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Ntali G, Markussis V, Chrisoulidou A. An Overview of Cardiovascular Risk in Pituitary Disorders. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1241. [PMID: 39202522 PMCID: PMC11356746 DOI: 10.3390/medicina60081241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Revised: 07/16/2024] [Accepted: 07/20/2024] [Indexed: 09/03/2024]
Abstract
Cardiovascular comorbidities owing to hormonal excess or deficiency are the main cause of mortality in patients with pituitary disorders. In patients with Cushing's Disease, there is an increased prevalence of cardiovascular diseases and/or risk factors including visceral obesity, insulin resistance, atherosclerosis, arterial hypertension, dyslipidaemia, hypercoagulability as well as structural and functional changes in the heart, like cardiac hypertrophy and left ventricle (LV) dysfunction. Notably, these demonstrate limited reversibility even after remission. Furthermore, patients with acromegaly may manifest insulin resistance but also structural and functional heart changes, also known as "acromegalic cardiomyopathy". Patients with prolactinomas demonstrate an aggravation of metabolic parameters, obesity, dysregulation of glucose and lipid metabolism as well as endothelial dysfunction. Hypopituitarism and conventional hormonal replacement therapy may also contribute to an unhealthy metabolic status, which promotes atherosclerosis and may lead to premature mortality. This review discusses the literature on cardiovascular risk in patients with pituitary disorders to increase physician awareness regarding this aspect of management in patients with pituitary disorders.
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Affiliation(s)
- Georgia Ntali
- Department of Endocrinology “D. Ikkos”, Diabetes Center, Evangelismos General Hospital, 10676 Athens, Greece
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Dzialach L, Sobolewska J, Zak Z, Respondek W, Witek P. Prolactin-secreting pituitary adenomas: male-specific differences in pathogenesis, clinical presentation and treatment. Front Endocrinol (Lausanne) 2024; 15:1338345. [PMID: 38370355 PMCID: PMC10870150 DOI: 10.3389/fendo.2024.1338345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 01/22/2024] [Indexed: 02/20/2024] Open
Abstract
Prolactinomas (PRLomas) constitute approximately half of all pituitary adenomas and approximately one-fifth of them are diagnosed in males. The clinical presentation of PRLomas results from direct prolactin (PRL) action, duration and severity of hyperprolactinemia, and tumor mass effect. Male PRLomas, compared to females, tend to be larger and more invasive, are associated with higher PRL concentration at diagnosis, present higher proliferative potential, are more frequently resistant to standard pharmacotherapy, and thus may require multimodal approach, including surgical resection, radiotherapy, and alternative medical agents. Therefore, the management of PRLomas in men is challenging in many cases. Additionally, hyperprolactinemia is associated with a significant negative impact on men's health, including sexual function and fertility potential, bone health, cardiovascular and metabolic complications, leading to decreased quality of life. In this review, we highlight the differences in pathogenesis, clinical presentation and treatment of PRLomas concerning the male sex.
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Affiliation(s)
- Lukasz Dzialach
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
| | - Joanna Sobolewska
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
| | - Zuzanna Zak
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
| | - Wioleta Respondek
- Department of Internal Medicine, Endocrinology and Diabetes, Mazovian Brodnowski Hospital, Warsaw, Poland
| | - Przemysław Witek
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
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Auriemma RS, Pirchio R, Pivonello C, Garifalos F, Colao A, Pivonello R. Approach to the Patient With Prolactinoma. J Clin Endocrinol Metab 2023; 108:2400-2423. [PMID: 36974474 PMCID: PMC10438891 DOI: 10.1210/clinem/dgad174] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 03/03/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023]
Abstract
Prolactinomas are the most common pituitary tumor histotype, with microprolactinomas being prevalent in women and macroprolactinomas in men. Hyperprolactinemia is among the most common causes of hypogonadotropic hypogonadism in both sexes, prompting medical advice for hypogonadism (infertility, oligo-amenorrhea, impotence, osteoporosis/osteopenia) in both sexes, and for signs and symptoms of mass effects (hypopituitarism, visual loss, optic chiasm compression, cranial nerve deficits, headaches) predominantly in men. Diagnostic workup involves a single prolactin measurement and pituitary imaging, but some laboratory artifacts (ie, the "hook effect" and macroprolactin) can complicate or delay the diagnosis. The treatment of choice for prolactinomas is represented by dopamine agonists, mainly cabergoline, which are able to induce disease control, restore fertility in both sexes, and definitively cure one-third of patients, thus permitting treatment discontinuation. Pregnancy and menopause may promote spontaneous prolactin decline and anticipate cabergoline discontinuation in women. Surgery and/or radiotherapy are indicated in case of resistance to cabergoline not overcome by the increase in drug dose up to the maximally tolerated or the patient's personal choice of surgery. The evidence of resistance to cabergoline in invasive and proliferative tumors may indicate biological aggressiveness, thus requiring alternative therapeutic approaches mainly based on temozolomide use as monotherapy or combined with radiotherapy. In uncontrolled patients, new medical approaches (alternative hormonal treatments, cytotoxic drugs, peptide receptor radionuclide therapy, mTOR/Akt inhibitors, tyrosine kinase inhibitors, or immunotherapy) may be offered but the experience collected to date is still very scant. This article reviews different facets of prolactinomas and discusses approaches to the condition in more common clinical situations.
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Affiliation(s)
- Renata S Auriemma
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, 80131 Naples, Italy
| | - Rosa Pirchio
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, 80131 Naples, Italy
| | - Claudia Pivonello
- Dipartimento di Sanità Pubblica, Università Federico II di Napoli, 80131 Naples, Italy
| | - Francesco Garifalos
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, 80131 Naples, Italy
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Unità di Andrologia e Medicina della Riproduzione e Sessualità Maschile e Femminile (FERTISEXCARES), Università Federico II di Napoli, 80131 Naples, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, 80131 Naples, Italy
- Unesco Chair for Health Education and Sustainable Development, “Federico II” University, 80131 Naples, Italy
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, 80131 Naples, Italy
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Unità di Andrologia e Medicina della Riproduzione e Sessualità Maschile e Femminile (FERTISEXCARES), Università Federico II di Napoli, 80131 Naples, Italy
- Unesco Chair for Health Education and Sustainable Development, “Federico II” University, 80131 Naples, Italy
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Alikasifoglu A, Celik NB, Ozon ZA, Gonc EN, Kandemir N. Management of prolactinomas in children and adolescents; which factors define the response to treatment? Pituitary 2022; 25:167-179. [PMID: 34518999 DOI: 10.1007/s11102-021-01184-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/30/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE Prevalence, presentation and clinical outcome of prolactinomas vary in children and adults. In this study, we evaluated the clinical features and outcome of children and adolescents with prolactinoma to identify the differences from that of adults, and thus to establish the management strategies for this age group. METHODS Patients with prolactinoma diagnosed before 18 years of age from a single center in the last 20-years were included. Clinical and laboratory data, radiological findings and treatment outcome were evaluated retrospectively. RESULTS Twenty-eight patients (23 female; 82.1%) with prolactinoma were included. Median age at diagnosis was 15.2 years (12.6-17.7 years) in girls, 12.9 years (12.0-16.7 years) in boys. First line treatment was cabergoline in 82% of patients and normal prolactin level was achieved with maximum dose of 2 mg/week in 78%. Surgery was required in 28% of patients. Adenomas < 13.5 mm responded conventional doses of CAB. Adenomas > 30 mm were drug resistant or required surgery. Adenomas between 13.5 mm and 30 mm with invasion/extension were more likely to have drug resistance. CAB had to be continued following surgery in all patients. One macroprolactinoma had an increase in size which was accompanied with increasing prolactin level. CONCLUSIONS All microprolactinomas responded well to DA treatment. However, all adenomas larger than 30 mm was resistant to CAB or required surgery. Probability of drug resistance and requirement of second line therapy were higher in adenomas between 13.5 mm and 30 mm with invasion/extension. Doses over 2 mg/week of CAB in drug-resistant patients may not provide additional benefit. The frequency of follow-up MRI could be determined based on prolactin levels and emergence of new neurological symptoms.
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Affiliation(s)
- Ayfer Alikasifoglu
- Division of Pediatric Endocrinology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Nur Berna Celik
- Division of Pediatric Endocrinology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey.
| | - Zeynep Alev Ozon
- Division of Pediatric Endocrinology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Elmas Nazli Gonc
- Division of Pediatric Endocrinology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Nurgun Kandemir
- Division of Pediatric Endocrinology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
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De Sousa SMC. Dopamine agonist therapy for prolactinomas: do we need to rethink the place of surgery in prolactinoma management? ENDOCRINE ONCOLOGY (BRISTOL, ENGLAND) 2022; 2:R31-R50. [PMID: 37435462 PMCID: PMC10259306 DOI: 10.1530/eo-21-0038] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 04/20/2022] [Indexed: 07/13/2023]
Abstract
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.
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Affiliation(s)
- Sunita M C De Sousa
- Endocrine & Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia
- South Australian Adult Genetics Unit, Royal Adelaide Hospital, Adelaide, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, Australia
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Wildemberg LE, Fialho C, Gadelha MR. Prolactinomas. Presse Med 2021; 50:104080. [PMID: 34687915 DOI: 10.1016/j.lpm.2021.104080] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 08/31/2021] [Accepted: 10/12/2021] [Indexed: 12/28/2022] Open
Abstract
Hyperprolactinemia, defined by a level of serum prolactin above the standard upper limit of normal range, is a common finding in clinical practice and prolactinomas are the main pathological cause. Prolactinomas lead to signs and symptoms of hormone oversecretion, such as galactorrhea and hypogonadism, as well as symptoms of mass effect, including visual impairment, headaches and intracranial hypertension. Diagnosis involves prolactin measurement and sellar imaging, but several pitfalls are involved in this evaluation, which may difficult the proper management. Treatment is medical in the majority of cases, consisting of dopamine agonists, which present high response rates, with a very favorable safety profile. Major adverse effects that should be monitored consist of cardiac valvulopathy and impulse control disorders. Other treatment options include surgery and radiotherapy. Temozolomide may be used for aggressive or malignant carcinomas. Finally, pregnancy outcomes are similar to general population even when dopamine agonist treatment is maintained.
