1
|
Zeng Y, Zhang D, Fu N, Zhao W, Huang Q, Cui J, Chen Y, Liu Z, Zhang X, Zhang S, Mansoor KM. Risk Factors for Granulomatous Mastitis and Establishment and Validation of a Clinical Prediction Model (Nomogram). Risk Manag Healthc Policy 2023; 16:2209-2222. [PMID: 37881167 PMCID: PMC10596285 DOI: 10.2147/rmhp.s431228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/13/2023] [Indexed: 10/27/2023] Open
Abstract
Background This study aimed to explore the risk factors and clinical characteristics of granulomatous mastitis (GM) using a case-control study and establish and validate a clinical prediction model (nomogram). Methods This retrospective case-control study was conducted in three hospitals in China from June 2017 to December 2021. A total of 1634 GM patients and 186 healthy women during the same period were included and randomly divided into the modeling and validation groups in a 7:3 ratio. To identify the independent risk factors of GM, univariate and multivariate logistic analyses were conducted and used to develop a nomogram. The prediction model was internally and externally validated using the Bootstrap technique and validation cohort. The receiver operating characteristic (ROC) curve and calibration curve were used to evaluate the discrimination and calibration of the prediction model. Decision curve analysis (DCA) and clinical impact curve (CIC) were used to evaluate the clinical significance of the model. Results The average age of GM patients was 33.14 years (mainly 20-40). The incidence was high within five years from delivery and mainly occurred in the unilateral breast. The majority of the patients exhibited local skin alterations, while some also presented with systemic symptoms. On multivariate logistic analysis, age, high prolactin level, sex hormone intake, breast trauma, nipple discharge or invagination, and depression were independent risk factors for GM. The mean area under the curve (AUC) in the modeling and validation groups were 0.899 and 0.889. The internal and external validation demonstrated the model's predictive ability and clinical value. Conclusion Lactation-related factors are the main risk factors of GM, leading to milk stasis or increased ductal secretion. Meanwhile, hormone disorders could affect the secretion and expansion of mammary ducts. All these factors can obstruct or injure the duct, inducing inflammatory reactions and immune responses. Additionally, blunt trauma, depressed mood, and diet preference can accelerate the process. The nomogram can effectively predict the risk of GM.
Collapse
Affiliation(s)
- Yifei Zeng
- Department of Galactophore, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, People’s Republic of China
- Beijing University of Chinese Medicine, Beijing, People’s Republic of China
| | - Dongxiao Zhang
- Department of Galactophore, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, People’s Republic of China
| | - Na Fu
- Department of Galactophore, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, People’s Republic of China
| | - Wenjie Zhao
- Department of Galactophore, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, People’s Republic of China
| | - Qiao Huang
- Department of Galactophore, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, People’s Republic of China
| | - Jianchun Cui
- Liaoning Provincial People’s Hospital (Department of Thyroid and Breast Surgery, People’s Hospital of China Medical University), Shenyang, People’s Republic of China
| | - Yunru Chen
- Centre for Evidence-Based Chinese Medicine, School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, People’s Republic of China
| | - Zhaolan Liu
- Centre for Evidence-Based Chinese Medicine, School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, People’s Republic of China
| | - Xiaojun Zhang
- Xiyuan Hospital of China Academy of Chinese Medical Sciences, Beijing, People’s Republic of China
| | - Shiyun Zhang
- Guang’ Anmen Hospital, China Academy of Chinese Medical Science, Beijing, People’s Republic of China
| | - Khattak Mazher Mansoor
- Liaoning Provincial People’s Hospital (Department of Thyroid and Breast Surgery, People’s Hospital of China Medical University), Shenyang, People’s Republic of China
| |
Collapse
|
2
|
Zeng Y, Zhang D, Zhao W, Fu N, Huang Q, Li S, Gao C, Yu J. Predisposing Factors for Granulomatous Lobular Mastitis: A Case-Control Study. Int J Womens Health 2023; 15:1063-1075. [PMID: 37795195 PMCID: PMC10547110 DOI: 10.2147/ijwh.s414054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 07/11/2023] [Indexed: 10/06/2023] Open
Abstract
Background Despite the rising incidence rate of granulomatous lobular mastitis (GLM), uncertainties persist about its etiologic and predisposing factors to guide clinical treatment and early prevention. The objective of this study is to explore the predisposing factors for GLM. Patients and methods This case-control study was conducted from 2018 to 2021 at Beijing Hospital of Traditional Chinese Medicine, Capital Medical University. Patients with GLM (cases) were matched with healthy examinees (controls) in a 1:1 ratio according to gender and living area. We analyzed their demographic features and investigated 75 factors that may be relevant to GLM using a standard questionnaire. Univariate and multivariable binary conditional logistic regression analyses were used to compare the differences between the two groups and evaluate the predisposing factors that may induce GLM. Results There were 594 female GLM patients and 594 matched controls included in the study. The average age of the cases was 32.78 years (mainly 20 to 40). The incidence was high within five years after childbirth, and lesions were mainly in the unilateral breast. Univariate and multivariable conditional logistic regression analyses obtained six relevant factors and six high-risk factors. The six relevant factors included age, marriage, emotional abnormality, high prolactin, psychiatric drug intake, and sex hormone intake. Additionally, the independent high-risk factors for GLM included gestation, nipple invagination, blunt trauma, non-iatrogenic massage, lactation disorder, and nipple discharge (odds ratio (OR)=17.378, 8.518, 4.887, 3.116, 2.522, 1.685, P<0.05). Menopause was an independent protective factor (OR=0.249, P<0.05). Conclusion The factors that increase milk and secretion production in the mammary duct are the main risk factors of GLM, especially when the nipples are invaginated. These factors can obstruct the duct and induce inflammation. Additionally, hormonal disorders, extrinsic trauma, and emotional abnormalities can accelerate the occurrence of GLM.
