Dopamine agonist therapy for a prolactinoma

The goals of dopamine agonist therapy for a prolactinoma are to normalise the serum prolactin concentration, restore normal gonadal function, and reduce or stabilise prolactinoma size. Use:

1 cabergoline 0.5 mg orally, weekly in one or two doses, increasing according to response by 0.5 mg in monthly intervals, up to a maximum total weekly dose of 3 mg prolactinoma cabergoline    

OR

2 bromocriptine 1.25 mg orally, daily at night, increasing according to response by 1.25 mg every 3 to 7 days up to a maximum of 15 mg daily in 2 or 3 divided doses prolactinoma bromocriptine    

OR

3 quinagolide 25 micrograms orally, daily at night for 3 days, then 50 micrograms daily at night for 3 days, then 75 micrograms daily at night, then increase the dose according to response at intervals of at least 1 week, up to a maximum of 300 micrograms once daily. prolactinoma quinagolide    

Tailor the dose according to the prolactin concentration and pituitary imaging.

In women of reproductive age, ovulation can be restored soon after starting dopamine agonist therapy. Provide advice on contraception if pregnancy is not desired. In some patients, restoring gonadal function can take several months, particularly for males with larger or more resistant prolactinomas.

Allow around 6 months of therapy to determine if the normalisation of serum prolactin concentration has restored adequate endogenous testosterone secretion in men, or menstrual cyclicity in women. If hypogonadism persists, replacement testosterone or estrogen/progestin therapy is indicated; see Approach to testosterone replacement therapy and Treatment of amenorrhoea.

Consider a trial of drug withdrawal after about 3 years if:

  • symptoms have resolved
  • the size of the prolactinoma has reduced markedly
  • the serum prolactin concentration is well controlled with cabergoline 0.5 mg once a week (or a similar dose of another dopamine agonist).

If relapse occurs in a woman with a microprolactinoma, restart treatment and continue until their natural menopause. If relapse occurs in a woman with a macroprolactinoma, or in a man, restart treatment and continue lifelong.