Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA.
Eur J Endocrinol. 2020 Sep;183(3):C11-C13. doi: 10.1530/EJE-20-0607.
There can potentially be a number of clinical interactions that could adversely affect patient outcomes in a patient with a prolactinoma and psychiatric disease that might require antipsychotic and dopamine agonist treatment. Dopamine agonists stimulate the dopamine D2 receptor, resulting in a decrease in prolactin (PRL) levels and in prolactinoma size but action on dopamine receptors in the meso-limbic system may rarely cause psychosis and more commonly cause impulse control disorders. The psychiatric benefits of antipsychotic agents involve blocking the D2 and other dopamine receptors but this blockade often also causes hyperprolactinemia. In patients with macroprolactinomas and psychosis, observation, estrogen/progestin replacement, and surgery can be considered in addition to dopamine agonists. In those who require dopamine agonists for PRL and tumor size control, the introduction of antipsychotics may blunt this effect, so that higher doses of the dopamine agonists may be needed. Alternatively, antipsychotics that have less of a blocking effect at the D2 receptor, such as aripiprazole, can be tried, if appropriate. For patients already on antipsychotic drugs who are found to have a macroprolactinoma for which dopamine agonists are required, dopamine agonists can be initiated at low dose and the dose escalated slowly. However, such patients require careful monitoring of psychiatric status to avoid the rare complication of exacerbation of the underlying psychosis. Again, if appropriate, use of antipsychotics that have less of a blocking effect at the D2 receptor may allow lower doses of dopamine agonists to be used in this situation.
可能会有一些临床相互作用，这些相互作用可能会对患有催乳素瘤和精神疾病的患者的预后产生不利影响，这些患者可能需要抗精神病药物和多巴胺激动剂治疗。多巴胺激动剂刺激多巴胺 D2 受体，导致催乳素（PRL）水平和催乳素瘤体积下降，但在中边缘系统的多巴胺受体上的作用很少会导致精神病，更常见的是导致冲动控制障碍。抗精神病药物的精神益处涉及阻断 D2 和其他多巴胺受体，但这种阻断通常也会导致高催乳素血症。对于患有巨泌乳素瘤和精神病的患者，可以考虑除多巴胺激动剂外，还可以观察、雌激素/孕激素替代和手术。对于那些需要多巴胺激动剂来控制 PRL 和肿瘤大小的患者，引入抗精神病药物可能会削弱这种作用，因此可能需要更高剂量的多巴胺激动剂。或者，如果合适，可以尝试使用在 D2 受体上阻断作用较小的抗精神病药物，如阿立哌唑。对于已经服用抗精神病药物且发现需要多巴胺激动剂治疗的巨泌乳素瘤患者，可以开始低剂量使用多巴胺激动剂，并缓慢增加剂量。然而，此类患者需要密切监测精神状态，以避免潜在精神病恶化的罕见并发症。同样，如果合适，使用在 D2 受体上阻断作用较小的抗精神病药物可能允许在此情况下使用较低剂量的多巴胺激动剂。
