Prolactinoma medical therapy: Difference between revisions

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Latest revision as of 23:49, 29 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Anmol Pitliya, M.B.B.S. M.D.[2], Faizan Sheraz, M.D. [3]

Overview

Medical therapy for prolactinoma includes dopamine agonists (either cabergoline or bromocriptine). The goals of treatment include lowering the prolactin secretion to normal, reduction of tumor size, correction of any visual abnormalities, and restoration of normal pituitary function.

Medical Therapy

Medical therapy for prolactinoma includes dopamine agonists (cabergoline or bromocriptine).^[1]^[2]^[3]^[4]^[5]
- Preferred regimen: Cabergoline 0.25 mg PO twice weekly or 0.5 mg PO once per week
  - The dose may be gradually increased every 4 weeks as needed
  - The maximum dose can be administered up to 1 mg PO twice per week
- Alternative regimen: Bromocriptine 1.25 mg PO once daily at bedtime for 1 week
  - The dose may be gradually increased every 3 to 7 days as needed and taken in divided doses

These drugs reduce the tumor size in approximately 85% of cases and lower the prolactin concentration to normal in more than 90% of patients.
Both drugs have been approved by the U.S Food and Drug Administration for the treatment of hyperprolactinemia.

Medical therapy in pregnancy

Bromocriptine is considered safe to use during pregnancy.^[1]

Indications for withdrawal of dopamine agonist therapy

Dopamine therapy can be tapered down to lower doses if the patient fulfills the following criteria:^[1]
- Normal prolactin level for at least 2 years.
- Reduction in tumor size by at least 50%.
- No compression of optic chiasm.
Drug cessation can be tried if:
- Cavernous sinus invasion is not present.

Radiation Therapy

Rarely, radiation therapy is used if medical therapy and surgery fail to reduce prolactin concentration. Depending on the size and location of the tumor, radiation is delivered either in low doses over the course of 5 to 6 weeks or in a single high dose. Radiation therapy is effective in approximately 30% of cases.^[2]

References

↑ ^1.0 ^1.1 ^1.2 Liu JK, Couldwell WT (2004). "Contemporary management of prolactinomas". Neurosurg Focus. 16 (4): E2. PMID 15191331.
↑ ^2.0 ^2.1 Colao A, Savastano S (2011). "Medical treatment of prolactinomas". Nat Rev Endocrinol. 7 (5): 267–78. doi:10.1038/nrendo.2011.37. PMID 21423245.
↑ Nomikos P, Buchfelder M, Fahlbusch R (2001). "Current management of prolactinomas". J Neurooncol. 54 (2): 139–50. PMID 11761431.
↑ "Prolactinoma | NIDDK".
↑ Ciccarelli E, Camanni F (1996). "Diagnosis and drug therapy of prolactinoma". Drugs. 51 (6): 954–65. PMID 8736617.

Template:WikiDoc Sources

[pmid15191331-1] 1.0 ^1.1 ^1.2 Liu JK, Couldwell WT (2004). "Contemporary management of prolactinomas". Neurosurg Focus. 16 (4): E2. PMID 15191331.

[pmid21423245-2] 2.0 ^2.1 Colao A, Savastano S (2011). "Medical treatment of prolactinomas". Nat Rev Endocrinol. 7 (5): 267–78. doi:10.1038/nrendo.2011.37. PMID 21423245.

[pmid11761431-3] Nomikos P, Buchfelder M, Fahlbusch R (2001). "Current management of prolactinomas". J Neurooncol. 54 (2): 139–50. PMID 11761431.

[urlProlactinoma_|_NIDDK-4] "Prolactinoma | NIDDK".

[pmid8736617-5] Ciccarelli E, Camanni F (1996). "Diagnosis and drug therapy of prolactinoma". Drugs. 51 (6): 954–65. PMID 8736617.