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Affiliation(s)
- Luiz Eduardo Wildemberg
- Endocrine Unit and Neuroendocrinology Research Center, Medical School and Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil; Neuroendocrine Unit - Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil
| | - Christhiane Fialho
- Endocrine Unit and Neuroendocrinology Research Center, Medical School and Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Monica R Gadelha
- Endocrine Unit and Neuroendocrinology Research Center, Medical School and Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil; Neuroendocrine Unit - Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil; Neuropathology and Molecular Genetics Laboratory, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil.
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McCormack A. Childhood-onset prolactinomas-Should earlier surgery be considered? Clin Endocrinol (Oxf) 2021; 95:571-573. [PMID: 33876444 DOI: 10.1111/cen.14477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 03/29/2021] [Accepted: 03/30/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Ann McCormack
- Department of Endocrinology, St Vincent's Hospital, Sydney, NSW, Australia
- Garvan Institute of Medical Research, Sydney, NSW, Australia
- Faculty of Medicine, St Vincent's Clinical School, UNSW Sydney, Sydney, NSW, Australia
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Chen Y, Moutal A, Navratilova E, Kopruszinski C, Yue X, Ikegami M, Chow M, Kanazawa I, Bellampalli SS, Xie J, Patwardhan A, Rice K, Fields H, Akopian A, Neugebauer V, Dodick D, Khanna R, Porreca F. The prolactin receptor long isoform regulates nociceptor sensitization and opioid-induced hyperalgesia selectively in females. Sci Transl Med 2021; 12:12/529/eaay7550. [PMID: 32024801 DOI: 10.1126/scitranslmed.aay7550] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 12/08/2019] [Indexed: 12/11/2022]
Abstract
Pain is more prevalent in women for reasons that remain unclear. We have identified a mechanism of injury-free nociceptor sensitization and opioid-induced hyperalgesia (OIH) promoted by prolactin (PRL) in females. PRL signals through mutually inhibitory long (PRLR-L) and short (PRLR-S) receptor isoforms, and PRLR-S activation induces neuronal excitability. PRL and PRLR expression were higher in females. CRISPR-mediated editing of PRLR-L promoted nociceptor sensitization and allodynia in naïve, uninjured female mice that depended on circulating PRL. Opioids, but not trauma-induced nerve injury, decreased PRLR-L promoting OIH through activation of PRLR-S in female mice. Deletion of both PRLR-L and PRLR-S (total PRLR) prevented, whereas PRLR-L overexpression rescued established OIH selectively in females. Inhibition of circulating PRL with cabergoline, a dopamine D2 agonist, up-regulated PRLR-L and prevented OIH only in females. The PRLR-L isoform therefore confers protection against PRL-promoted pain in females. Limiting PRL/PRLR-S signaling pharmacologically or with gene therapies targeting the PRLR may be effective for reducing pain in a female-selective manner.
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Affiliation(s)
- Yanxia Chen
- Department of Pharmacology, University of Arizona College of Medicine, Tucson, AZ 85724, USA
| | - Aubin Moutal
- Department of Pharmacology, University of Arizona College of Medicine, Tucson, AZ 85724, USA
| | - Edita Navratilova
- Department of Pharmacology, University of Arizona College of Medicine, Tucson, AZ 85724, USA
| | - Caroline Kopruszinski
- Department of Pharmacology, University of Arizona College of Medicine, Tucson, AZ 85724, USA
| | - Xu Yue
- Department of Pharmacology, University of Arizona College of Medicine, Tucson, AZ 85724, USA
| | - Megumi Ikegami
- Department of Pharmacology, University of Arizona College of Medicine, Tucson, AZ 85724, USA
| | - Michele Chow
- Department of Pharmacology, University of Arizona College of Medicine, Tucson, AZ 85724, USA
| | - Iori Kanazawa
- Department of Pharmacology, University of Arizona College of Medicine, Tucson, AZ 85724, USA
| | - Shreya Sai Bellampalli
- Department of Pharmacology, University of Arizona College of Medicine, Tucson, AZ 85724, USA
| | - Jennifer Xie
- Department of Pharmacology, University of Arizona College of Medicine, Tucson, AZ 85724, USA
| | - Amol Patwardhan
- Department of Pharmacology, University of Arizona College of Medicine, Tucson, AZ 85724, USA
| | - Kenner Rice
- National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD 20892, USA
| | - Howard Fields
- Department of Neurology, University of California San Francisco, San Francisco, CA 94143, USA
| | - Armen Akopian
- University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | | | | | - Rajesh Khanna
- Department of Pharmacology, University of Arizona College of Medicine, Tucson, AZ 85724, USA
| | - Frank Porreca
- Department of Pharmacology, University of Arizona College of Medicine, Tucson, AZ 85724, USA. .,Mayo Clinic, Scottsdale, AZ 85752, USA
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Stiles CE, Lloyd G, Bhattacharyya S, Steeds RP, Boomla K, Bestwick JP, Drake WM. Incidence of Cabergoline-Associated Valvulopathy in Primary Care Patients With Prolactinoma Using Hard Cardiac Endpoints. J Clin Endocrinol Metab 2021; 106:e711-e720. [PMID: 33247916 PMCID: PMC7823250 DOI: 10.1210/clinem/dgaa882] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Controversy exists as to whether low-dose cabergoline is associated with clinically significant valvulopathy. Few studies examine hard cardiac endpoint data, most relying on echocardiographic findings. OBJECTIVES To determine the prevalence of valve surgery or heart failure in patients taking cabergoline for prolactinoma against a matched nonexposed population. DESIGN Population-based cohort study based on North East London primary care records. METHODS Data were drawn from ~1.5 million patients' primary care records. We identified 646 patients taking cabergoline for >6 months for prolactinoma. These were matched to up to 5 control individuals matched for age, gender, ethnicity, location, diabetes, hypertension, ischemic heart disease, and smoking status. Cumulative doses/durations of treatment were calculated. Cardiac endpoints were defined as cardiac valve surgery or heart failure diagnosis (either diagnostic code or prescription code for associated medications). RESULTS A total of 18 (2.8%) cabergoline-treated patients and 62 (2.33%) controls reached a cardiac endpoint. Median cumulative cabergoline dose was 56 mg (interquartile range [IQR] 27-123). Median treatment duration was 27 months (IQR 15-46). Median weekly dose was 2.1 mg. Neither univariate nor multivariate analysis demonstrated a significant association between cabergoline treatment at any cumulative dosage/duration and an increased incidence of cardiac endpoints. In a matched analysis, the relative risk for cardiac complications in the cabergoline-treated group was 0.78 (95% CI, 0.41-1.48; P = 0.446). Reanalysis of echocardiograms for 6/18 affected cabergoline-treated patients showed no evidence of ergot-derived drug valvulopathy. CONCLUSIONS The data did not support an association between clinically significant valvulopathy and low-dose cabergoline treatment and provide further evidence for a reduction in frequency of surveillance echocardiography.
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Affiliation(s)
- Craig Edward Stiles
- Queen Mary University of London, London, UK
- Department of Endocrinology, Saint Bartholomew’s Hospital, London, UK
| | - Guy Lloyd
- Department of Cardiology, Saint Bartholomew’s Hospital, London, UK
| | | | - Richard Paul Steeds
- University Hospital Birmingham, Birmingham, UK
- Institute of Cardiology, University of Birmingham, Birmingham, UK
| | - Kambiz Boomla
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Jonathan Paul Bestwick
- Centre for Environmental and Preventive Medicine, Queen Mary University of London, London, UK
| | - William Martyn Drake
- Queen Mary University of London, London, UK
- Department of Endocrinology, Saint Bartholomew’s Hospital, London, UK
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Giese S, Nasi-Kordhishti I, Honegger J. Outcomes of Transsphenoidal Microsurgery for Prolactinomas - A Contemporary Series of 162 Cases. Exp Clin Endocrinol Diabetes 2021; 129:163-171. [PMID: 33461233 DOI: 10.1055/a-1247-4908] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Renewed interest in transsphenoidal surgery (TSS) as a therapeutic option for prolactinomas has emerged. This study is aimed at defining the current role of pituitary surgery in the management of prolactinomas. MATERIALS AND METHODS In this retrospective, consecutive single-center study, 162 patients who underwent primary microscopic TSS for prolactinomas between 2006 and 2019 were analyzed regarding surgical indication, previous dopamine-agonist (DA) treatment, early remission rates (3 months postoperatively), surgical complications and pituitary function. RESULTS Seventy-four microprolactinomas and 88 macroprolactinomas were operated by TSS. 62.3% of the patients had received prior DA treatment. For microprolactinomas, the predominant indication for surgery was patient's wish (41.9%), while indications for macroprolactinomas varied. For enclosed microprolactinomas, the initial remission rate was 92.1%, while for macroprolactinomas, the rate was 70.4%. No significant difference of remission rates was found between DA-pretreated (65.3%) and non-pretreated (72.1%) patients (p=0.373).None of the patients suffered a significant complication. Re-operation for a postoperative cerebrospinal fluid leak was required in one patient (0.6%). Permanent postoperative deterioration of pituitary function was only observed in one of 158 patients with surgery for a prolactinoma (0.6%). Improvement of pituitary function was observed in 8 of 25 patients (32%) with preoperative deficits. CONCLUSION Transsphenoidal microsurgery is safe and efficient for treatment of prolactinomas. It is particularly suitable for enclosed prolactinomas. The patient should be well informed of the pros and cons of the treatment options, which include DA medication and TSS, and the patient's preference should be taken into account during decision-making.
