Treatments of psychiatric disorders, hyperprolactinemia and dopamine agonists

Determining Ideal Management for Patients With Coexisting Prolactinomas and Psychiatric Symptoms: A Systematic Review

OBJECTIVE

Prolactinomas-pituitary tumors that overproduce prolactin-can cause various troublesome symptoms. Dopamine agonists (DAs) reduce prolactin production in the prolactin pathway, making them the first-line treatment for prolactinomas. However, the main side effect of DA treatment, hyperdopaminergia, is an explicit etiology for psychiatric side effects. Psychiatric conditions are often treated with dopamine antagonists, which can induce hyperprolactinemia. This presents a challenge for patients with both a prolactinoma and a preexisting psychiatric condition, as treatment of one condition could worsen the other. This review seeks to identify an adequate therapeutic regimen for patients with coexisting prolactinomas and psychiatric symptoms.

METHODS

This review examined PubMed citations from 1960 to 2023 published in English and involving human subjects. Case reports, case series, and cohort studies involving patients with concomitant prolactinomas and psychiatric symptoms, as validated by brain imaging, serologic prolactin levels, and medical history or chart reports of psychiatric symptoms, were included.

RESULTS

Thematic analysis included 23 reports involving 42 participants; 27 of the 42 patients experienced a significant reduction in prolactin levels and psychiatric symptoms (64%). Treatment of those 42 patients included discontinuing or altering antipsychotic/dopamine antagonist therapy or discontinuing DA therapy to reduce psychiatric symptoms, with surgery or radiation postpharmacotherapy as a last-line strategy. However, in some cases (reported in Tables 2 to 4), either psychiatric or prolactin-related symptoms recurred despite adjustment.

CONCLUSIONS

Clinicians may find it beneficial to prioritize specific antipsychotics (aripiprazole, olanzapine, ziprasidone, or clozapine) over others (risperidone, thioridazine, thiothixene, and remoxipride). Discontinuing DA medication at least periodically until the patient's condition improves may also be advisable. If these 2 initial approaches do not yield a significant improvement in symptom management, surgery or radiation therapy may be considered. As patients may respond differently to these therapies, our study still recommends a patient-centered approach.

New insight into interference-free and highly sensitive dopamine electroanalysis

Early diagnosis of Parkinson's disease and hyperprolactinemia based on electrochemical dopamine (DA) sensing appears as an efficient and promising practical diagnostic method. However, the coexistence of DA in real samples with ascorbic acid (AA) and uric acid (UA), which oxidize at potentials close to its own, prevents the accurate electrochemical DA sensing and therefore, hinders the effective diagnosis of these diseases. In this work, we successfully combined the electrostatic proprieties of GO, the electron transfer properties of an AuNPs@MWCNTs nanocomposite and the ability of thiol group of the amino acid l-cysteine to react chemically with carbonyl groups of UA, to develop a novel approach that enabled complete suppression of interference from AA and UA and hence, accurate DA electroanalysis in the conditions close to those of human blood serum. The chemical reaction between l-cysteine and UA was evidenced by monitoring the DPV responses of UA under different conditions. XRD, Raman spectroscopy, XPS and FE-SEM revealed the successful synthesis of GO and AuNPs@MWCNTs. The study of the electrode material (GO-AuNPs@MWCNTs) morphology via FE-SEM and HR-TEM showed that AuNPs@MWCNTs are distributed throughout the exfoliated GO layers. The fabricated sensor was calibrated in the concentration range of 0.5-5 μM, in the presence of the highest blood concentrations of AA and UA for healthy individuals. A linear relationship was observed and the LOD was found to be 1.31 nM (S/N = 3). Furthermore, the sensor showed good electron transfer kinetics, good repeatability and reproducibility, satisfactory long-term stability, and recoveries in human blood serum.

Diagnosis and management of prolactin-secreting pituitary adenomas: a Pituitary Society international Consensus Statement

This Consensus Statement from an international, multidisciplinary workshop sponsored by the Pituitary Society offers evidence-based graded consensus recommendations and key summary points for clinical practice on the diagnosis and management of prolactinomas. Epidemiology and pathogenesis, clinical presentation of disordered pituitary hormone secretion, assessment of hyperprolactinaemia and biochemical evaluation, optimal use of imaging strategies and disease-related complications are addressed. In-depth discussions present the latest evidence on treatment of prolactinoma, including efficacy, adverse effects and options for withdrawal of dopamine agonist therapy, as well as indications for surgery, preoperative medical therapy and radiation therapy. Management of prolactinoma in special situations is discussed, including cystic lesions, mixed growth hormone-secreting and prolactin-secreting adenomas and giant and aggressive prolactinomas. Furthermore, considerations for pregnancy and fertility are outlined, as well as management of prolactinomas in children and adolescents, patients with an underlying psychiatric disorder, postmenopausal women, transgender individuals and patients with chronic kidney disease. The workshop concluded that, although treatment resistance is rare, there is a need for additional therapeutic options to address clinical challenges in treating these patients and a need to facilitate international registries to enable risk stratification and optimization of therapeutic strategies.