Collapse
Affiliation(s)
- Yifei Zeng
- Department of Galactophore, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, People’s Republic of China
- Graduate School, Beijing University of Chinese Medicine, Beijing, People’s Republic of China
| | - Dongxiao Zhang
- Department of Galactophore, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, People’s Republic of China
| | - Wenjie Zhao
- Department of Galactophore, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, People’s Republic of China
| | - Na Fu
- Department of Galactophore, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, People’s Republic of China
| | - Qiao Huang
- Department of Galactophore, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, People’s Republic of China
| | - Shuqi Li
- Graduate School, Beijing University of Chinese Medicine, Beijing, People’s Republic of China
| | - Chang Gao
- Graduate School, Beijing University of Chinese Medicine, Beijing, People’s Republic of China
| | - Jiale Yu
- Graduate School, Beijing University of Chinese Medicine, Beijing, People’s Republic of China
| |
Collapse
|
3
|
Abstract
While the prevalence of hyperprolactinemia under antidepressants is very low, its prevalence under antipsychotics, particularly of the first generation, is high. Antipsychotics act by blocking dopamine activity at the level of the dopamine type 2 receptor (D2R). When prolactin levels exceed 80-100 ng/ml, a pituitary adenoma must be ruled out by MRI. Treatment of hyperprolactinemia is necessary only in cases with clinical symptoms of hypogonadism. Three treatment options are possible: switch to a less hyperprolactinemic antipsychotic, sex steroid supplementation or dopamine agonist (which normalizes prolactin levels in only half of cases). Fortunately, psychotic exacerbation due to the opposing effects of antipsychotics and dopamine agonists on the D2R seems very rare. When a patient presents with a macroprolactinoma, particularly with optic chiasm compression, surgery or dopamine agonists may be proposed. The agonists are effective in reducing tumor mass and improving visual defects in the majority of patients but rarely normalize prolactin levels.
Collapse
Affiliation(s)
- Philippe Chanson
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, 94275 Le Kremlin-Bicêtre, France.
| |
Collapse
|
4
|
Cozzi R, Ambrosio MR, Attanasio R, Battista C, Bozzao A, Caputo M, Ciccarelli E, De Marinis L, De Menis E, Faustini Fustini M, Grimaldi F, Lania A, Lasio G, Logoluso F, Losa M, Maffei P, Milani D, Poggi M, Zini M, Katznelson L, Luger A, Poiana C. Italian Association of Clinical Endocrinologists (AME) and International Chapter of Clinical Endocrinology (ICCE). Position statement for clinical practice: prolactin-secreting tumors. Eur J Endocrinol 2022; 186:P1-P33. [PMID: 35000899 PMCID: PMC8859924 DOI: 10.1530/eje-21-0977] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 01/06/2022] [Indexed: 12/03/2022]
Abstract
Prolactinomas are the most frequent pituitary adenomas. Prolactinoma may occur in different clinical settings and always require an individually tailored approach. This is the reason why a panel of Italian neuroendocrine experts was charged with the task to provide indications for the diagnostic and therapeutic approaches that can be easily applied in different contexts. The document provides 15 recommendations for diagnosis and 54 recommendations for treatment, issued according to the GRADE system. The level of agreement among panel members was formally evaluated by RAND-UCLA methodology. In the last century, prolactinomas represented the paradigm of pituitary tumors for which the development of highly effective drugs obtained the best results, allowing to avoid neurosurgery in most cases. The impressive improvement of neurosurgical endoscopic techniques allows a far better definition of the tumoral tissue during surgery and the remission of endocrine symptoms in many patients with pituitary tumors. Consequently, this refinement of neurosurgery is changing the therapeutic strategy in prolactinomas, allowing the definitive cure of some patients with permanent discontinuation of medical therapy.
Collapse
Affiliation(s)
- Renato Cozzi
- Division of Endocrinology, Niguarda Hospital, Milan, Italy
- Correspondence should be addressed to R Cozzi;
| | - Maria Rosaria Ambrosio
- Section of Endocrinology and Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | | | - Claudia Battista
- Endocrinology Unit, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo (FG), Italy
| | - Alessandro Bozzao
- Neuroradiology, S. Andrea Hospital, NESMOS Department (Neuroscience, Mental Health, Sensorial Organs), Sapienza University of Rome, Rome, Italy
| | - Marco Caputo
- Laboratorio Analisi Cliniche e Microbiologia, Synlab SRL, Calenzano, Florence, Italy
| | | | - Laura De Marinis
- Pituitary Unit, Department of Endocrinology, Catholic University of the Sacred Heart, School of Medicine, Rome, Italy
| | | | | | - Franco Grimaldi
- AME President, Endocrinology and Metabolism Unit, University Hospital S. Maria della Misericordia, Udine, Italy
| | - Andrea Lania
- Department of Biomedical Sciences, Endocrinology Unit, Rozzano, Italy
| | - Giovanni Lasio
- Department of Neurosurgery, Humanitas Clinical and Research Center IRCCS, Rozzano, Italy
| | | | - Marco Losa
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Pietro Maffei
- Department of Medicine (DIMED), 3rd Medical Clinic, Padua University Hospital, Padua, Italy
| | - Davide Milani
- Department of Neurosurgery, Humanitas Clinical and Research Center IRCCS, Rozzano, Italy
| | - Maurizio Poggi
- Endocrinology, Department of Clinical and Molecular Medicine, S. Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Michele Zini
- Endocrinology Unit, Azienda Ospedaliera S. Maria Nuova IRCCS, Reggio Emilia, Italy
| | | | - Anton Luger
- Division of Endocrinology and Metabolism, Medical University of Vienna, Vienna, Austria
| | - Catalina Poiana
- ‘Carol Davila’ University of Medicine and Pharmacy – Endocrinology, “C.I. Parhon” National Institute of Endocrinology – Pituitary and Neuroendocrine Disorders, Bucharest, Romania
| | | |
Collapse
|
5
|
Vilar L, Abucham J, Albuquerque JL, Araujo LA, Azevedo MF, Boguszewski CL, Casulari LA, Cunha Neto MBC, Czepielewski MA, Duarte FHG, Faria MDS, Gadelha MR, Garmes HM, Glezer A, Gurgel MH, Jallad RS, Martins M, Miranda PAC, Montenegro RM, Musolino NRC, Naves LA, Ribeiro-Oliveira Júnior A, Silva CMS, Viecceli C, Bronstein MD. Controversial issues in the management of hyperprolactinemia and prolactinomas - An overview by the Neuroendocrinology Department of the Brazilian Society of Endocrinology and Metabolism. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2018; 62:236-263. [PMID: 29768629 PMCID: PMC10118988 DOI: 10.20945/2359-3997000000032] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 08/09/2017] [Indexed: 11/23/2022]
Abstract
Prolactinomas are the most common pituitary adenomas (approximately 40% of cases), and they represent an important cause of hypogonadism and infertility in both sexes. The magnitude of prolactin (PRL) elevation can be useful in determining the etiology of hyperprolactinemia. Indeed, PRL levels > 250 ng/mL are highly suggestive of the presence of a prolactinoma. In contrast, most patients with stalk dysfunction, drug-induced hyperprolactinemia or systemic diseases present with PRL levels < 100 ng/mL. However, exceptions to these rules are not rare. On the other hand, among patients with macroprolactinomas (MACs), artificially low PRL levels may result from the so-called "hook effect". Patients harboring cystic MACs may also present with a mild PRL elevation. The screening for macroprolactin is mostly indicated for asymptomatic patients and those with apparent idiopathic hyperprolactinemia. Dopamine agonists (DAs) are the treatment of choice for prolactinomas, particularly cabergoline, which is more effective and better tolerated than bromocriptine. After 2 years of successful treatment, DA withdrawal should be considered in all cases of microprolactinomas and in selected cases of MACs. In this publication, the goal of the Neuroendocrinology Department of the Brazilian Society of Endocrinology and Metabolism (SBEM) is to provide a review of the diagnosis and treatment of hyperprolactinemia and prolactinomas, emphasizing controversial issues regarding these topics. This review is based on data published in the literature and the authors' experience.