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Affiliation(s)
- Sabrina Giese
- Department of Neurosurgery, University of Tübingen, Tübingen
| | | | - Jürgen Honegger
- Department of Neurosurgery, University of Tübingen, Tübingen
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Pirchio R, Auriemma RS, Solari D, Arnesi M, Pivonello C, Negri M, de Angelis C, Cavallo LM, Cappabianca P, Colao A, Pivonello R. Effects of Pituitary Surgery and High-Dose Cabergoline Therapy on Metabolic Profile in Patients With Prolactinoma Resistant to Conventional Cabergoline Treatment. Front Endocrinol (Lausanne) 2021; 12:769744. [PMID: 34917030 PMCID: PMC8670228 DOI: 10.3389/fendo.2021.769744] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 10/29/2021] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE Control of prolactin excess is associated with the improvement in gluco-insulinemic and lipid profile. The current study aimed at investigating the effects of pituitary surgery and medical therapy with high dose cabergoline (≥2mg/week) on metabolic profile in patients with prolactinoma resistant to cabergoline conventional doses (<2mg/week). DESIGN Thirty-four patients (22 men, 12 women, aged 33.9 ± 12.5 years) with prolactinoma (4 microadenomas and 30 macroadenomas) were included in the present study. Among them 17 (50%) received pituitary surgery (PS, Group1) and 17 (50%) medical therapy with high dose cabergoline (Group 2). METHODS In the whole patient cohort, anthropometric (weight, BMI) and biochemical (fasting glucose and insulin, triglycerides, total, HDL and LDL-cholesterol, HOMA-IR, HOMA-β and ISI0) parameters were evaluated before and within 12 months after treatment. RESULTS In Group 1, prolactin (p=0.002), total cholesterol (p=0.012), and triglycerides (p=0.030) significantly decreased after pituitary surgery compared to the baseline. Prolactin significantly correlated with fasting glucose (r=0.056, p=0.025). In Group 2, fasting insulin (p=0.033), HOMA-β (p=0.011) and ISI0 (p=0.011) significantly improved compared to baseline. Postoperative cabergoline dose significantly correlated with Δfasting glucose (r=-0.556, p=0.039) and ΔLDL cholesterol (r=- 0.521, p=0.046), and was the best predictor of ΔLDL cholesterol (r2 = 0.59, p=0.002) in Group 1. CONCLUSIONS The rapid decrease in PRL levels induced by PS might improve lipid metabolism, whereas HD-CAB might exert a beneficial impact on both insulin secretion and peripheral sensitivity, thus inducing a global metabolic improvement.
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Affiliation(s)
- Rosa Pirchio
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università “Federico II” di Napoli, Naples, Italy
| | - Renata S. Auriemma
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università “Federico II” di Napoli, Naples, Italy
| | - Domenico Solari
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Mauro Arnesi
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università “Federico II” di Napoli, Naples, Italy
| | - Claudia Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università “Federico II” di Napoli, Naples, Italy
| | - Mariarosaria Negri
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università “Federico II” di Napoli, Naples, Italy
| | - Cristina de Angelis
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università “Federico II” di Napoli, Naples, Italy
| | - Luigi M. Cavallo
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Paolo Cappabianca
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università “Federico II” di Napoli, Naples, Italy
- Unesco Chair for Health Education and Sustainable Development, “Federico II” University, Naples, Italy
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università “Federico II” di Napoli, Naples, Italy
- *Correspondence: Rosario Pivonello,
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12
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Castinetti F, Albarel F, Amodru V, Cuny T, Dufour H, Graillon T, Morange I, Brue T. The risks of medical treatment of prolactinoma. ANNALES D'ENDOCRINOLOGIE 2020; 82:15-19. [PMID: 33373604 DOI: 10.1016/j.ando.2020.12.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/16/2020] [Indexed: 01/14/2023]
Abstract
First-line treatment of prolactinoma is usually medical, based on dopamine agonists receptors, mainly cabergoline. The classical side-effects of cabergoline (low blood pressure and nausea) have been well known since it was first introduced. Other side-effects, however, are more controversial or simply less frequent, but need to be considered during monitoring. This review will focus on these side-effects: cardiac valvular fibrosis, pleural, pericardial and retroperitoneal fibrosis, addictive/compulsive behaviors, and risks secondary to significantly decreased tumor volume. We will also describe how such side-effects should be monitored and managed. In our opinion, the low prevalence of these side-effects should not cast doubt on the role of cabergoline in the therapeutic algorithm of prolactinoma.
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Affiliation(s)
- Frederic Castinetti
- Service d'endocrinologie, hôpital de la Conception, 147, boulevard Baille, 13005 Marseille, France; Aix Marseille université, centre de références maladies rares HYPO, Assistance Publique-Hôpitaux de Marseille, Marseille, France.
| | - Frederique Albarel
- Service d'endocrinologie, hôpital de la Conception, 147, boulevard Baille, 13005 Marseille, France; Aix Marseille université, centre de références maladies rares HYPO, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Vincent Amodru
- Service d'endocrinologie, hôpital de la Conception, 147, boulevard Baille, 13005 Marseille, France; Aix Marseille université, centre de références maladies rares HYPO, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Thomas Cuny
- Service d'endocrinologie, hôpital de la Conception, 147, boulevard Baille, 13005 Marseille, France; Aix Marseille université, centre de références maladies rares HYPO, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Henry Dufour
- Service de neurochirurgie, hôpital de la Timone, Timone, France; Aix Marseille université, centre de références maladies rares HYPO, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Thomas Graillon
- Service de neurochirurgie, hôpital de la Timone, Timone, France; Aix Marseille université, centre de références maladies rares HYPO, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Isabelle Morange
- Service d'endocrinologie, hôpital de la Conception, 147, boulevard Baille, 13005 Marseille, France; Aix Marseille université, centre de références maladies rares HYPO, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Thierry Brue
- Service d'endocrinologie, hôpital de la Conception, 147, boulevard Baille, 13005 Marseille, France; Aix Marseille université, centre de références maladies rares HYPO, Assistance Publique-Hôpitaux de Marseille, Marseille, France
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13
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Stiles CE, Steeds RP, Drake WM. Monitoring patients receiving dopamine agonist therapy for hyperprolactinaemia. ANNALES D'ENDOCRINOLOGIE 2020; 82:182-186. [PMID: 32178837 DOI: 10.1016/j.ando.2020.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The surveillance strategy for patients taking low dose cabergoline for hyperprolactinaemia is controversial. As more evidence has emerged that the risks of cardiac valvulopathy in this population of patients are low, fewer and fewer endocrinologists adhere strictly to the original medicines and healthcare products agency MHRA guidance of "at least" annual echocardiography. Strict adherence to this guidance would be costly in monetary terms (£5.76 million/year in the UK) and also in resource use (90,000 extra echocardiograms/year). This article reviews the proposed pathophysiological mechanism underlying the phenomenon of dopamine agonist valvulopathy, the characteristic echocardiographic changes seen, summarises the published literature on the incidence of valvulopathy with low dose cabergoline and examines the previous and current evidence-based screening guidelines.
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Affiliation(s)
- C E Stiles
- Department of Endocrinology, Queen Mary University of London, E1 4NS London, United Kingdom; Department of Endocrinology, Saint-Bartholomew's Hospital, EC1A 7BE London, United Kingdom.
| | - R P Steeds
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, B15 2GW Birmingham, United Kingdom; Institute of Cardiovascular Sciences, University of Birmingham, B15 2TT Birmingham, United Kingdom
| | - W M Drake
- Department of Endocrinology, Queen Mary University of London, E1 4NS London, United Kingdom; Department of Endocrinology, Saint-Bartholomew's Hospital, EC1A 7BE London, United Kingdom
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14
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Abstract
PURPOSE Renewed interest in transsphenoidal surgery (TSS) as a therapeutic option for prolactinomas has emerged. METHODS Based on contemporary literature and own experience, the changing role of surgery for treatment of prolactinomas is discussed. RESULTS Today, TSS is performed by minimally invasive microscopic or endoscopic techniques. Normoprolactinemia is obtained in 71-100% of patients with microprolactinomas by TSS. Almost equal results are found in circumscribed intrasellar macroprolactinomas. In experienced hands, pituitary function is preserved in TSS. The risk of cardiac valve disease is still a concern with ergot-derived dopamine-agonists (DAs) in patients requiring long-term, high-dose dopamine-agonist (DA) treatment. Cost-utility analysis favors TSS over DA treatment. The possible negative impact of DA treatment on future surgical results is still a controversial and unsettled issue. In patients who wish to become pregnant, the advantages of microprolactinoma removal to avoid DAs and macroprolactinoma debulking to avoid symptomatic enlargement during pregnancy should be discussed with the patients. Young patients' age is an argument for surgery to circumvent the unpredictable sequelae of long-term DA treatment. Surgery should be discussed in male gender because of a higher likelihood of DA resistance and aggressive behavior of prolactinoma. CONCLUSION Given excellent results of TSS and concerns about medical treatment, the scale of indications for TSS as an alternative to DAs has increased. The patient's wishes concerning a chance at a cure with TSS instead of a long-term treatment with DAs has become an important and accepted indication. With DA medication and TSS, two effective treatment modalities for prolactinomas are available that can be used in a complementary fashion.
