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KEY CONCEPTS

KEY CONCEPTS

  • imagePharmacologic therapy for acromegaly should be considered when surgery and irradiation are contraindicated, when there is a poor likelihood of surgical success, when rapid control of symptoms is needed, or when other treatments have failed to normalize growth hormone (GH) and insulin-like growth factor-1 (IGF-1) serum concentrations.

  • imagePharmacotherapy for acromegaly using dopamine agonists has several advantages including oral administration and lower cost when compared to somatostatin analogs and pegvisomant. However, dopamine agonists effectively normalize IGF-1 serum concentrations in only 10% to 30% of patients. Therefore, somatostatin analogs remain the mainstay of therapy.

  • imageBlood glucose concentrations should be monitored frequently in the early stages of somatostatin analog therapy, especially when using pasireotide.

  • imagePegvisomant appears to be the most effective agent for normalizing IGF-1 serum concentrations.

  • imageRecombinant growth hormone (GH) is currently considered the drug of choice for the treatment of children with growth hormone–deficient short stature. Prompt diagnosis of growth hormone deficiency (GHD) and initiation of replacement therapy with recombinant GH is crucial for optimizing final adult heights.

  • imageAll GH products are equally effective. The recommended initial dose for treatment of GHD short stature in children is 0.16 to 0.24 mg/kg/wk.

  • imagePharmacologic agents that antagonize dopamine or increase the release of prolactin can induce hyperprolactinemia. Discontinuation of the offending medication and initiation of an appropriate therapeutic alternative usually normalizes serum prolactin concentrations.

  • imageCabergoline is more effective than bromocriptine for the medical management of prolactinomas and offers the advantage of less-frequent dosing and fewer adverse effects.

  • imageAlthough currently available data do not suggest that cabergoline has significant teratogenic potential, cabergoline is not recommended for use during pregnancy. Patients receiving cabergoline or bromocriptine who plan to become pregnant should discontinue the medication as soon as pregnancy is detected.

  • imagePharmacologic treatment of panhypopituitarism includes the use of glucocorticoids, thyroid hormone, sex steroids, and recombinant GH, when appropriate, as lifelong replacement therapies.

PATIENT CARE PROCESS

Patient Care Process for Hyperprolactinemia

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Collect

  • Patient characteristics (eg, age, sex, pregnancy status)

  • Patient history (past medical, menstrual cycle, family medical history)

  • Social history (stress level, physical activity, dietary habits)

  • Current medications including prescription, non-prescription, and herbal products

  • Objective data

  • Labs (eg, prolactin, macroprolactin, serum β-HCG, FSH, TSH, free T4, AST, ALT, BUN, and SCr)

    • DXA T-score of the lumbar spine

    • MRI of the pituitary gland

    • Objective confirmation of signs (see Table e98-5)

Assess

  • Presence of symptoms related to local effects of prolactinoma (see Table e98-5)

  • Presence of medications likely to impact prolactin levels (see Table e98-4)

  • Emotional status (ie, presence of stress)

  • Patient’s desire to become pregnant in the future

Plan*

  • If drug-induced, discontinuation of offending medication and initiation of therapeutic alternative

  • If not drug-induced, treat with a dopamine agonist, if appropriate

  • Consider sex hormone replacement therapy if clinically appropriate

  • Monitoring parameters including efficacy (eg, prolactin, gonadal function, tumor size, galactorrhea) and safety (bromocriptine: central nervous system [CNS] and gastrointestinal [GI] adverse effects, cabergoline: CNS ...

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