Collapse
Affiliation(s)
- Lucio Vilar
- Serviço de Endocrinologia, Hospital das Clínicas, Universidade Federal de Pernambuco (UFPE), Recife, PE, Brasil
| | - Julio Abucham
- Unidade de Neuroendócrino, Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp/EPM), São Paulo, SP, Brasil
| | - José Luciano Albuquerque
- Serviço de Endocrinologia, Hospital das Clínicas, Universidade Federal de Pernambuco (UFPE), Recife, PE, Brasil
| | - Luiz Antônio Araujo
- Centro de Endocrinologia e Diabetes de Joinville (Endoville), Joinville, SC, Brasil
| | - Monalisa F Azevedo
- Serviço de Endocrinologia do Hospital Universitário de Brasília, Universidade de Brasília (UnB), Brasília, DF, Brasil
| | - Cesar Luiz Boguszewski
- Serviço de Endocrinologia e Metabologia, Hospital de Clínicas, Universidade Federal do Paraná (SEMPR), Curitiba, PR, Brasil
| | - Luiz Augusto Casulari
- Serviço de Endocrinologia do Hospital Universitário de Brasília, Universidade de Brasília (UnB), Brasília, DF, Brasil
| | - Malebranche B C Cunha Neto
- Divisão de Neurocirurgia Funcional, Instituto de Psiquiatria do Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (IPq-HC-FMUSP), São Paulo, SP, Brasil
| | - Mauro A Czepielewski
- Serviço de Endocrinologia, Hospital de Clínicas de Porto Alegre, PPG Endocrinologia, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brasil
| | - Felipe H G Duarte
- Serviço de Endocrinologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| | - Manuel Dos S Faria
- Serviço de Endocrinologia, Hospital Universitário Presidente Dutra, Universidade Federal do Maranhão (UFMA), São Luís, MA, Brasil
| | - Monica R Gadelha
- Serviço de Endocrinologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (HUCFF-UFRJ), Rio de Janeiro, RJ, Brasil.,Unidade de Neuroendocrinologia, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, RJ, Brasil
| | - Heraldo M Garmes
- Departamento de Clínica Médica, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (FCM/Unicamp), Campinas, SP, Brasil
| | - Andrea Glezer
- Serviço de Endocrinologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| | - Maria Helane Gurgel
- Serviço de Endocrinologia, Hospital Universitário Walter Cantídio, Universidade Federal do Ceará (UFCE), Fortaleza, CE, Brasil
| | - Raquel S Jallad
- Serviço de Endocrinologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| | - Manoel Martins
- Serviço de Endocrinologia, Hospital Universitário Walter Cantídio, Universidade Federal do Ceará (UFCE), Fortaleza, CE, Brasil
| | - Paulo A C Miranda
- Serviço de Endocrinologia e Metabologia, Santa Casa de Belo Horizonte, Belo Horizonte, MG, Brasil
| | - Renan M Montenegro
- Serviço de Endocrinologia, Hospital Universitário Walter Cantídio, Universidade Federal do Ceará (UFCE), Fortaleza, CE, Brasil
| | - Nina R C Musolino
- Divisão de Neurocirurgia Funcional, Instituto de Psiquiatria do Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (IPq-HC-FMUSP), São Paulo, SP, Brasil
| | - Luciana A Naves
- Serviço de Endocrinologia do Hospital Universitário de Brasília, Universidade de Brasília (UnB), Brasília, DF, Brasil
| | | | - Cíntia M S Silva
- Serviço de Endocrinologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (HUCFF-UFRJ), Rio de Janeiro, RJ, Brasil
| | - Camila Viecceli
- Serviço de Endocrinologia, Hospital de Clínicas de Porto Alegre, PPG Endocrinologia, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brasil
| | - Marcello D Bronstein
- Serviço de Endocrinologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| |
Collapse
|
6
|
Montejo ÁL, Arango C, Bernardo M, Carrasco JL, Crespo-Facorro B, Cruz JJ, Del Pino-Montes J, García-Escudero MA, García-Rizo C, González-Pinto A, Hernández AI, Martín-Carrasco M, Mayoral-Cleries F, Mayoral-van Son J, Mories MT, Pachiarotti I, Pérez J, Ros S, Vieta E. Multidisciplinary consensus on the therapeutic recommendations for iatrogenic hyperprolactinemia secondary to antipsychotics. Front Neuroendocrinol 2017; 45:25-34. [PMID: 28235557 DOI: 10.1016/j.yfrne.2017.02.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 02/15/2017] [Accepted: 02/17/2017] [Indexed: 01/08/2023]
Abstract
Hyperprolactinemia is an underappreciated/unknown adverse effects of antipsychotics. The consequences of hyperprolactinemia compromise therapeutic adherence and can be serious. We present the consensus recommendations made by a group of experts regarding the management of antipsychotic-induced hyperprolactinemia. The current consensus was developed in 3 phases: 1, review of the scientific literature; 2, subsequent round table discussion to attempt to reach a consensus among the experts; and 3, review by all of the authors of the final conclusions until reaching a complete consensus. We include recommendations on the appropriate time to act after hyperprolactinemia detection and discuss the evidence on available options: decreasing the dose of the antipsychotic drug, switching antipsychotics, adding aripiprazole, adding dopaminergic agonists, and other type of treatment. The consensus also included recommendations for some specific populations such as patients with a first psychotic episode and the pediatric-youth population, bipolar disorder, personality disorders and the elderly population.