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Affiliation(s)
- Jürgen Honegger
- Department of Neurosurgery, University of Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany.
| | - Isabella Nasi-Kordhishti
- Department of Neurosurgery, University of Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany
| | - Nuran Aboutaha
- Department of Neurosurgery, University of Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany
| | - Sabrina Giese
- Department of Neurosurgery, University of Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany
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15
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Caputo C, Inder WJ. Letter to the Editor: "A Meta-Analysis of the Prevalence of Cardiac Valvulopathy in Patients With Hyperprolactinemia Treated With Cabergoline". J Clin Endocrinol Metab 2019; 104:4319-4320. [PMID: 30933294 DOI: 10.1210/jc.2019-00577] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 03/26/2019] [Indexed: 02/13/2023]
Affiliation(s)
- Carmela Caputo
- Department of Diabetes and Endocrinology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - Warrick J Inder
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital Brisbane, and Faculty of Medicine, the University of Queensland, Brisbane, Queensland, Australia
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16
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Giant cabergoline-resistant prolactinoma in a man who presented with a psychotic episode during treatment: a case report. J Med Case Rep 2019; 13:183. [PMID: 31202268 PMCID: PMC6571118 DOI: 10.1186/s13256-019-2071-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 04/04/2019] [Indexed: 11/10/2022] Open
Abstract
Background Prolactinomas are tumors of the pituitary gland that usually respond very well to treatment with cabergoline. Resistance to cabergoline is very rare, but when it occurs, it is a difficult problem to resolve if the tumor is inoperable. Case presentation A 62-year-old white man was treated for a giant macroprolactinoma detected during investigation of a subacute subdural hematoma of the left frontal lobe. The patient was treated with cabergoline for 17 years with a dose ranging from 1.0 mg to 3.5 mg per week. We were not able to normalize his prolactin level, which initially was 14,992 ng/ml and ultimately 1754 ng/ml. The tumor significantly shrank during the follow-up period but persisted. The patient had cardiac valvulopathies that did not worsen. He had an ischemic stroke and developed a psychotic condition that was successfully treated by lowering the cabergoline and administering quetiapine and mirtazapine together. This regimen led to a small increase in the patient’s prolactin that returned to previous levels and remained as such until the last medical evaluation. The tumor continued to shrink and had a cystic degeneration in the last evaluation. Conclusions Combined use of cabergoline with quetiapine and mirtazapine to treat a psychotic crisis may have contributed to shrinking the tumor in our patient because these antipsychotics have action mediated by growth factors that interfere with growth of pituitary tumors.
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17
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Steeds RP, Stiles CE, Sharma V, Chambers JB, Lloyd G, Drake W. Echocardiography and monitoring patients receiving dopamine agonist therapy for hyperprolactinaemia: a joint position statement of the British Society of Echocardiography, the British Heart Valve Society and the Society for Endocrinology. Echo Res Pract 2019; 6:G1-G8. [PMID: 30825409 PMCID: PMC6391931 DOI: 10.1530/erp-18-0069] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 01/28/2019] [Indexed: 12/12/2022] Open
Abstract
This is a joint position statement of the British Society of Echocardiography, the British Heart Valve Society and the Society for Endocrinology on the role of echocardiography in monitoring patients receiving dopamine agonist (DA) therapy for hyperprolactinaemia. (1) Evidence that DA pharmacotherapy causes abnormal valve morphology and dysfunction at doses used in the management of hyperprolactinaemia is extremely limited. Evidence of clinically significant valve pathology is absent, except for isolated case reports around which questions remain. (2) Attributing change in degree of valvular regurgitation, especially in mild and moderate tricuspid regurgitation, to adverse effects of DA in hyperprolactinaemia should be avoided if there are no associated pathological changes in leaflet thickness, restriction or retraction. It must be noted that even where morphological change in leaflet structure and function may be suspected, grading is semi-quantitative on echocardiography and may vary between different machines, ultrasound settings and operators. (3) Decisions regarding discontinuation of medication should only be made after review of serial imaging by an echocardiographer experienced in analysing drug-induced valvulopathy or carcinoid heart disease. (4) A standard transthoracic echocardiogram should be performed before a patient starts DA therapy for hyperprolactinaemia. Repeat transthoracic echocardiography should then be performed at 5 years after starting cabergoline in patients taking a total weekly dose less than or equal to 2 mg. If there has been no change on the 5-year scan, repeat echocardiography could continue at 5-yearly intervals. If a patient is taking more than a total weekly dose of 2 mg, then annual echocardiography is recommended.
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Affiliation(s)
- Richard P Steeds
- University Hospital Birmingham, Birmingham, UK.,Institute of Cardiology, University of Birmingham, Birmingham, UK
| | - Craig E Stiles
- Department of Endocrinology, Saint Bartholomew's Hospital, London, UK
| | - Vishal Sharma
- Department of Cardiology, Royal Liverpool and Broadgreen University Hospital, Liverpool, UK
| | - John B Chambers
- Cardiothoracic Centre, Guy's and St Thomas' Hospitals - London, UK
| | - Guy Lloyd
- Department of Cardiology, Saint Bartholomew's Hospital, London, UK
| | - William Drake
- Department of Endocrinology, Bartholomew's Hospital, London, UK
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18
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Vroonen L, Daly AF, Beckers A. Epidemiology and Management Challenges in Prolactinomas. Neuroendocrinology 2019; 109:20-27. [PMID: 30731464 DOI: 10.1159/000497746] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 02/06/2019] [Indexed: 11/19/2022]
Abstract
Clinically relevant pituitary adenomas are present in about 1 per 1,000 of the general population and prolactinomas are by far the most common clinical subtype of pituitary adenomas. Usually prolactinomas affect premenopausal women and present with typical symptoms of menstrual disturbance and/or galactorrhea. They are generally managed with dopamine agonists to restore fertility and to control symptoms and tumor size. In a subset of prolactinomas, however, management remains challenging. Studies in recent years have identified the factors related to dopamine agonist resistance, such as male sex, genetic features, and aggressive tumor behavior. Certain other patient groups represent particular challenges for management, such as pediatric patients and pregnant women. Treatment with dopamine agonists is usually safe and effective, and adverse effects such as clinically relevant cardiac valvular complications and impulse control disorders may occur in isolated instances. A number of important disease characteristics of prolactinomas remain to be explained, such as the difference in sex prevalence before and after menopause, the higher prevalence of macroadenomas in older males, and the biochemical mechanisms of resistance to dopaminergic agonists.
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Affiliation(s)
- Laurent Vroonen
- Department of Endocrinology, Centre Hospitalier Universitaire de Liège, Liège Université, Liège, Belgium
| | - Adrian F Daly
- Department of Endocrinology, Centre Hospitalier Universitaire de Liège, Liège Université, Liège, Belgium
| | - Albert Beckers
- Department of Endocrinology, Centre Hospitalier Universitaire de Liège, Liège Université, Liège, Belgium,
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19
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Liu S, Hu C, Peters J, Tsang A, Cremers S, Bies R, Page-Wilson G. Pharmacokinetics and pharmacodynamics of ropinirole in patients with prolactinomas. Br J Clin Pharmacol 2018; 85:366-376. [PMID: 30362146 DOI: 10.1111/bcp.13802] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 09/20/2018] [Accepted: 10/12/2018] [Indexed: 01/10/2023] Open
Abstract
AIMS Treatment of prolactinomas with ergoline dopamine agonists can be complicated by intolerance and resistance. This study investigated the pharmacokinetics and pharmacodynamics of the nonergot dopamine agonist ropinirole, to assess its therapeutic potential as a novel therapy for prolactinomas. METHODS Five female subjects with prolactinomas participated in this dose-response study. Subjects received up to three doses of ropinirole (0.5, 1.0 and 2.0 mg), each on separate occasions. Frequent blood samples for prolactin and ropinirole were collected for 24 h following drug administration. Data were analysed using noncompartmental and compartmental pharmacokinetic-pharmacodynamic (PKPD) techniques. RESULTS Seven 24-h curves revealed increased systemic drug exposure with increasing ropinirole doses. Ropinirole concentrations peaked at 4.4 ± 2.7 h and exhibited a half-life of 5.8 ± 1.7 h. A dose-dependent prolactin nadir occurred 4.4 ± 1.2 h after drug intake and prolactin concentrations transiently normalized in two of five subjects. PKPD modelling revealed that single-dose PK of ropinirole is dose-independent and can be described with a one-compartment model with linear absorption and elimination. An indirect response model successfully captures the inhibitory effect of ropinirole on prolactin secretion and incorporates time-dependent receptor desensitization for three of five subjects whose prolactin concentrations nadired before ropinirole reached Cmax . CONCLUSIONS This data-rich study has informed our understanding of the clinical pharmacokinetics and pharmacodynamics of ropinirole, which are successfully captured by the proposed semi-mechanistic PKPD model. This model can be used to further investigate the PKPD of ropinirole and may facilitate the identification of optimal dose regimens for the treatment of prolactinomas and the establishment of a new therapeutic option for patients impacted by this rare disease.
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Affiliation(s)
- Sihang Liu
- State University of New York at Buffalo, Buffalo, NY, USA
| | - Can Hu
- College of Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Jane Peters
- College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Amanda Tsang
- College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Serge Cremers
- College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Robert Bies
- State University of New York at Buffalo, Buffalo, NY, USA
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20
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Stiles CE, Tetteh-Wayoe ET, Bestwick J, Steeds RP, Drake WM. A meta-analysis of the prevalence of cardiac valvulopathy in hyperprolactinemic patients treated with Cabergoline. J Clin Endocrinol Metab 2018; 104:5094016. [PMID: 30215804 DOI: 10.1210/jc.2018-01071] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 09/04/2018] [Indexed: 01/08/2023]
Abstract
CONTEXT Cabergoline is first line treatment for most patients with lactotrope pituitary tumors and hyperprolactinemia. Its use at high-dose in Parkinson's disease has largely been abandoned, because of its association with the development of a characteristic restrictive cardiac valvulopathy. Whether similar valvular changes occur in patients receiving lower doses for treatment of hyperprolactinemia is unclear, although stringent regulatory recommendations for echocardiographic screening exist. OBJECTIVE To conduct a meta-analysis exploring any link between the use of cabergoline for the treatment of hyperprolactinemia and clinically-significant cardiac valvulopathy. DATA SOURCES Full-text papers published up to and including January 2017 were found via PubMed and selected according to strict inclusion criteria. STUDY SELECTION All case-control studies were included where patients had received ≥6 months cabergoline treatment for hyperprolactinemia. Single case reports, previous meta-analyses, review papers and papers pertaining solely to Parkinson's disease were excluded. 13/76 originally selected studies met inclusion criteria. DATA EXTRACTION A list of desired data were compiled and extracted from papers by independent observers. Each also independently graded for paper quality (bias) and met to reach consensus. DATA SYNTHESIS More tricuspid regurgitation was observed (OR 3.74; 95% CI 1.79-7.8 p<0.001) in the cabergoline treated patients compared to controls. In no patient was tricuspid valve dysfunction diagnosed as a result of clinical symptoms. There was no significant increase in any other valvulopathy. CONCLUSIONS Treatment with low dose cabergoline in hyperprolactinemia appears to be associated with an increased prevalence of tricuspid regurgitation. The clinical significance of this is unclear and requires further investigation. 51.
