191 - Summary of management

Summary of management

Schizophrenia and related psychoses CHAPTER 1 Contraindications Prolactin-­elevating drugs with high risk should, if possible, be avoided in the following patient groups: ■ ■Patients under 25 years of age (i.e. before peak bone mass). ■ ■Patients with osteoporosis. ■ ■Patients with a history of hormone-­dependent breast cancer. ■ ■Young women. Management Treatment of hyperprolactinaemia depends more on symptoms and long-­term risk than on the reported plasma prolactin level. Below, we suggest an algorithm for managing antipsychotic-­induced hyperprolactinaemia (Figure 1.5). If treatment of hyperprolactinaemia is required, switching to an antipsychotic with a lower liability for prolactin elevation is usually the first choice, although switching always carries a risk of destabilising the illness and of relapse.24 An alternative is to add aripiprazole to existing treatment.25 Aripiprazole lowers prolactin levels in a dose-­dependent manner: 3mg/day is effective but 6mg/day more so. Higher doses appear unnecessary.26 Other strategies to reduce long-­term risk to bone mineral density should also be discussed (e.g. stopping smoking, increasing weight-­bearing exercise and ensuring adequate calcium and vitamin D3 intake).19,27 For patients who need to remain on a prolactin-­elevating antipsychotic medication and who cannot tolerate aripiprazole, dopamine agonists can be effective.28–30 Amantadine, cabergoline and bromocriptine have all been used, but each has, theoretically at least, the potential to worsen psychosis (although this has not been reported in trials). High-­dose vitamin B6 (600mg/day) seems to be effective in reducing antipsychotic-­induced hyperprolactinaemia and is well tolerated.31 A herbal remedy – Peony–Glycyrrhiza Decoction – has also been shown to improve prolactin-­related symptoms,32,33 but the data are limited. A reduction in prolactin levels was also achieved by taking high daily doses (2.5–3g) of metformin34 in a study of women with diabetes on antipsychotic medication. A 2022 network meta-­ analysis of all the above treatments confirmed the efficacy of aripiprazole 5mg a day and of vitamin B6 600mg/day in patients whose baseline prolactin exceeded 50ng/mL.35 Two other meta-­analyses concluded that adjunctive aripiprazole was the most effective treatment.36,37 Summary of management First-choice adjunct treatment Aripiprazole 5mg/day Second-choice adjunct Vitamin B6 600mg/day Third-choice adjunct (in no particular order) DA agonists – cabergoline, bromocriptine, amantadine Peony–Glycyrrhiza Decoction Metformin 2.5–3g/day

192 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 For all patients, measure plasma prolactin level at baseline Add adjunctive aripiprazole* At 3 months:

• Ask about prolactin-related symptoms
• If hyperprolactinaemia suspected or patient is prescribed a prolactin-elevating antipsychotic, obtain plasma prolactin level Prolactin concentration interpretation Normal Women 0–25ng/ml (~0–530mIU/L)

Men 0–20ng/ml (~0–424mIU/L) Elevated

25–118ng/ml (530–2500mIU/L) Systematically assess prolactinrelated adverse effects

Discuss clinical consequences of

prolonged raised prolactin levels Highly elevated

118ng/ml 2500mIU/L Refer for tests to rule out prolactinoma Elevated Symptomatic Successful Not appropriate/not successful Switch not appropriate Not tolerated Unsuccessful Elevated Asymptomatic *May not normalise prolactin levels in amisulpride-induced hyperprolactinaemia.34 Discuss clinical implications of the test results with the patient and take a joint decision on whether to continue current treatment with annual monitoring or switch to another antipsychotic Switch to an antipsychotic with a lower liability for plasma prolactin elevation Consider slowly reducing dose of prolactin-raising drug and aim for aripiprazole as sole treatment Only if this strategy fails or is considered clinically inappropriate should long-term combined antipsychotics be considered Consider treatment with vitamin B6 600mg/day Consider treatment with dopamine agonists or metformin or Peony–Glycyrrhiza decoction Figure 1.5  Management of antipsychotic-­induced hyperprolactinaemia.38