Collapse
Affiliation(s)
- Ángel L Montejo
- Neurosciences Area, Instituto de Biomedicina de Salamanca (IBSAL), University of Salamanca, Psychiatry Department, University Hospital of Salamanca, Salamanca, Spain.
| | - Celso Arango
- Department of Child and Adolescent Psychiatry, Hospital General Universitario Gregorio Marañón, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), IiSGM, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Miquel Bernardo
- Barcelona Clínic Schizophrenia Unit, Neuroscience Institute, Hospital Clínic of Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Barcelona, Spain
| | - José L Carrasco
- Instituto de Investigación Sanitaria, Hospital Clínico San Carlos, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
| | - Benidicto Crespo-Facorro
- Department of Medicine & Psychiatry, University Hospital Marqués de Valdecilla, IDIVAL, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Santander, Spain
| | - Juan J Cruz
- Department of Medical Oncology, Instituto de Biomedicina de Salamanca (IBSAL), University of Salamanca, University Hospital of Salamanca, Salamanca, Spain
| | | | | | - Clemente García-Rizo
- Barcelona Clínic Schizophrenia Unit, Neuroscience Institute, Hospital Clínic of Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Barcelona, Spain
| | - Ana González-Pinto
- International Mood Disorders Research Centre, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Hospital Santiago Apóstol, University of the Basque Country, Vitoria, Spain
| | - Ana I Hernández
- FEA Psiquiatría, Red de Salud Mental de Guipúzcoa, San Sebastián, Spain
| | - Manuel Martín-Carrasco
- Institute of Psychiatric Research, Mª Josefa Recio Foundation, Bilbao, Spain; Psychiatry Clinic Padre Menni, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Pamplona, Spain
| | - Fermín Mayoral-Cleries
- University Regional Hospital of Malaga, Biomedical Research Institute (IBIMA), Malaga, Spain
| | | | - M Teresa Mories
- Endocrinology and Nutrition Department, University Hospital of Salamanca, Salamanca, Spain
| | - Isabella Pachiarotti
- Bipolar Disorders Program, Psychiatry Department, Hospital Clinic, University of Barcelona, IDIBAPS, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Barcelona, Spain
| | - Jesús Pérez
- Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
| | - Salvador Ros
- International Institute of Applied Neurosciences, Barcelona, Spain
| | - Eduard Vieta
- Bipolar Disorders Program, Psychiatry Department, Hospital Clinic, University of Barcelona, IDIBAPS, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Barcelona, Spain
| |
Collapse
|
7
|
Abstract
Introduction: Antipsychotics represent a large portion of the psychotropics that may induce hyperprolactinemia. Clinical psychiatric pharmacists must be adept in stratifying the relative risk of hyperprolactinemia among psychotropics, identifying patient risk factors, recognizing differential diagnoses, and recommending therapeutic alternatives and treatment strategies. High-potency, typical antipsychotics are more likely to elevate prolactin although exceptions to the rule exist. Methods: A literature search of PubMed and Google Scholar was performed to identify English language articles on the treatment of antipsychotic-induced hyperprolactinemia in humans. Methodological rigor is summarized for compiled studies in addition to feasibility and limitations of application to clinical practice. Results: There is an absence of robust evidence for the management of antipsychotic-induced hyperprolactinemia. Among the pharmacological treatments studied, aripiprazole (switching or augmentation) possessed the strongest evidence. Pharmacological treatments with less evidence encompassed dose reduction, switching to lower potency antipsychotics, and adding dopamine agonists. To date, no head-to-head studies have been published on the above approaches. Discussion: Atypical antipsychotics with low affinity for dopamine (D2) receptors, such as olanzapine, are logical alternatives for the patient experiencing drug-induced hyperprolactinemia. When augmentation is clinically preferred to switching, a viable option is the addition of a full or partial dopamine agonist, such as bromocriptine or aripiprazole, respectively. Patient-specific risk of psychiatric decompensation and the severity of symptomatic hyperprolactinemia should be weighed when formulating treatment strategies.