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Affiliation(s)
- C E Stiles
- Queen Mary University of London, Department of Endocrinology, London
- Department of Endocrinology, St Bartholomew's Hospital, London
| | - E T Tetteh-Wayoe
- Queen Mary University of London, Department of Endocrinology, London
| | - J Bestwick
- Queen Mary University of London, Centre for Environmental and Preventive Medicine, London
| | - R P Steeds
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham
| | - W M Drake
- Department of Endocrinology, St Bartholomew's Hospital, London
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21
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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.
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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
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22
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Caputo C, Prior D, Inder WJ. The Third Case of Cabergoline-Associated Valvulopathy: The Value of Routine Cardiovascular Examination for Screening. J Endocr Soc 2018; 2:965-969. [PMID: 30083627 PMCID: PMC6070051 DOI: 10.1210/js.2018-00139] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 07/06/2018] [Indexed: 12/21/2022] Open
Abstract
A decade after the alarming association of cabergoline-associated valvulopathy (CAV) in Parkinson disease, only two confirmed cases have occurred in patients with prolactinoma. Routine screening for CAV by echocardiography has not proved to be of diagnostic utility, has several limitations, and is not widely practiced. We have previously highlighted the value of annual cardiovascular examination as a screening tool for CAV in patients with prolactinoma. We present a case, now the third confirmed case of CAV, to highlight the value of the cardiovascular examination. A 52-year-old woman with a 25-year history of macroprolactinoma had received multimodal treatment, including surgery, radiosurgery, and medical therapy. Her medical therapy initially consisted of bromocriptine, followed by cabergoline. The cabergoline dose was 6 mg weekly. In 2009, the cumulative dose was 3272 mg when an echocardiogram showed no evidence of valvular disease. A routine cardiovascular examination in the clinic detected a new murmur in 2016. The echocardiogram demonstrated new-onset mild to moderate aortic regurgitation, with a thickened and restricted valve consistent with CAV. The cumulative dose of cabergoline at that point was 4192 mg. Follow-up echocardiography at 6-month intervals showed progression to moderate to severe aortic regurgitation, which has since stabilized. Cabergoline therapy was weaned and stopped completely in April 2017. An annual cardiovascular examination is the best screening test for CAV and can change the course of a patient’s treatment. Echocardiograms should be reserved for patients with a new-onset cardiac murmur or a high cumulative dose of cabergoline.
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Affiliation(s)
- Carmela Caputo
- Department of Diabetes and Endocrinology, St. Vincent's Hospital Melbourne, Victoria, Australia
| | - David Prior
- Department of Cardiology, St. Vincent's Hospital Melbourne and The University of Melbourne, Victoria, Australia
| | - Warrick J Inder
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital Brisbane, and Faculty of Medicine, University of Queensland, Brisbane, Australia
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Rutkowski MJ, Aghi MK. Medical versus surgical treatment of prolactinomas: an analysis of treatment outcomes. Expert Rev Endocrinol Metab 2018; 13:25-33. [PMID: 30063440 DOI: 10.1080/17446651.2018.1411798] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Prolactinomas are unique tumors that may go into both hormonal and radiographic remission with dopamine agonist therapy or transsphenoidal surgery. Regardless of modality, the goals of therapy remain the same: (1) biochemical remission, including reduction of prolactin and normalization of sex hormones; (2) radiographic tumor control, with a range including prevention of tumor growth, tumor regression, or complete tumor resolution; (3) resolution of preoperative symptoms, including those that are hormonal or neurologic; and (4) prevention of new hypopituitarism or new neurologic symptoms. AREAS COVERED In the following review, we performed a search of the literature using keywords 'prolactinoma,' 'dopamine agonist,' 'surgery,' 'cost-effectiveness,' 'recurrence,' and 'complication' to compare the relative merits of medical versus surgical therapy for prolactinoma, including special circumstances such as cystic tumors, pregnant patients, and the cost-effectiveness of different strategies. EXPERT COMMENTARY Medical therapy can offer a cure, but surgery provides an important adjunct to patients with resistance or intolerance to dopamine agonists, and offers excellent outcomes including when combined with continued postoperative medical therapy. Further head to head comparisons will benefit patients and practitioners weighing the relative risks and benefits of medical and surgical intervention, including the issue of their relative cost-effectiveness.
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Affiliation(s)
- Martin J Rutkowski
- a California Center for Pituitary Disorders, Department of Neurological Surgery , University of California , San Francisco , CA , USA
| | - Manish K Aghi
- a California Center for Pituitary Disorders, Department of Neurological Surgery , University of California , San Francisco , CA , USA
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Nachtigall LB. Cabergoline for hyperprolactinemia: getting to the heart of it. Endocrine 2017; 57:3-5. [PMID: 28260205 DOI: 10.1007/s12020-017-1271-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 02/20/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Lisa B Nachtigall
- Neuroendocrine Clinic Center, Massachusetts General Hospital, Zero Emerson Place Suite 112, Boston, MA, 02114, USA.
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Gamble D, Fairley R, Harvey R, Farman C, Cantley N, Leslie SJ. Screening for valve disease in patients with hyperprolactinaemia disorders prescribed cabergoline: a service evaluation and literature review. Ther Adv Drug Saf 2017; 8:215-229. [PMID: 28845230 DOI: 10.1177/2042098617703647] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES The indication for screening for valvular heart disease in patients taking cabergoline is based on evidence from patients with Parkinson's disease on high-dose medication. However, current patients take much lower doses for indications such as hyperprolactinaemia disorders. Contemporary guidelines for echocardiogram monitoring in patients taking cabergoline are conflicting. This study aimed to review current clinical practice in our area regarding echocardiographic screening and to review the literature examining the evidence of valvular heart disease in patients taking lower dose cabergoline. METHODS This was a retrospective study of all patients with hyperprolactinaemia disorders prescribed cabergoline in a single UK NHS health board between January 2014 and July 2015. The proportion of patients receiving baseline and follow-up echocardiograms was recorded. A review of the published literature was carried out using the databases EMBASE and Medline to examine the current evidence for the effect cabergoline has on cardiac valves in patients treated for hyperprolactinaemia disorders. RESULTS The mean age was 51.7 ± 16.5 years with a 64.4% female predominance. The mean duration of therapy was 5.9 years ± 4.1 years. Of the total cohort (n = 45), two (4.4%) patients had an initial baseline echocardiogram and five (13.2%) had follow-up echocardiograms every 24 months. Of the 25 articles identified, 12 showed no clinically significant evidence of valvular dysfunction in the cabergoline group groups. Of the remaining 13 articles, evidence for valvular changes was confined to high cumulative dose cabergoline patients and there was only one confirmed case of 'cabergoline associated valvulopathy' described. CONCLUSIONS Clinically significant valvular dysfunction is uncommon and generally only reported in high cumulative dose treatment groups. We propose that clearer national guidelines are required and that echocardiogram screening be reserved for patients who are high risk, are taking a high weekly dose (≥2 mg cabergoline weekly) or high cumulative dose.
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Affiliation(s)
- David Gamble
- University of Aberdeen, Aberdeen Royal Infirmary, NHS Grampian, Foresterhill, Aberdeen, UK
| | - Rachel Fairley
- NHS Highland Medicine Information, Pharmacy Department, Raigmore Hospital, Inverness, UK
| | - Roderick Harvey
- Raigmore Hospital, NHS Highland, Old Perth Road, Inverness, UK
| | - Colin Farman
- Raigmore Hospital, NHS Highland, Old Perth Road, Inverness, UK
| | - Nathan Cantley
- Raigmore Hospital, NHS Highland, Old Perth Road, Inverness, UK
| | - Stephen J Leslie
- Cardiac Unit, Raigmore Hospital, NHS Highland, Old Perth Road, Inverness IV2 3UJ, UK
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Abstract
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.
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Affiliation(s)
- Emmanuelle Kuhn
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre Service d'Endocrinologie et des Maladies de la Reproduction, 78 rue du Général Leclerc, 94275, Le Kremlin-Bicêtre, France
- Faculté de Médecine Paris-Sud, Université Paris-Sud, Orsay, France
- Unité Mixte de Recherche-S1185, 94276, Le Kremlin Bicêtre, France
- Institut National de la Santé et de la Recherche Médicale (INSERM) U1185, 94276, Le Kremlin Bicêtre, France
| | - Philippe Chanson
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre Service d'Endocrinologie et des Maladies de la Reproduction, 78 rue du Général Leclerc, 94275, Le Kremlin-Bicêtre, France.
- Faculté de Médecine Paris-Sud, Université Paris-Sud, Orsay, France.
- Unité Mixte de Recherche-S1185, 94276, Le Kremlin Bicêtre, France.
- Institut National de la Santé et de la Recherche Médicale (INSERM) U1185, 94276, Le Kremlin Bicêtre, France.
