Thread by @CerebralWizard

Microlearning thread (1/17) on Hyper-prolactenemia in Psychiatry.

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Please read this case report we published recently in the primary care companion for CNS disorders @PCC_CNSDisord.

psychiatrist.com/pcc/effects/am…

(2/17) Three facts about Prolactin (PRL)
1. 199 amino acid single chain PP secreted by lactotroph cells in the Anterior Pituitary
2. The (TIDA) neurons in the hypothalamus tonically release dopamine (DA) into the portal pituitary circulation
3. DA inhibits prolactin secretion.

(3/17) PRL functions

1. Lactogenesis
2. Contraceptive effect in the postpartum period
3. Modulates complex maternal behaviour and stress-related alterations in the HPA axis
4. Oligodendrocyte precursor cells growth modulation.

(4/17) Normal levels
Males:< 15ng/mL
Females:<25 ng/mL
- Up to 200ng/mL during pregnancy,
- Up to 300ng/mL during lactation
Diurnal peak during REM sleep & in the early morning.
Levels rise after exercise, sleep, meals, sexual intercourse, seizures, & surgical procedures.

(5/17) Interpreting the report [some pearls]

a) > 30 ng/mL should be thoroughly assessed
b) Antipsychotic induced: 30 – 180 ng/mL
c) > 180 ng/mL likely due to prolactinoma
d) > 3000 ng/mL likely due to macro-prolactinoma

(6/17) Who is at an increased risk for antipsychotic induced hyper-prolactenemia ?

a) Women (50-70%) > Men (30-40%)
b) Reproductive age group > postmenopausal age group
c) Post-natal period
d) Children & adolescents

(7/17) What are short-term effects of hyper-PRL?

a) Mild (30–50 ng/mL): short luteal phase, decreased libido & sexual dysfunction.
b) Mod (50–75 ng/mL ): Oligomenorrhoea 
c) Marked (> 100 ng/mL): galactorrhea & amenorrhea 
[PS: Use these clues for clinically estimating levels]

(8/17) What are long term effects ?

a) Infertility
b) Hypogonadism 
c) Bone demineralization, loss of muscle mass
d) Osteoporosis

This predisposes persons to fractures

(9/17) When do we avoid giving PRL elevating agents ?

a) Pts under 25 years of age (i.e. before peak bone mass)
b) Patients with osteoporosis
c) Patients with a history of hormone‐dependent breast cancer
d) Young women.

(10/17) The usual suspects among anti-psychotics that elevate PRL are as follows

1. Amisulpride
2. Paliperidone
3. Risperidone
4. Haloperidol

(11/17) Prolactin sparing or safer antipsychotics include

Aripiprazole
Asenapine
Brexpiprazole
Cariprazine
Iloperidone
Quetiapine
Clozapine
Olanzapine

(12/17) Don't forget to check for ..
Decreased libido
Swelling, pain in chest, white discharge from nipples
Oligo(or A)menorrhea
Acne, Hirsuitsm
Pain in weight bearing joints, recent fractures
Increase in weight, polyuria, polydipsia
Headache, diplopia, visual field defects

(13/17) Small digression: Can you spot the Microadenoma?

PC: [Creative commons]
Case courtesy of Frank Gaillard, <a href="radiopaedia.org/?lang=us">Radiopaedia.org</a>. From the case <a href="radiopaedia.org/cases/16787?la…">rID: 16787</a>

(14/17) Treatment strategies

Asymptomatic hyperprolactinemia less than 50 ng/mL - Close follow up

Dose reduction – If feasible

> 100 ng/mL – always intervene

Antipsychotic switch to Aripiprazole [low dose], Olanzapine, Quetiapine

Week 1 - significant reduction in PRL

(15/17) When to use DA agonist?

If you cannot change the antipsychotic + If Aripiprazole trial fails + patient continues to be symptomatic due to increase in PRL.
Options: Bromocriptine, Cabergoline & Quinagolide

(16/17) How to use Cabergoline?

Average dose - 0.5 to 1 mg per week
Advantages - better tolerated & longer half life i.e. once or twice a week dosing
Caution in Peptic Ulcer
Special risk: Normalization of fertility and risk of unplanned pregnancy

(17/17) And that wraps it up.

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Regards,