Collapse
Affiliation(s)
- Ashley Tewksbury
- Pharmacist, Clinical Specialist Psychiatry, Lutheran Hospital, Cleveland Clinic, Cleveland, Ohio,
| | - Amy Olander
- PharmD Candidate, The Ohio State University College of Pharmacy, Columbus, Ohio
| |
Collapse
|
8
|
Snellen M, Power J, Blankley G, Galbally M. Pharmacological lactation suppression with D2 receptor agonists and risk of postpartum psychosis: A systematic review. Aust N Z J Obstet Gynaecol 2016; 56:336-40. [PMID: 27297803 DOI: 10.1111/ajo.12479] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 04/19/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND It has been suggested that D2 receptor agonists commonly used postpartum for the physiological suppression of lactation, such as bromocriptine and cabergoline, may increase the risk of illness onset or relapse in women where there is a predisposition for or history of schizophrenia, bipolar disorder or postpartum psychosis. This is based on two lines of reasoning: current models of psychosis assume episodes are triggered by dysregulation of brain dopaminergic activity and treated by medications that universally have D2 receptor antagonist properties; and limited research suggesting these agents may be associated with psychotic episodes in vulnerable individuals outside of the postpartum period. AIM The aim of this study was to examine whether D2 agonists trigger psychosis in previously well mothers, or psychotic relapse or exacerbation of symptoms in mothers with known psychotic illnesses, when used to suppress lactation during the early postpartum period. MATERIALS AND METHODS A systematic review of the literature was undertaken of electronic databases, including: MEDLINE, EMBASE and PsychINFO from 1950 to 2015 using keywords. RESULTS Eight case reports, three case series and a pharmacovigilance survey were identified. CONCLUSION Whilst D2 receptor agonists appear to increase the risk of triggering psychosis in previously well mothers and those previously diagnosed with schizophrenia, bipolar disorder and postpartum psychosis, bromocriptine appears to pose a much greater risk than cabergoline. When considering the use of pharmacological agents to suppress lactation, physicians should carefully screen patients for a history of psychosis and consider alternatives to moderate this risk.
Collapse
Affiliation(s)
- Martien Snellen
- Perinatal Mental Health, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Josephine Power
- Perinatal Mental Health, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Gaynor Blankley
- Perinatal Mental Health, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Megan Galbally
- School of Medicine, University of Notre Dame, Fremantle, Western Australia, Australia.,Fiona Stanley Hospital, Murdoch, Western Australia, Australia.,Murdoch University, Murdoch, Western Australia, Australia
| |
Collapse
|
9
|
Zatelli MC, Ambrosio MR, Bondanelli M, Degli Uberti E. Pituitary side effects of old and new drugs. J Endocrinol Invest 2014; 37:917-23. [PMID: 25070042 DOI: 10.1007/s40618-014-0133-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 07/08/2014] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Pituitary function is influenced by several drugs, including anti-depressant, opioids, glucocorticoids, chemotherapeutic agents, immunomodulators and the newly developed tyrosine kinase inhibitors. In most instances, treatment with these drugs negatively affects pituitary function, but in rare cases an activation of specific hypothalamic-pituitary axes may be observed. Several of the observed pituitary side effects are reversible after drug withdrawal, but pituitary function deficiency may persist long-term. In addition to the well known drugs, recent evidence shows that also non-steroidal anti-inflammatory drugs impair gonadal axis at pituitary level, while antipsychotic phenothiazines alter TSH response to TRH and TSH levels. Atypical antipsychotics may decrease TRH-stimulated TSH. Tricyclic antidepressant drugs interfere with the hypothalamo-pituitary-thyroid axis by decreasing TSH response to TRH. Anabolic-androgenic steroids, marijuana, cocaine, methamphetamines, and opioid narcotics negatively impact fertility, also acting at hypothalamic-pituitary level. CONCLUSIONS Many of the drugs administered routinely in the intensive care unit significantly impact the hypothalamic-pituitary axis. Therefore, an increased awareness on pituitary side effects of drugs commonly used in clinical practice is necessary in order to rule out possible pharmacological interference when assessing patients with pituitary deficiencies.
Collapse
Affiliation(s)
- Maria Chiara Zatelli
- Department of Medical Sciences, Section of Endocrinology, University of Ferrara, Via Savonarola 9, 44100, Ferrara, Italy,
| | | | | | | |
Collapse
|
10
|
Lewis Metcalfe WE, Washington NB, Brahm N. Treatment of antipsychotic-induced hyperprolactinemia with bromocriptine: A case report. Ment Health Clin 2013. [DOI: 10.9740/mhc.n167098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Nicole B. Washington
- 2 School of Community Medicine, Department of Psychiatry, University of Oklahoma, Tulsa, OK
| | - Nancy Brahm
- 3 The University of Oklahoma College of Pharmacy, Tulsa, OK
| |
Collapse
|
11
|
Cabergoline associated with first episode mania. PSYCHOSOMATICS 2012; 53:595-600. [PMID: 22658326 DOI: 10.1016/j.psym.2012.01.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2011] [Revised: 01/09/2012] [Accepted: 01/09/2012] [Indexed: 11/24/2022]
|
12
|
Abstract
BACKGROUND AND OBJECTIVES Antipsychotic medications are a potential cause of hyperprolactinaemia and may be implicated in the development of pituitary adenomas. This review examines the effect of different antipsychotic medications on prolactin and sexual function, and provides practical guidelines for investigation and management of antipsychotic-induced hyperprolactinaemia. METHOD Literature review. RESULTS AND CONCLUSIONS Antipsychotic-induced hyperprolactinaemia occurs overall in up to 70% of patients with schizophrenia, depending on the medications used. It is associated with significant levels of hypogonadism and sexual dysfunction, which in general relates to the degree of prolactin elevation. A consequence of the hypogonadism is clinically significant bone loss which may lead to osteoporosis and increased risk of minimal trauma fracture. Where the potentially offending drug cannot be safely withdrawn to document a normal prolactin, imaging with MRI should be undertaken to exclude a structural pituitary lesion. The management strategy of choice is switching to a prolactin-sparing antipsychotic. Sex steroid replacement can reverse many of the adverse effects including the hypogonadal symptoms and bone loss. Low dose dopamine agonist therapy should be used with caution as a third line treatment, since there have been cases of dopamine agonist-induced exacerbation of psychosis. There is a need for a randomised controlled trial of low dose dopamine agonist therapy versus sex steroid replacement to establish the relative safety and efficacy of each approach.