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Khare S, Lila AR, Patil R, Phadke M, Kerkar P, Bandgar T, Shah NS. Long-term cardiac (valvulopathy) safety of cabergoline in prolactinoma. Indian J Endocrinol Metab 2017; 21:154-159. [PMID: 28217516 PMCID: PMC5240058 DOI: 10.4103/2230-8210.196010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Clinical relevance of association of cabergoline use for hyperprolactinemia and cardiac valvulopathy remains unclear. OBJECTIVE The aim of the study was to determine the prevalence of valvular heart abnormalities in patients taking cabergoline for the treatment of prolactinoma and to explore any associations with the cumulative dose of drug used. DESIGN A cross-sectional echocardiographic study was performed in patients who were receiving cabergoline therapy for prolactinoma. RESULTS Hundred (61 females, 39 males) prolactinoma cases (81 macroprolactinoma and 19 microprolactinoma) were included in the study. The mean age at presentation was 33.9 ± 9.0 years (range: 16-58 years). The mean duration of treatment was 53.11 ± 43.15 months (range: 12-155 months). The mean cumulative dose was 308.6 ± 290.2 mg (range: 26-1196 mg; interquartile range: 104-416 mg). Mild mitral regurgitation was present in one patient (cumulative cabergoline dose 104 mg). Mild tricuspid regurgitation was present in another two patients (cumulative cabergoline dose 52 mg and 104 mg). Aortic and pulmonary valve functioning was normal in all the cases. There were no cases of significant valvular regurgitation (moderate to severe, Grade 3-4). None of the patients had morphological abnormalities such as thickening, calcification, and restricted mobility of any of the cardiac valves. CONCLUSION Cabergoline appears to be safe in patients with prolactinoma up to the cumulative dose of ~300 mg. The screening for valvulopathy should be restricted to those with higher cumulative cabergoline exposure.
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Affiliation(s)
- Shruti Khare
- Department of Endocrinology, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Anurag R. Lila
- Department of Endocrinology, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Rishikesh Patil
- Department of Cardiology, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Milind Phadke
- Department of Cardiology, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Prafulla Kerkar
- Department of Cardiology, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Tushar Bandgar
- Department of Endocrinology, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Nalini S. Shah
- Department of Endocrinology, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
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Vroonen L, Lancellotti P, Garcia MT, Dulgheru R, Rubio-Almanza M, Maiga I, Magne J, Petrossians P, Auriemma R, Daly AF, Beckers A. Prospective, long-term study of the effect of cabergoline on valvular status in patients with prolactinoma and idiopathic hyperprolactinemia. Endocrine 2017; 55:239-245. [PMID: 27709470 DOI: 10.1007/s12020-016-1120-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 09/07/2016] [Indexed: 10/20/2022]
Abstract
Since the 1990's cabergoline has been the treatment of choice in prolactinoma, as it permits rapid and effective hormonal and tumor control in most cases. Evidence of cardiac valvulopathy was demonstrated in Parkinson's disease patients treated with dopamine agonists. Retrospective studies in prolactinoma patients treated with cabergoline at lower doses did not show such an effect. However, few prospective data with long-term follow-up are available. The aim of this study was to assess the safety of cabergoline regarding cardiac valvular status during prospective follow-up in patients treated for prolactinoma or idiopathic hyperprolactinemia. We report here a series of 100 patients (71F; median age at diagnosis: 41.5 years) treated with cabergoline for endocrine diseases (prolactinoma n = 89, idiopathic hyperprolactinemia n = 11). All patients underwent complete transthoracic echocardiographic studies at baseline and during long-term prospective surveillance using the same equipment and performed by the same technicians. The median interval between baseline and last follow-up echocardiographic studies while on cabergoline was 62.5 months (interquartile range: 34.75-77.0). The median total duration of cabergoline treatment was 124.5 months (interquartile range: 80.75-188.75) and the median cumulative total dose of cabergoline was 277.8 mg (interquartile range : 121.4-437.8 mg) at last follow-up. We found no clinically relevant alterations in cardiac valve function or valvular calcifications with cabergoline treatment. Our data suggest that findings from retrospective analyses are correct and that cabergoline is a safe chronic treatment at the doses used typically in endocrinology.
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Affiliation(s)
- Laurent Vroonen
- Department of Endocrinology, Center Hospitalier Universitaire de Liège, University of Liège, Domaine Universitaire du Sart-Tilman, Liège, 4000, Belgium
| | - Patrizio Lancellotti
- Department of Cardiology, Center Hospitalier Universitaire de Liège, University of Liège, Domaine Universitaire du Sart-Tilman, Liège, 4000, Belgium
| | - Monica Tomé Garcia
- Department of Endocrinology, Center Hospitalier Universitaire de Liège, University of Liège, Domaine Universitaire du Sart-Tilman, Liège, 4000, Belgium
| | - Raluca Dulgheru
- Department of Cardiology, Center Hospitalier Universitaire de Liège, University of Liège, Domaine Universitaire du Sart-Tilman, Liège, 4000, Belgium
| | - Matilde Rubio-Almanza
- Department of Endocrinology, Center Hospitalier Universitaire de Liège, University of Liège, Domaine Universitaire du Sart-Tilman, Liège, 4000, Belgium
| | - Ibrahima Maiga
- Department of Endocrinology, Center Hospitalier Universitaire de Liège, University of Liège, Domaine Universitaire du Sart-Tilman, Liège, 4000, Belgium
| | - Julien Magne
- Department of Cardiology, Center Hospitalier Universitaire de Liège, University of Liège, Domaine Universitaire du Sart-Tilman, Liège, 4000, Belgium
| | - Patrick Petrossians
- Department of Endocrinology, Center Hospitalier Universitaire de Liège, University of Liège, Domaine Universitaire du Sart-Tilman, Liège, 4000, Belgium
| | - Renata Auriemma
- Department of Endocrinology, Center Hospitalier Universitaire de Liège, University of Liège, Domaine Universitaire du Sart-Tilman, Liège, 4000, Belgium
| | - Adrian F Daly
- Department of Endocrinology, Center Hospitalier Universitaire de Liège, University of Liège, Domaine Universitaire du Sart-Tilman, Liège, 4000, Belgium
| | - Albert Beckers
- Department of Endocrinology, Center Hospitalier Universitaire de Liège, University of Liège, Domaine Universitaire du Sart-Tilman, Liège, 4000, Belgium.
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Auriemma RS, Grasso LFS, Pivonello R, Colao A. The safety of treatments for prolactinomas. Expert Opin Drug Saf 2016; 15:503-12. [DOI: 10.1517/14740338.2016.1151493] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Renata S. Auriemma
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, University ‘Federico II’, Naples, Italy
| | - Ludovica F. S. Grasso
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, University ‘Federico II’, Naples, Italy
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, University ‘Federico II’, Naples, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, University ‘Federico II’, Naples, Italy
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Noronha S, Stokes V, Karavitaki N, Grossman A. Treating prolactinomas with dopamine agonists: always worth the gamble? Endocrine 2016; 51:205-10. [PMID: 26336835 DOI: 10.1007/s12020-015-0727-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 08/22/2015] [Indexed: 11/25/2022]
Abstract
Dopamine agonists are the treatment of choice for all patients with prolactinomas. They are generally safe, effective, and well-tolerated. However, a link between their use and the development of impulse control disorders has been well recognized in the field of neurology for some time, and evidence for a similar effect in endocrine patients is emerging. This has mainly been revealed through clinical case reports, plus a small number of comparative studies of varying robustness. We review the current available literature and discuss the implications for clinical practice, in particular emphasizing the need for clinicians to be alert to these uncommon but serious adverse effects.
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Affiliation(s)
- Sean Noronha
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
| | - Victoria Stokes
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK.
| | - Niki Karavitaki
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
| | - Ashley Grossman
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
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Caputo C, Prior D, Inder WJ. The need for annual echocardiography to detect cabergoline-associated valvulopathy in patients with prolactinoma: a systematic review and additional clinical data. Lancet Diabetes Endocrinol 2015; 3:906-13. [PMID: 25466526 DOI: 10.1016/s2213-8587(14)70212-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Present recommendations by the US Food and Drug Administration advise that patients with prolactinoma treated with cabergoline should have an annual echocardiogram to screen for valvular heart disease. Here, we present new clinical data and a systematic review of the scientific literature showing that the prevalence of cabergoline-associated valvulopathy is very low. We prospectively assessed 40 patients with prolactinoma taking cabergoline. Cardiovascular examination before echocardiography detected an audible systolic murmur in 10% of cases (all were functional murmurs), and no clinically significant valvular lesion was shown on echocardiogram in the 90% of patients without a murmur. Our systematic review identified 21 studies that assessed the presence of valvular abnormalities in patients with prolactinoma treated with cabergoline. Including our new clinical data, only two (0·11%) of 1811 patients were confirmed to have cabergoline-associated valvulopathy (three [0·17%] if possible cases were included). The probability of clinically significant valvular heart disease is low in the absence of a murmur. On the basis of these findings, we challenge the present recommendations to do routine echocardiography in all patients taking cabergoline for prolactinoma every 12 months. We propose that such patients should be screened by a clinical cardiovascular examination and that echocardiogram should be reserved for those patients with an audible murmur, those treated for more than 5 years at a dose of more than 3 mg per week, or those who maintain cabergoline treatment after the age of 50 years.
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Affiliation(s)
- Carmela Caputo
- Department of Endocrinology, St Vincent's Hospital Melbourne, Melbourne, Australia.
| | - David Prior
- Department of Cardiology, St Vincent's Hospital Melbourne, Melbourne, Australia; Department of Medicine, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Warrick J Inder
- Department of Diabetes and Endocrinology, The University of Queensland, Brisbane, Australia; Princess Alexandra Hospital, and School of Medicine, The University of Queensland, Brisbane, Australia
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Auriemma RS, Pivonello R, Ferreri L, Priscitelli P, Colao A. Cabergoline use for pituitary tumors and valvular disorders. Endocrinol Metab Clin North Am 2015; 44:89-97. [PMID: 25732645 DOI: 10.1016/j.ecl.2014.10.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Cabergoline (CAB) is widely used for the medical treatment of pituitary tumors, particularly those associated with hormone hypersecretion. Whether treatment with CAB is associated with an increased risk of clinically relevant cardiac valve disease in patients with pituitary tumors is still debated. In most studies, CAB has been found not associated with an increased risk of significant valvulopathy, and no correlation has been shown between valvular abnormalities and CAB duration or cumulative dose. This review provides an overview of the studies reporting on the outcome of CAB in terms of cardiac valve disease in patients with pituitary tumors.