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@@ Line 1: / Line 1: @@
 __NOTOC__
 {{Prolactinoma}}
-{{CMG}} {{AE}}{{Faizan}}
+{{CMG}}; {{AE}}{{Anmol}}, {{Faizan}}
 ==Overview==
+Medical therapy for prolactinoma includes [[dopamine agonists]] (either [[cabergoline]] or [[bromocriptine]]). The goals of treatment include lowering the [[prolactin]] secretion to normal, reduction of [[tumor]] size, correction of any [[visual]] abnormalities, and restoration of normal [[pituitary]] function.
-Medical therapy for prolactinoma includes dopamine agonists. Dopamine is the chemical that normally inhibits prolactin secretion. The goal of treatment is to:
-*Return [[prolactin]] secretion to normal
-*Reduce [[tumor]] size
-*Correct any visual abnormalities
-*Restore normal [[pituitary]] function
-As mentioned above, the impact of stress should be ruled out before the diagnosis of [[prolactinoma]] is given.  Exercise can significantly reduce [[stress]] and, thereby, prolactin levels.  It should also be noted that higher prolactin levels may contribute to the development of prolactinomas so the diagnosis can be self-fulfilling if the original cause is stress. In the case of very large tumors, only partial reduction of the prolactin levels may be possible.
 ==Medical Therapy==
-Medical therapy for prolactinoma includes dopamine agonists. Dopamine is the chemical that normally inhibits prolactin secretion.
+*Medical therapy for prolactinoma includes [[Dopamine agonist|dopamine agonists]] ([[cabergoline]] or [[bromocriptine]]).<ref name="pmid15191331">{{cite journal| author=Liu JK, Couldwell WT| title=Contemporary management of prolactinomas. | journal=Neurosurg Focus | year= 2004 | volume= 16 | issue= 4 | pages= E2 | pmid=15191331 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15191331  }} </ref><ref name="pmid21423245">{{cite journal| author=Colao A, Savastano S| title=Medical treatment of prolactinomas. | journal=Nat Rev Endocrinol | year= 2011 | volume= 7 | issue= 5 | pages= 267-78 | pmid=21423245 | doi=10.1038/nrendo.2011.37 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21423245  }} </ref><ref name="pmid11761431">{{cite journal| author=Nomikos P, Buchfelder M, Fahlbusch R| title=Current management of prolactinomas. | journal=J Neurooncol | year= 2001 | volume= 54 | issue= 2 | pages= 139-50 | pmid=11761431 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11761431  }} </ref><ref name="urlProlactinoma | NIDDK">{{cite web |url=https://www.niddk.nih.gov/health-information/endocrine-diseases/prolactinoma |title=Prolactinoma &#124; NIDDK |format= |work= |accessdate=}}</ref><ref name="pmid8736617">{{cite journal |vauthors=Ciccarelli E, Camanni F |title=Diagnosis and drug therapy of prolactinoma |journal=Drugs |volume=51 |issue=6 |pages=954–65 |year=1996 |pmid=8736617 |doi= |url=}}</ref>
+**Preferred regimen: [[Cabergoline]] 0.25 mg PO twice weekly or 0.5 mg PO once per week
+***The dose may be gradually increased every 4 weeks as needed
+***The maximum dose can be administered up to 1 mg PO twice per week
+**Alternative regimen: [[Bromocriptine]] 1.25 mg PO once daily at bedtime for 1 week
+***The dose may be gradually increased every 3 to 7 days as needed and taken in divided doses
-'''[[Bromocriptine]]''' (Parlodel)
+*These [[drug]]s reduce the [[tumor]] size in approximately 85% of cases and lower the [[prolactin]] concentration to normal in more than 90% of patients.
-*Dosage
+*Both drugs have been approved by the U.S [[Food and Drug Administration]] for the treatment of [[hyperprolactinemia]].
-A typical starting dose is one-quarter to one-half of a 2.5 milligram (mg) tablet taken at bedtime with a snack.  The dose is gradually increased every 3 to 7 days as needed and taken in divided doses with meals or at bedtime with a snack.  Most people are successfully treated with 7.5 mg a day or less, although some people need 15 mg or more each day.  Because bromocriptine is short acting, it should be taken either twice or three times daily.
-'''[[Cabergoline]]''' (Dostinex)
+===Medical therapy in pregnancy===
-Cabergoline is a newer drug that may be more effective than bromocriptine in normalizing prolactin levels and shrinking tumor size.  Cabergoline also has less frequent and less severe side effects.  Cabergoline is more expensive than [[bromocriptine]] and, being newer on the market, its long-term safety record is less well defined.
+*[[Bromocriptine]] is considered safe to use during [[pregnancy]].<ref name="pmid15191331">{{cite journal| author=Liu JK, Couldwell WT| title=Contemporary management of prolactinomas. | journal=Neurosurg Focus | year= 2004 | volume= 16 | issue= 4 | pages= E2 | pmid=15191331 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15191331  }} </ref>