Collapse
Affiliation(s)
- Warrick J Inder
- Department of Endocrinology and Diabetes, St Vincent's Hospital, 41 Victoria Parade, Fitzroy, Victoria 3065, Australia.
| | | |
Collapse
|
13
|
Adjunctive treatment with low-dosage pramipexole for risperidone-associated hyperprolactinemia and sexual dysfunction in a male patient with schizophrenia. J Clin Psychopharmacol 2011; 31:243-5. [PMID: 21364336 DOI: 10.1097/jcp.0b013e31820f4fbd] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
14
|
Tardieu S, Micallef J, Bonierbale M, Frauger E, Lançon C, Blin O. [Sexual behaviour in schizophrenic patients: the impact of antipsychotics]. Encephale 2011; 32:697-704. [PMID: 17099593 DOI: 10.1016/s0013-7006(06)76221-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In spite of the frequency of sexual dysfunction in schizophrenic patients and antipsychotic-treated schizophrenic patients, few studies have been performed. The relationship of schizophrenia to sexual pathology is variable and complex, and of course different between men and women. Few evaluation methods have been proposed or validated. Antipsychotics may improve some aspects of sexual behaviour in schizophrenic patients. However, sexual dysfunction is also a possible side effect of these drugs. The evaluation of antipsychotics is often restricted to prolactin measurement, the relationship with sexual disorders of which has not been fully established. Preliminary data suggest that the capacity to induce sexual disorders differs from one antipsychotic to another. The available data on the mechanisms of sexual dysfunction, the pharmacological profile and the sexual effects of classical neuroleptics (haloperidol and thioridazine) and second generation antipsychotics available in France (amisulpride, clozapine, risperidone, olanzapine) are reviewed.
Collapse
Affiliation(s)
- S Tardieu
- Cellule d'Evaluation Médicale, Santé Publique, Assistance Publique-Hôpitaux de Marseille, 80, rue Brochier, 13354 Marseille cedex 05, France
| | | | | | | | | | | |
Collapse
|
15
|
Madhusoodanan S, Parida S, Jimenez C. Hyperprolactinemia associated with psychotropics--a review. Hum Psychopharmacol 2010; 25:281-97. [PMID: 20521318 DOI: 10.1002/hup.1116] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
Collapse
|
16
|
Lee MS, Song HC, An H, Yang J, Ko YH, Jung IK, Joe SH. Effect of bromocriptine on antipsychotic drug-induced hyperprolactinemia: eight-week randomized, single-blind, placebo-controlled, multicenter study. Psychiatry Clin Neurosci 2010; 64:19-27. [PMID: 19968833 DOI: 10.1111/j.1440-1819.2009.02032.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM The objective of the present study was to assess the efficacy and safety of bromocriptine treatment for patients with antipsychotic-drug-induced hyperprolactinemia in clinical practice. METHODS This was an 8-week randomized, single-blind, placebo-controlled, multicenter study. Sixty female schizophrenia patients were enrolled and were randomly assigned to one of four treatment groups: bromocriptine 2.5 mg/day, 5 mg/day, 10 mg/day, and placebo. Serum levels of prolactin, estradiol (E2), luteinizing hormone (LH), and follicle-stimulating hormone (FSH) were evaluated on three occasions (baseline, and 4 and 8 weeks after commencement of the treatment paradigm). Extrapyramidal symptoms (EPS) and clinical symptoms were assessed using the Simpson-Angus scale and the Positive and Negative Syndrome Scale (PANSS), respectively. RESULTS Of the 60 subjects who were enrolled, 48 completed the study (n = 14, 13, 11, and 10 in the bromocriptine 2.5 mg/day, 5 mg/day, and 10 mg/day, and placebo groups, respectively). Four patients in the 10-mg/day group, two in the 5-mg/day group, and one in the placebo group resumed menses during the study. The mean level of prolactin significantly decreased from baseline to week 4, and then plateaued, showing no significant change for the remaining 4 weeks of the study. No significant changes in LH, FSH, or E2 levels were observed throughout the 8-week study period, either within or between groups. CONCLUSION Administration of bromocriptine is a safe method for treating antipsychotic-drug-induced hyperprolactinemia without exacerbating either psychotic symptoms or EPS.
Collapse
Affiliation(s)
- Moon-Soo Lee
- Department of Psychiatry, Korea University, College of Medicine, Seoul, Korea
| | | | | | | | | | | | | |
Collapse
|
17
|
Chang SC, Chen CH, Lu ML. Cabergoline-induced psychotic exacerbation in schizophrenic patients. Gen Hosp Psychiatry 2008; 30:378-80. [PMID: 18585544 DOI: 10.1016/j.genhosppsych.2007.11.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2007] [Revised: 11/06/2007] [Accepted: 11/13/2007] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Hyperprolactinemia is a well-recognized side effect of antipsychotic treatment. Cabergoline, a dopamine agonist, has been introduced on the market to treat hyperprolactinemia, even secondary to antipsychotic use. CASE REPORT In this article, we described two schizophrenic patients who received cabergoline to treat their antipsychotic-induced hyperprolactinemia and developed a subsequent psychotic exacerbation. The first patient received amisulpride as antipsychotic medication, and the second one took risperidone and fluoxetine for her psychotic and depressive symptoms, respectively. Both patients improved significantly their psychotic symptoms in 1 week without changing their former antipsychotic regimens. DISCUSSION To the best of our knowledge, we found no previous report of cabergoline-induced psychotic exacerbation in schizophrenic patients who received antipsychotics. We brought up questions whether schizophrenic patients on amisulpride or with the addition of fluoxetine may have higher risk to experience psychotic worsening. We also highlighted the possible role of dose-dependent nature in cabergoline-induced psychotic exacerbation, suggesting that the single starting dose of 0.5 mg or higher might be unsafe in schizophrenic patients. CONCLUSION These cases suggest that cabergoline, like other dopaminergic agents, should be used with caution in psychotic patients and the dose should be as low as possible.
