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CAUSES, DIAGNOSIS,
MANAGEMENT
Abdullah M. Kharbosh, B.Sc. Pharm
OPTIONS
Prolactin (PRL)
Clearance pathway
Plasma level:
♀:25 ng/ml
♂:20 ng/ml
PRL
Remember
Hyperprolactinemia inhibits gonadotropin secretion.
Up to 20%.
PEG ppt.
Measure in patients with:
o Moderately elevated PRL (25-150 mcg/l) &
o Less typical symptoms: headaches or libido + regular menses.
Diagnostic Pitfalls
The Hook Effect
To overcome:
- Perform PRL assay at 1:100 serum dilution.
with
- Normal or mildly elevated PRL levels.
Prolactinomas
Generally classified (according to size):
– Microadenomas (< 10 mm in diameter).
– Macroadenomas (> 10 mm in diameter).
Over 90% of prolactinomas are:
– Small.
– Intrasellar.
– Rarely size.
Occasionally, can be:
– Aggressive, progressive.
– Locally invasive.
– Compress on vital structures “mass effect”.
Very rarely, can be malignant:
– Resistant to therapy.
– Disseminates inside & outside the CNS.
Familial prolactinomas also described (a genetic component?).
Prolactinomas
Pituitary Adenomas
About 40% of all pituitary adenomas are prolactinomas.
* Rarely reported
Drug-Induced
Antipsychotics
Atypical Typical
3+ Risperidone 3+ Phenothiazines
2+ Molindone 3+ Butyrophenones
0 Clozapine
+ Quetiapine
0 Ziprasidone
0: No effect; +: Increase to abnormal levels in a small % of patients; 2+: Increase to abnormal levels in 25-
50% of patients; 3+: Increase to abnormal levels in > 50% of patients;
Adapted from: Molitch M.E. (2005) Medication induced hyperprolactinemia. Mayo Clinic Proceedings.
Drug-Induced
Antidepressants
Other SSRIs MAOIs Tricyclics
0 Nefazodone CR Fluoxetine 0 Aripiprazole + Amitryptyline
0 Bupropion Paroxetine + Olanzapine + Desipramine
0 Venlaflaxine Citalopram 3+ Pargyline 3+ Chlomipramine
0 Trazodone Fluvoxamine 3+ Clorgyline - Nortriptyline
MAOIs: monoamine oxidase inhibitors Tranylcypromine CR Imipramine
SSRIs: selective serotonin re-uptake
inhibitors. CR Maprotiline
CR Amoxapine
0: No effect; : Minimal increase but not to abnormal level; +: Increase to abnormal levels in a small % of
patients; ++: Increase to abnormal levels in 25-50% of patients; 3+: Increase to abnormal levels in > 50%
of patients; CR: Isolated case reports of hyperprolactinemia but generally no increase in PRL levels.
Adapted from: Molitch M.E. (2005) Medication induced hyperprolactinemia. Mayo Clinic Proceedings.
Drug-Induced
- Tolerability
- Convenience
PRL secretion
Felipe F. Casanueva, Mark E. Molitch, et al. Guidelines of the pituitary society for the diagnosis &
management of prolactinomas. Clinical Endocrinology (2006) 65, 265-273.
Management
Stop once 1st menstrual period missed & +Ve preg. test obtained