188 - Hyperprolactinaemia

Hyperprolactinaemia

190 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Hyperprolactinaemia is often superficially asymptomatic (that is, the patient does not spontaneously report problems) and there is some evidence that hyperprolactinaemia does not affect subjective quality of life.13 Nonetheless, persistent elevation of plasma prolactin is associated with suppression of the hypothalamic–pituitary–gonadal axis.14 Symptoms of this include sexual dysfunction15 (but note that other pharmacological activities also give rise to sexual dysfunction),16 menstrual disturbances,4,17 breast growth and galactorrhoea,17 and may include delusions of pregnancy.18 Long-­ term adverse consequences are reductions in bone mineral density19,20 and a possible increase in the risk of breast cancer.21 Prolactin can also be raised because of stress, pregnancy and lactation, seizures, renal impairment and other medical conditions,7,22,23 including prolactinoma. When measuring prolactin, the sample should be taken early in the morning and stress during venepuncture should be minimised.23 Hyperprolactinaemia Dopamine inhibits prolactin release and so dopamine antagonists can be expected to increase prolactin plasma levels. The degree of prolactin elevation is probably dose-­ related,1 and for most antipsychotic medications the threshold activity (D2 occupancy) for increased prolactin is very close to that of therapeutic efficacy.2 Genetic differences may also play a part.3 Table 1.43 groups individual antipsychotics according to their effect on prolactin concentrations. Table 1.43  Effects of antipsychotic medication on prolactin concentration.4–12 Effect Risk Drug Prolactin-­sparing Prolactin increase very rare Aripiprazole Asenapine Brexpiprazole Cariprazine Clozapine Iloperidone Lumateperone Pimavanserin Quetiapine Xanomeline Prolactin-­elevating Low risk, minor changes only Lurasidone Olanzapine Ziprasidone Prolactin-­elevating High risk; major changes Amisulpride Paliperidone Risperidone Sulpiride First-­generation antipsychotics