higher and more frequently increased prolactin concentrations caused by risperidone could adversely affect patient health and compliance.