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Affiliation(s)
- Renata S Auriemma
- Ios-Coleman Medicina Futura Medical Center, Centro Direzionale, Naples 80143, Italy
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, University "Federico II", via Sergio Pansini 5, Naples 80131, Italy
| | - Lucia Ferreri
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, University "Federico II", via Sergio Pansini 5, Naples 80131, Italy
| | - Prisco Priscitelli
- Ios-Coleman Medicina Futura Medical Center, Centro Direzionale, Naples 80143, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, University "Federico II", via Sergio Pansini 5, Naples 80131, Italy.
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Faje AT, Klibanski A. The treatment of hyperprolactinemia in postmenopausal women with prolactin-secreting microadenomas: cons. Endocrine 2015; 48:79-82. [PMID: 24888765 DOI: 10.1007/s12020-014-0308-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 05/16/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Alexander T Faje
- BUL 457, Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
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Vilar L, Albuquerque JL, Gadelha PS, Rangel Filho F, Siqueira AMC, da Fonseca MM, Viana KF, Gomes BS, Lyra R. Second Attempt of Cabergoline Withdrawal in Patients with Prolactinomas after a Failed First Attempt: Is it Worthwhile? Front Endocrinol (Lausanne) 2015; 6:11. [PMID: 25699020 PMCID: PMC4316769 DOI: 10.3389/fendo.2015.00011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 01/17/2015] [Indexed: 11/13/2022] Open
Abstract
Successful discontinuation of cabergoline (CAB) treatment has been reported in 31-75% of prolactinomas patients treated for at least 2 years. In contrast, it is not well established whether CAB therapy can be successfully withdrawn after a failed first attempt. This prospective open trial was designed to address this topic and to try to identify possible predictor factors. Among 180 patients with prolactinomas on CAB therapy, the authors selected those who fulfilled very strict criteria, particularly additional CAB therapy for at least 2 years, normalization of serum prolactin (PRL) levels following CAB restart, no tumor remnant >10 mm, no previous pituitary radiotherapy or surgery; and current CAB dose ≤1.0 mg/week. Recurrence was defined as an increase of PRL levels above the upper limit of normal. A total of 34 patients (70.6% female) treated with CAB for 24-30 months were recruited. Ten patients (29.4%) remained without evidence of recurrence after 24-26 months of follow-up. Twenty-four patients (70.6%) recurred within 15 months (75% within 12 months) after drug withdrawal and ~80% were restarted CAB. Median time to recurrence was 10.5 months (range, 3-15). Despite overlapping values, non-recurring patients had significantly lower mean PRL levels before withdrawal. Moreover, the recurrence rate was lower in subjects without visible tumor on pituitary magnetic resonance imaging (MRI) than in those with small remnant tumor (60 vs. 79%), though the difference was not statistically significant (P = 0.20). No other characteristic could be identified as a predictor of successful CAB discontinuation. In conclusion, a second attempt of CAB withdrawal after two additional years of therapy may be successful, particularly in patients with lower PRL levels and no visible tumor on pituitary MRI. Close monitoring of PRL level is mandatory, especially within the first year after withdrawal, where most recurrences are detected.
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Affiliation(s)
- Lucio Vilar
- Division of Endocrinology, Hospital das Clínicas, Federal University of Pernambuco, Recife, Brazil
- *Correspondence: Lucio Vilar, Rua Clovis Silveira Barros, 84/1202, Boa Vista, Recife (PE), CEP 50050-270, Brazil e-mail:
| | - José Luciano Albuquerque
- Division of Endocrinology, Hospital das Clínicas, Federal University of Pernambuco, Recife, Brazil
| | - Patrícia Sampaio Gadelha
- Division of Endocrinology, Hospital das Clínicas, Federal University of Pernambuco, Recife, Brazil
| | - Frederico Rangel Filho
- Division of Endocrinology, Hospital das Clínicas, Federal University of Pernambuco, Recife, Brazil
| | - Aline Maria C. Siqueira
- Division of Endocrinology, Hospital das Clínicas, Federal University of Pernambuco, Recife, Brazil
| | - Maíra Melo da Fonseca
- Division of Endocrinology, Hospital das Clínicas, Federal University of Pernambuco, Recife, Brazil
| | - Karoline Frazão Viana
- Division of Endocrinology, Hospital das Clínicas, Federal University of Pernambuco, Recife, Brazil
| | - Barbara Sales Gomes
- Division of Endocrinology, Hospital das Clínicas, Federal University of Pernambuco, Recife, Brazil
| | - Ruy Lyra
- Division of Endocrinology, Hospital das Clínicas, Federal University of Pernambuco, Recife, Brazil
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Samson SL. Pasireotide in Acromegaly: An Overview of Current Mechanistic and Clinical Data. Neuroendocrinology 2015; 102:8-17. [PMID: 25792118 DOI: 10.1159/000381460] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 03/04/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Acromegaly is an insidious neuroendocrine disorder caused by hypersecretion of growth hormone (GH) by a somatotroph adenoma. Somatostatin receptor ligands (SRLs) are recommended as first-line medical therapy in patients for whom surgery has failed or is contraindicated. There are 5 known somatostatin receptor subtypes (SSTRs), 2 of which, i.e. SSTR2 and SSTR5, are expressed by a majority of somatotroph adenomas. The currently available SRLs, i.e. octreotide and lanreotide, primarily bind to SSTR2. Pasireotide (SOM230) is a new multireceptor-targeted SRL which has a broader binding profile and an increased affinity for SSTR1, 2, 3, and 5. METHODS PubMed searches were performed to identify all of the available published English language data on pasireotide with regard to the mechanism of action, in vitro effects, and clinical data. RESULTS Preclinical studies have demonstrated that pasireotide has a broader range of functional activity than octreotide. Recently, the efficacy of pasireotide in attenuating GH and insulin-like growth factor 1 (IGF-1) levels in patients with acromegaly has been evaluated in phase III clinical trials. Pasireotide demonstrated superiority over octreotide in achieving biochemical control (i.e. GH ≤2.5 µg/l and age- and sex-matched IGF-1 normalization) in patients with acromegaly, as well as significant efficacy in treating patients who were previously inadequately controlled on the maximum allowed doses of octreotide and lanreotide. Pasireotide-induced hyperglycemia was the most concerning adverse event but was reversible upon discontinuation of pasireotide. CONCLUSION The clinical data support pasireotide as a promising new therapy for the treatment of acromegaly, and the long-acting formulation was recently approved in the US and Europe for the treatment of acromegaly.
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Affiliation(s)
- Susan L Samson
- The Pituitary Center at Baylor St. Luke's Medical Center, Division of Endocrinology, Department of Medicine, Baylor College of Medicine, Houston, Tex., USA
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Auriemma RS, Galdiero M, Vitale P, Granieri L, Lo Calzo F, Salzano C, Ferreri L, Pivonello C, Cariati F, Coppola G, de Angelis C, Colao A, Pivonello R. Effect of chronic cabergoline treatment and testosterone replacement on metabolism in male patients with prolactinomas. Neuroendocrinology 2015; 101:66-81. [PMID: 25592453 DOI: 10.1159/000371851] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 01/05/2015] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Hyperprolactinemia and hypogonadism are reportedly associated with an impaired metabolic profile. The current study aimed at investigating the effects of testosterone replacement and cabergoline (CAB) treatment on the metabolic profile in male hyperprolactinemic patients. PATIENTS AND METHODS Thirty-two men with prolactinomas, including 22 with total testosterone (TT) <8 nmol/l (HG, 69%) and 10 with TT >8 nmol/l (non-HG, 31%), were entered in the study. In all patients, metabolic parameters were assessed at diagnosis and after 12- and 24-month treatment. RESULTS Compared to non-HG patients, at baseline the HG patients had higher waist circumference (WC). TT significantly correlated with body mass index (BMI). Twelve-month CAB induced PRL normalization in 84%. HG prevalence significantly decreased (28%) and non-HG prevalence significantly increased (72%). Anthropometric and lipid parameters, fasting insulin (FI), insulin sensitivity index (ISI0), homeostatic model assessment of insulin secretion (HOMA-β) and homeostatic model assessment of insulin resistance (HOMA-IR) significantly improved compared to baseline. TT was the best predictor for FI. Percent change (Δ) of TT significantly correlated with ΔCholesterol, ΔWeight and ΔBMI. Compared to non-HG patients, the HG patients had a higher weight, BMI, WC and HOMA-β. In HG, testosterone replacement was started. After 24 months, PRL normalized in 97%. HG prevalence significantly decreased (6%) and non-HG prevalence significantly increased (94%). Anthropometric and lipid parameters, FI, ISI0, HOMA-β and HOMA-IR significantly improved compared to baseline, with FI, ISI0, HOMA-β and HOMA-IR further ameliorating compared to the 12-month evaluation. Compared to non-HG patients, the HG patients still had a higher weight, BMI and WC. CONCLUSIONS In hyperprolactinemic hypogonal men, proper testosterone replacement induces a significant improvement in the metabolic profile, even though the amelioration in the lipid profile might reflect the direct action of CAB.
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Affiliation(s)
- Renata S Auriemma
- Ios and Coleman Medicina Futura Medical Center, Università 'Federico II', Naples, Italy
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Abstract
Recent studies have reported a higher prevalence of pituitary tumors than previously thought. Among these tumors, prolactinomas occur in up to 66% of cases. Since the mid-1980s, the widespread use of dopamine agonists has facilitated the management of the majority of prolactinomas, allowing biological and tumoral control in most cases. The less frequent cases of resistant prolactinomas remain challenging despite a multimodal therapy approach. The understanding of genetic alterations in familial and aggressive pituitary tumors provides new perspectives in the management of some prolactinomas. Genetic screening should be considered, particularly in familial cases but also in young patients with macroprolactinomas, as some mutations can predict potential aggressiveness.