-*Dosage
-The usual starting dose is .25 mg twice a week.  The dose may be increased every 4 weeks as needed, up to 1 mg two times a week. Cabergoline should not be stopped without consulting a qualified endocrinologist. Recent studies suggest prolactin levels are more likely to remain normal after discontinuing long-term cabergoline therapy than after discontinuing bromocriptine.
-These drugs shrink the tumor and return prolactin levels to normal in approximately 80 percent of patients.  Both drugs have been approved by the U.S. Food and Drug Administration for the treatment of hyperprolactinemia.  [[Bromocriptine]] is the only dopamine agonist approved for the treatment of [[infertility]].  This drug has been in use longer than [[cabergoline]] and has a well-established safety record.
-Because limited information exists about the risks of long-term, low-dose cabergoline use, generally the lowest effective dose is prescribed and periodically the need for continuing therapy is reassessed. People taking cabergoline who develop symptoms of shortness of breath or swelling of the feet should promptly notify their physician because these may be signs of heart [[valve]] damage<ref>http://www.niddk.nih.gov/health-information/health-topics/endocrine/prolactinoma/Pages/fact-sheet.aspx</ref>.
-*Side Effects
-[[Nausea]] and dizziness are possible side effects of [[bromocriptine]].  To avoid these side effects, bromocriptine treatment must be started slowly.In people taking cabergoline or bromocriptine to treat [[Parkinson's disease]] at doses more than 10 times higher than those used for prolactinomas, heart valve damage has been reported. Rare cases of valve damage have been reported in people taking low doses of cabergoline to treat hyperprolactinemia.  Before starting these medications, the physician will order an [[ echocardiogram]].
-==Prolactinoma and Pregnancy==
+===Indications for withdrawal of dopamine agonist therapy===
+*[[Dopamine]] therapy can be tapered down to lower doses if the patient fulfills the following criteria:<ref name="pmid15191331">{{cite journal| author=Liu JK, Couldwell WT| title=Contemporary management of prolactinomas. | journal=Neurosurg Focus | year= 2004 | volume= 16 | issue= 4 | pages= E2 | pmid=15191331 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15191331  }} </ref>
+**Normal [[prolactin]] level for at least 2 years.
+**Reduction in [[tumor]] size by at least 50%.
+**No compression of [[optic chiasm]].
+*Drug cessation can be tried if:
+**[[Cavernous sinus]] invasion is not present.
-A woman with a prolactinoma should discuss her plans to conceive with her physician, so she can be carefully evaluated prior to becoming pregnant. This evaluation will include a magnetic resonance imaging ([[MRI]]) scan to assess the size of the tumor and an eye examination with measurement of visual fields. As soon as a patient is pregnant, her doctor will usually advise that she stop taking bromocriptine or [[cabergoline]], the common treatments for prolactinoma. Most endocrinologists see patients every two months throughout the pregnancy. The patient should consult her endocrinologist promptly if she develops symptoms--particularly headaches, visual changes, nausea, vomiting, excessive thirst or urination, or extreme lethargy. [[Bromocriptine]] or [[cabergoline]] treatment may be renewed and additional treatment may be required if the patient develops symptoms from growth of the tumor during pregnancy. At one time, [[oral contraceptives]] were thought to contribute to the development of prolactinomas. However, this is no longer thought to be true. Patients with prolactinoma treated with bromocriptine or cabergoline may also take oral contraceptives. Similarly, post-menopausal [[estrogen]] replacement is safe in patients with prolactinoma treated with medical therapy or surgery.
+==Radiation Therapy==
+*Rarely, [[radiation therapy]] is used if medical therapy and [[surgery]] fail to reduce [[prolactin]] concentration. Depending on the size and location of the [[tumor]], [[radiation]] is delivered either in low doses over the course of 5 to 6 weeks or in a single high dose. [[Radiation therapy]] is effective in approximately 30% of cases.<ref name="pmid21423245">{{cite journal| author=Colao A, Savastano S| title=Medical treatment of prolactinomas. | journal=Nat Rev Endocrinol | year= 2011 | volume= 7 | issue= 5 | pages= 267-78 | pmid=21423245 | doi=10.1038/nrendo.2011.37 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21423245  }} </ref>
 == References ==
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