Collapse
Affiliation(s)
- Shen-Chieh Chang
- Department of Psychiatry, Taipei Medical University-Wan Fang Medical Center, Taipei, Taiwan
| | | | | |
Collapse
|
18
|
A randomized, crossover comparison of herbal medicine and bromocriptine against risperidone-induced hyperprolactinemia in patients with schizophrenia. J Clin Psychopharmacol 2008; 28:264-370. [PMID: 18480682 DOI: 10.1097/jcp.0b013e318172473c] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hyperprolactinemia is a common adverse effect that occurs as a result of antipsychotic therapies, which often results in discontinuation. Empirical evidence has shown that some herbal medicines have suppressive effects on prolactin (PRL) hyperactivities. This study was designed to compare the herbal preparation called Peony-Glycyrrhiza Decoction (PGD) with bromocriptine (BMT), a dopamine agonist widely used for PRL-secreting disorders, in the treatment of risperidone-induced hyperprolactinemia. Twenty schizophrenic women who were under risperidone maintenance treatment, diagnosed with hyperprolactinemia (serum PRL levels >50 mug/L), and currently experiencing oligomenorrhea or amenorrhea were selected for the study. Subjects were randomized to additional treatment with PGD (45 g/d) followed by BMT (5 mg/d) or BMT followed by PGD at the same doses for 4 weeks each, with an interval of 4-week washout period between 2 treatment sessions. The severity of psychotic symptoms, adverse events, serum PRL, estradiol, testosterone, and progesterone levels were examined at baseline and end point. Peony-Glycyrrhiza Decoction treatment produced a significant baseline-end point decrease in serum PRL levels, without exacerbating psychosis and changing other hormones, and the decreased amplitudes were similar to those of BMT (24% vs 21%-38%). Moreover, there was a significantly greater proportion of patients during PGD treatment than BMT treatment showing improvements on adverse effects associated with hyperprolactinemia (56% vs 17%, P = 0.037). These results suggest that the herbal therapy can yield additional benefits while having comparable efficacy in treating antipsychotic-induced hyperprolactinemia in individuals with schizophrenia.
Collapse
|
19
|
Abstract
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.
Collapse
Affiliation(s)
- Mark E Molitch
- Division of Endocrinology, Metabolism, and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
| |
Collapse
|
20
|
Costa AMN, Lima MSD, Mari JDJ. A systematic review on clinical management of antipsychotic-induced sexual dysfunction in schizophrenia. SAO PAULO MED J 2006; 124:291-7. [PMID: 17262163 DOI: 10.1590/s1516-31802006000500012] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2005] [Accepted: 09/19/2006] [Indexed: 04/07/2023] Open
Abstract
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.
Collapse
|
21
|
Abstract
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.
Collapse
Affiliation(s)
- Mark E Molitch
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
| |
Collapse
|
22
|
Abstract
Hyperprolactinemia affects the gonadotropic axis. Its results in women include amenorrhea, menstrual disorders and galactorrhea; in men, the frequency of macroadenomas tends to lead to problems related to sexual performance or tumor volume. Radioimmunoassays make diagnosis easy. Secondary causes of hyperprolactinemia, drug reactions in particular, must be ruled out before MRI exploration to look for a pituitary tumor. First-line treatment of prolactin adenomas is based on the use of dopaminergic agonists, especially cabergoline, because of their excellent efficacy and the risk of relapse following surgery. For patients who wish to become pregnant, the dopaminergic agonist must be continued during pregnancy for those with macroadenoma and withdrawn for women with microadenoma. When hyperprolactinemia is induced by anti-psychotic agents, treatment requires an in-depth assessment.
Collapse
Affiliation(s)
- Anne Bachelot
- Service d'endocrinologie et médecine de la reproduction, Hôpital Necker, Paris (75)
| | | | | |
Collapse
|
23
|
Haddad PM, Wieck A. Antipsychotic-induced hyperprolactinaemia: mechanisms, clinical features and management. Drugs 2005; 64:2291-314. [PMID: 15456328 DOI: 10.2165/00003495-200464200-00003] [Citation(s) in RCA: 400] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
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.
Collapse
Affiliation(s)
- Peter M Haddad
- Bolton, Salford & Trafford Mental Health NHS Trust, Salford, UK
| | | |
Collapse
|
24
|
Vera-Llonch M, Delea TE, Richardson E, Rupnow M, Grogg A, Oster G. Outcomes and costs of risperidone versus olanzapine in patients with chronic schizophrenia or schizoaffective disorders: a Markov model. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2004; 7:569-584. [PMID: 15367252 DOI: 10.1111/j.1524-4733.2004.75008.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVE To compare expected outcomes and costs of care in patients with chronic schizophrenia or schizoaffective disorders who are treated with risperidone versus olanzapine. METHODS A Markov model was developed to examine outcomes and costs of care in patients with chronic schizophrenia or schizoaffective disorders receiving risperidone or olanzapine. The time frame of interest was 1 year. The model focused particular attention on the likelihood of therapy switching and discontinuation as a result of treatment-emergent side effects, as the efficacy of these two agents is similar. Measures of interest included the incidence of relapse and selected side effects including extrapyramidal symptoms (EPS), prolactin-related disorders and diabetes, expected change in body weight, and the percentage of patients remaining on initial therapy at the end of 1 year. Costs of antipsychotic therapy and psychiatric and nonpsychiatric services also were examined. RESULTS At 1 year, the rate of EPS was estimated to be slightly higher for risperidone, as was the incidence of symptomatic prolactin-related disorders. The expected incidence of diabetes mellitus, while low, was slightly higher for olanzapine. Approximately 25% and 4% of olanzapine and risperidone patients, respectively, were projected to experience an increase in body weight > or = 7%. The estimated percentage of patients remaining on initial therapy at the end of 1 year was higher for risperidone than olanzapine (76.9% vs. 45.6%, respectively). Expected mean total costs of care per month of therapy were $2163 for risperidone and $2316 for olanzapine. Results from sensitivity analyses suggest that the probability of therapy discontinuation following weight gain >5 kg would have to be lower than 0.1 for the number of patients remaining on therapy at the end of 1 year to be the same for risperidone and olanzapine. CONCLUSIONS Compared with risperidone, treatment with olanzapine may result in greater increases in body weight, higher rates of therapy discontinuation, and higher costs of medical-care services.
