Hyperprolactinemia (Part 3/3): Management Recommendations

This is our third post in this series on hyperprolactinemia.

 


Part 1/3: Hyperprolactinemia & Antipsychotics

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Part 2/3: Hyperprolactinemia & Antidepressants

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This post will focus on management recommendations for hyperprolactinemia.

 

(1) WHEN TO MEASURE PROLACTIN LEVEL.

  • At least 2 hours after waking AND before eating breakfast.
  • Note that Stress including poor venepuncture technique can cause high prolactin levels (but <1000 mU/L or <47 ng/ml).

Source: 

  1. Journal of Psychopharmacology 22(2) Supplement (2008) 28–37 
  2. Conversion of level done at: http://unitslab.com/node/129.

 


(2) WHAT IS NORMAL RANGE OF PROLACTIN LEVEL.

  • Male: 0 – 424 mIU/L (0-20 ng/ml)
  • Female: 0 – 530 mIU/L (0-25 ng/ml) (for not-pregnant or breast-feeding).

Source: 

  1. Therapeutics and Clinical Risk Management 2007:3(5) 929–951.

 


(3) LABORATORY WORKUP.

  • Baseline Prolactin Level: before adding medications with high likelihood of causing hyperprolactinemia. 
  • Thyroid function test: this should be done (1) before adding medications with high likelihood of causing hyperprolactinemia; and (2) patient developing symptoms of hyperprolactinemia. (Reason: impact of hypothalamus-pituitary-gonad/thyroid axis.)
  • Renal function test: Renal diseases can cause poor degradation of prolactin and causing high prolactin levels. 

Source: 

  1. Journal of Psychopharmacology 22(2) Supplement (2008) 28–37 

 


(4) CLINICAL MANAGEMENT RECOMMENDATIONS:

(A) IF ASYMPTOMATIC AND PROLACTIN LEVEL <47 ng/ml:

  • Repeat level and continue medications. 
  • Educate patient on symptoms of hyperprolactinemia.

 

(B) IF BASELINE PROLACTIN WAS NOT OBTAINED:

  • If possible discontinue medication for 72 hours and measure prolactin level.
  • If medication discontinuation is not possible: consider MRI brain to rule out pituitary or hypothalamic mass.

 

(B) IF HIGH PROLACTIN LEVELS AND/OR SYMPTOMATIC:

  • Reduce or discontinue medication.
  • Switch to medication with less potential of causing hyperprolactinemia.

If switch in medication is not possible/feasible, consider adding:-

(1) Aripiprazole:

  • Low dose of 5mg
  • Measure prolactin levels weekly.
  • Discontinue if prolactin level do not normalize after 4 weeks.

(2) Cabergoline:

 

Source: 

  1. Pharmaceutical Journal, 2009;283:101-104.
  2. J Clin Endocrin Metab. 2011; 96(2): 273–288.

Post by Dr. Harvinder Singh, M.D.

 

 


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