General
What are the dopamine agonists? Pros and cons?
bromocriptine and cabergoline
Pros: oral formulation and lower cost than somatostatin analogs
Cons: less effective than other options
What is the treatment goals for acromegaly?
Age normalized IGF-1
improve clinical s/sx, reduce mortality
What are the treatment goals for GH deficiency?
Children: increase growth velocity and maximize final adult height
adult: normalize GH levels, reverse metabolic complications
What is hyperprolactinemia? Who is it most prevalent in? Most common causes?
Increased serum prolactin levels
women of reproductive age
Pregnancy and breastfeeding, stress, prolactinomas, medications
What is the treatment for an asymptomatic prolactinoma?
close monitoring and follow up, dopamine agonist or oral contraceptive if amenorrhea
What are the 6 anterior pituitary hormones?
GH, prolactin, ACTH, TSH, FSH, LH
What are the treatment options for Acromegaly (GH excess)? First line for medication therapy?
Transphenoidal surgery
Medications: somatostatin analog (moderate to severe), dopamine agonist (mild), consider adding pegvisomant or cabergoline to somatostatin analog if inadequate response
radiation is last line, could take several years to achieve effective symptom control
just kids
What are the treatment goals for hyperprolactinemia?
normalize prolactin, restore gonadal function and fertility, prevent development of osteoporosis
What specific drug is preferred in the treatment of prolactinomas? Why?
cabergoline
improved efficacy and safety profile, more convenient dosing
But, is more expensive
Dopamine agonists AEs and monitoring?
CNS and GI (take with food)
Monitor IGF-1, GH and prolactin levels every 4-6 weeks
What are the somatostatin analogs?
octreotide, lanreotide, pasireotide
What is used to treat GH deficiency?
rhGH (somatotropin) - all are equally effective
rotate administration sites
What drugs can induce hyperprolactinemia?
First gen antipsychotics, antidepressants, antihypertensives, estrogens, progestins, H2RAs, benzodiazepines, opioids, protease inhibitors
What is the treatment for symptomatic prolactinoma? First line??
First line: dopamine agonist
transphenoidal surgery if unresponsive or intolerant of high dose cabergoline
radiation if surgery fails
Chemo if malignant
What is the GH receptor antagonist? MOA?
Pegvisomant
MOA: GH derivative the selectively binds to GH receptors in the liver, blocks endogenous GH binding, prevents IGF-1 production
Somatostatin analogs MOA
inhibits release of GH, decrease in GH and IGF-1 levels
rhGH AEs, CI, and monitoring?
AEs: insulin resistance and hyperglycemia, dose related edema, arthralgia, myalgia, HA
CI: active cancer
Monitoring: measure height in children every 3-6 months, IGF yearly for kids, IGF every 1-2 months during dose titrations for adults
How do we treat drug induced hyperprolactinemia if the patient is asymptomatic?
Close monitoring and follow up
estrogen or testosterone if long term hypogonadism
When should dopamine agonist therapy be immediately discontinued?
when pregnancy is detected
AEs: GI, flu like symptoms, injection site pain, increased LFTs (reversible once D/Ced)
monitoring: GH secreting tumor size (MRI), serum IGF-1 every 4-6 weeks, liver function
Somatostatin analogs main AEs, monitoring, and pearls?
AEs: GI, abnormal glucose metabolism, hypothyroidism
Monitor: GH and IGF-1 every 3 months, BG, and thyroid function
Pearls: renal and hepatic dosage adjustments, alternate injection sites
What is the human GH analog? Administration route? CI? AEs? Drug interactions?
Somapacitan
SubQ injection into abdomen or thigh once weekly
CI: active malignancy
AEs: arthralgia, back pain, can decrease insulin sensitivity
DDI: antidiabetic agents, glucocorticoids, oral estrogen, thyroid hormone
How do we treat drug induced hyperprolactinemia if the patient is symptomatic?
Discontinue offending drug, initiate an alternative agent
If agent cannot be stopped, consider a dopamine agonist with caution
How should dopamine agonist therapy be monitored? Can and when should it be tapered?
Monitor serum prolactin concentration every 3-4 weeks, then every 6-12 months once in normal limits
Can taper and possibly D/C if treated with dopamine agonist for more than 2 years, prolactin levels are within normal limits, and no visible tumor on MRI