Collapse
|
25
|
Chue P, Kovacs CS. Safety and tolerability of atypical antipsychotics in patients with bipolar disorder: prevalence, monitoring and management. Bipolar Disord 2004; 5 Suppl 2:62-79. [PMID: 14700015 DOI: 10.1111/j.1399-2406.2003.00063.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Atypical antipsychotics are associated with fewer movement disorders and a lower risk of tardive dyskinesia than conventional antipsychotics, but are not without side-effects. Metabolic side-effects associated with some of the atypical antipsychotics are a concern for both clinicians and patients. Adverse events related to central nervous system effects, weight gain, and alterations in glucose, lipid, and prolactin levels in patients with depression, bipolar, and anxiety disorders have been reported. Balancing the significant benefits of treatment with these agents against the potential risks of metabolic disturbances and other adverse effects is crucial. Emerging data are making it possible to determine the risk-benefit analysis for specific atypical antipsychotics in individual patients and allow for targeted selection of treatment. A new concept of effectiveness is emerging that attempts to balance adverse effects of treatment with patient quality of life. Patients treated with atypical antipsychotics should have their weight, waist circumference, glucose, and lipids monitored on a regular basis. Monitoring of prolactin levels is not suggested; however, a baseline measurement before initiating treatment can be useful, with subsequent assessment only if a patient demonstrates symptoms. Prevention of weight gain is important. Diet and exercise should be considered for prevention and management, with the use of pharmacologic strategies approached with caution in patients with mood disorders. If a patient is at high risk of developing diabetes, certain pharmacologic agents have been shown to delay the onset of overt diabetes. Once diabetes or dyslipidemia are diagnosed, management should proceed in accordance with approved guidelines for these conditions.
Collapse
Affiliation(s)
- Pierre Chue
- Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada
| | | |
Collapse
|
26
|
Green AI, Canuso CM, Brenner MJ, Wojcik JD. Detection and management of comorbidity in patients with schizophrenia. Psychiatr Clin North Am 2003; 26:115-39. [PMID: 12683263 DOI: 10.1016/s0193-953x(02)00014-x] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Approximately half of patients with schizophrenia have at least one comorbid psychiatric or medical condition, worsening prognosis and contributing to the high rate of morbidity and mortality. Depression is associated with suicide, the leading cause of premature death in patients with schizophrenia; obsessive-compulsive symptoms may worsen prognosis; alcohol and substance use disorders are associated with a poor outcome; and comorbid medical conditions, including cardiac and pulmonary disease, infectious diseases, diabetes, hyperlipidemia, hypogonadism, and osteoporosis, are often underrecognized and undertreated. The new generation of antipsychotic medications has improved the potential outcome of patients with schizophrenia. Providing optimal treatment for patients and fully realizing the potential of these new agents require focused attention on detection, recognition, and treatment of comorbid psychiatric and medical conditions in patients with schizophrenia.
Collapse
Affiliation(s)
- Alan I Green
- Department of Psychiatry, Harvard Medical School, Commonwealth Research Center, Massachusetts Mental Health Center, 74 Fenwood Road, Boston, MA 02115, USA.
| | | | | | | |
Collapse
|
27
|
Kapur S, Langlois X, Vinken P, Megens AAHP, De Coster R, Andrews JS. The differential effects of atypical antipsychotics on prolactin elevation are explained by their differential blood-brain disposition: a pharmacological analysis in rats. J Pharmacol Exp Ther 2002; 302:1129-34. [PMID: 12183672 DOI: 10.1124/jpet.102.035303] [Citation(s) in RCA: 120] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
All atypical antipsychotics avoid extrapyramidal side-effects yet differ in their propensity to cause other side-effects, like prolactin elevation. We proposed that the atypical antipsychotics with a propensity for prolactin elevation would show a higher pituitary versus striatal D2 receptor occupancy. To investigate this hypothesis, we tested four atypical antipsychotics, two that are commonly associated with prolactin elevation (amisulpride and risperidone) and two that are less frequently associated (quetiapine and olanzapine). In particular, we calculated their ED(50) values to increase plasma prolactin and block peripheral pituitary D2 receptors to their ED(50) values to antagonize apomorphine-induced stereotypy and occupy central striatal D2 receptors. All antipsychotics dose dependently increased prolactin levels and antagonized apomorphine-induced stereotypy. However, the central to peripheral potency (ED(50) for apomorphine antagonism to ED(50) for prolactin elevation) differed remarkably across these drugs: amisulpride (21764), risperidone (14), quetiapine (10), and olanzapine (1.7). Compounds displaying a higher peripheral potency brought about higher prolactin levels for a given level of functional central antagonism. This dissociation between central and peripheral effects was explained by the differential occupancy of D2 receptors in the striatum versus in the pituitary [ratio of striatal/pituitary ED(50) values (milligram per kilogram) for D2 occupancy): amisulpride (17/0.026 = 654), risperidone (0.89/0.081 = 14), quetiapine (24/4.1 = 6), olanzapine (0.30/0.43 = 0.7). These results indicate that dissociation between central and peripheral D2 receptor occupancy is a major determinant of the degree of prolactin elevation observed at therapeutic doses.
Collapse
Affiliation(s)
- S Kapur
- Centre for Addiction and Mental Health, Clarke Division, 250 College Street, Toronto, Ontario, Canada M5R 1T8.
| | | | | | | | | | | |
Collapse
|
28
|
Segraves RT. Female sexual disorders: psychiatric aspects. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2002; 47:419-25. [PMID: 12085676 DOI: 10.1177/070674370204700502] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE This manuscript reviews the current information concerning female sexual dysfunction that is relevant to general psychiatric practice. METHOD Research identified by the key words sexual dysfunction and prevalence, comorbidity, psychiatric drugs, or pharmacotherapy is reviewed. RESULTS Epidemiologic studies indicate that approximately 30% of female subjects between ages 18 and 59 years have sexual complaints of at least 3 months' duration in the past year. A high comorbidity with other psychiatric syndromes exists. Many psychiatric drugs are associated with sexual dysfunction. Drug treatments for female sexual dysfunction are being investigated. CONCLUSION Knowledge concerning the treatment of female sexual dysfunction is important to the general psychiatric clinician.
Collapse
Affiliation(s)
- Robert Taylor Segraves
- Department of Psychiatry, Case Western Reserve School of Medicine, MetroHealth Medical Center, Cleveland, OH 44109, USA.
| |
Collapse
|
29
|
Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2001; 10:263-78. [PMID: 11505947 DOI: 10.1002/pds.548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|