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Affiliation(s)
- Laurent Vroonen
- a Department of Endocrinology, CHU de Liège, University of Liège, 4000 Liège, Belgium
| | - Adrian F Daly
- a Department of Endocrinology, CHU de Liège, University of Liège, 4000 Liège, Belgium
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Kwancharoen R, Auriemma RS, Yenokyan G, Wand GS, Colao A, Salvatori R. Second attempt to withdraw cabergoline in prolactinomas: a pilot study. Pituitary 2014; 17:451-6. [PMID: 24078319 DOI: 10.1007/s11102-013-0525-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
PURPOSE According to Pituitary and Endocrine Society recommendations, cabergoline (CAB) therapy can be discontinued after 2 years in hyperprolactinemic patients who fit certain criteria. Previous studies found recurrence rates ranging between 26 and 69 %. Whether CAB therapy can be successfully discontinued after one unsuccessful withdrawal is unknown. METHODS We conducted a pilot prospective two-center study on a second attempt of CAB withdrawal. Inclusion criteria were: (1) recurrence of hyperprolactinemia after first withdrawal; (2) additional CAB therapy for at least 2 years; (3) normal serum prolactin; (4) CAB dose ≤ 1 mg/week. Prolactin level was monitored after discontinuing therapy. Median follow up for patients who are still in remission was 42 months (range = 24-60). RESULTS A total of 17 patients were recruited. Mean age was 41.0 ± 17.3 years. 65 % were female. Initial tumors were microadenoma in 64.7 %, and macroadenoma in 35.3 %. The average weekly CAB dose at second withdrawal was 0.38 ± 0.20 mg (median = 0.25, range = 0.175-1). Eleven of 17 patients (64.7 %) recurred. Median time to recurrence was 6 months. The incidence of recurrence was 44 events per 100 person-years. The estimated cumulative hazard of recurrence was 40 and 82 % at 6 and 12 months respectively. The probability to be recurrence-free at 6 and 12 months was 65 and 41 %, respectively. CONCLUSIONS Second attempt of CAB withdrawal after 2 additional years of therapy may be successful in some patients. A second withdrawal can be attempted with close monitoring of prolactin level. In this study, we could not identify any predictor of recurrence. Most of the recurrences occurred within the first 12 months after withdrawal.
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Effectiveness of risk minimization measures for cabergoline-induced cardiac valve fibrosis in clinical practice in Italy. J Neural Transm (Vienna) 2014; 122:799-808. [DOI: 10.1007/s00702-014-1314-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 09/10/2014] [Indexed: 10/24/2022]
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Yedinak CG, McCartney S, Dillard TH, Wei KS, Fleseriu M. Case Report: Reversible cabergoline-associated cardiac valvulopathy post drug discontinuation. F1000Res 2014; 3:171. [PMID: 25165538 PMCID: PMC4133764 DOI: 10.12688/f1000research.3062.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2014] [Indexed: 11/30/2022] Open
Abstract
We present a case of a 21 year old male patient diagnosed with a 2.2 cm prolactin-secreting adenoma in contact with the optic chiasm. The patient was treated with up to 6mg/week of cabergoline (total cumulative dose 814 mg) and developed mild valvulopathy. Valvulopathy was subsequently reversed after discontinuation of cabergoline therapy.
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Affiliation(s)
- Chris G Yedinak
- Northwest Pituitary Center, Oregon Health & Science University, Portland, Oregon, 97239, USA ; Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, 97239, USA
| | - Shirley McCartney
- Northwest Pituitary Center, Oregon Health & Science University, Portland, Oregon, 97239, USA ; Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, 97239, USA
| | - Troy H Dillard
- Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Portland, Oregon, 97239, USA
| | - Kevin S Wei
- Department of Cardiovascular Medicine, Oregon Health & Science University, Portland, Oregon, 97239, USA
| | - Maria Fleseriu
- Northwest Pituitary Center, Oregon Health & Science University, Portland, Oregon, 97239, USA ; Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, 97239, USA ; Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Portland, Oregon, 97239, USA
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Kasuki L, Vieira Neto L, Gadelha MR. Cabergoline treatment in acromegaly: cons. Endocrine 2014; 46:220-5. [PMID: 24504766 DOI: 10.1007/s12020-014-0183-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 01/23/2014] [Indexed: 12/25/2022]
Abstract
Many options are available for the treatment of acromegaly, including surgery, radiotherapy, and medical treatment. Cabergoline (CAB), a dopamine agonist with high affinity for dopamine receptor type 2, has been used both in monotherapy and in conjunction with somatostatin analogs (SSAs). Although it is administered orally and has a relatively lower-cost in comparison with SSAs, few studies have demonstrated its usefulness, there is a lack of randomized-controlled trials and other drugs (SSAs and pegvisomant) with more data in the literature are available; these issues are the main drawbacks of adopting CAB for the treatment of acromegaly.
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Affiliation(s)
- Leandro Kasuki
- Department of Internal Medicine and Endocrine Unit, Neuroendocrinology Research Center, Medical School and Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rua Professor Rodolpho Paulo Rocco, 255, sala 9F, Ilha do Fundão, Rio de Janeiro, 21941-913, Brazil
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Abstract
Acromegaly is predominantly caused by a pituitary adenoma, which secretes an excess of GH resulting in increased IGF1 levels. Most of the GH assays used currently measure only the levels of the 22 kDa form of GH. In theory, the diagnostic sensitivity may be lower compared with the previous assays, which have used polyclonal antibodies. Many GH-secreting adenomas are plurihormonal and may co-secrete prolactin, TSH and α-subunit. Hyperprolactinaemia is found in 30-40% of patients with acromegaly, and hyperprolactinaemia may occasionally be diagnosed before acromegaly is apparent. Although trans-sphenoidal surgery of a GH-secreting adenoma remains the first treatment at most centres, the role of somatostatin analogues, octreotide long-acting repeatable and lanreotide Autogel as primary therapy is still the subject of some debate. Although the normalisation of GH and IGF1 levels is the main objective in all patients with acromegaly, GH and IGF1 levels may be discordant, especially during somatostatin analogue therapy. This discordance usually takes the form of high GH levels and an IGF1 level towards the upper limit of the normal range. Pasireotide, a new somatostatin analogue, may be more efficacious in some patients, but the drug has not yet been registered for acromegaly. Papers published on pasireotide have reported an increased risk of diabetes mellitus due to a reduction in insulin levels. Pegvisomant, the GH receptor antagonist, is indicated - alone or in combination with a somatostatin analogue - in most patients who fail to enter remission on a somatostatin analogue. Dopamine-D2-agonists may be effective as monotherapy in a few patients, but it may prove necessary to apply combination therapy involving a somatostatin analogue and/or pegvisomant.
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Affiliation(s)
- Marianne Andersen
- Department of Endocrinology, Odense University Hospital, Sønder Boulevard 29, 5000 Odense C, Denmark and Institute of Clinical Research, University of Southern Denmark, Odense C, Denmark
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Abstract
INTRODUCTION Acromegaly is a rare disease that severely impacts patients' health all the while, being a slowly progressing illness. In the past decades, advancements in treatment modalities, especially development of new drugs, as well as focused guidelines has improved management of acromegaly. Still, many patients are considered not sufficiently treated and there remains an ongoing need for further development. AREAS COVERED This article reviews new medical treatments currently under clinical investigation (such as pasireotide, oral octreotide and somatoprim) and under experimental development (such as octreotide implants, CAM2029 and ATL-1103). EXPERT OPINION As it seems unlikely that one single agent may achieve cure in 100% of cases, there is an urgent need for new agents that help patients where current medication fails. Imperatively, this means we have to improve our understanding of the underlying pathogenetic and molecular mechanisms.
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Affiliation(s)
- Sylvère Störmann
- Klinikum der Universität München, Medizinische Klinik und Poliklinik IV , Ziemssenstr. 1, 80336 München , Germany +49 0 89 5160 2111 ; +49 0 89 5160 2194 ;
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Auriemma RS, Granieri L, Galdiero M, Simeoli C, Perone Y, Vitale P, Pivonello C, Negri M, Mannarino T, Giordano C, Gasperi M, Colao A, Pivonello R. Effect of cabergoline on metabolism in prolactinomas. Neuroendocrinology 2013; 98:299-310. [PMID: 24355865 DOI: 10.1159/000357810] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Accepted: 12/07/2013] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Hyperprolactinemia has been implicated in the pathogenesis of obesity and glucose intolerance and is reportedly associated with an impaired metabolic profile. The current study aimed at investigating the effects of 12- and 60-month treatment with cabergoline (CAB) on metabolic syndrome (MetS) in patients with prolactinomas. PATIENTS AND METHODS 61 patients with prolactinomas (13 men, 48 women, 41 with microadenoma, 20 with macroadenoma), aged 34.4 ± 10.3 years, entered the study. In all patients, prolactin (PRL) and metabolic parameters were assessed at diagnosis and after 12 and 60 months of continuous CAB treatment. MetS was diagnosed according to NCEP-ATP III criteria. RESULTS Compared to baseline, CAB induced a significant decrease in PRL with complete normalization in 93% of patients after the 60-month treatment. At baseline, MetS prevalence was significantly higher in patients with PRL above (34.5%) than in those with PRL lower (12.5%) than the median (129 μg/l, p = 0.03). MetS prevalence significantly decreased after 12 (11.5%, p = 0.039) and 60 (5.0%, p = 0.001) months compared to baseline (28.0%). At both evaluations the lipid profile significantly improved compared to baseline. Fasting insulin and homeostatic model assessment of insulin resistance significantly decreased after 1 year of CAB (p = 0.012 and p = 0.002, respectively) and further improved after 60 months (p = 0.000). The visceral adiposity index significantly decreased after the 60-month treatment (p = 0.000) compared to baseline. At the 5-year evaluation CAB dose was the best predictor of percent decrease in fasting insulin (t = 2.35, p = 0.022). CONCLUSIONS CAB significantly reduces MetS prevalence and improves the adipose tissue dysfunction index. The improvement in PRL, insulin sensitivity and other metabolic parameters might reflect the direct effect of CAB.
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Affiliation(s)
- Renata S Auriemma
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, 'Federico II' University, Naples, Italy
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