Cabergoline: a review of its use in the inhibition of lactation for women living with HIV

Abstract

Introduction In developed countries, breastfeeding is not recommended for women living with human immunodeficiency virus (WLWH). However, lactation symptoms can be distressing for women who choose not to breastfeed. There is currently no universal guideline on the most appropriate options for prevention or reduction of lactation symptoms amongst WLWH. This review describes the evidence base for using cabergoline, a dopaminergic agonist, for the post‐partum inhibition of lactation for WLWH. Methods A scoping review of post‐partum pharmaceutical lactation inhibition specific for WLWH was conducted using searches in PubMed, Medline Ovid, EBM Reviews Ovid, Embase, Web of Science and Scopus until 2019. A narrative review of cabergoline pharmacologic properties, therapeutic efficacy, tolerability data and drug interaction data relevant to lactation inhibition was then conducted. Results and discussion Among 1366 articles, the scoping review identified 13 relevant publications. Eight guidelines providing guidance regarding lactation inhibition for WLWH and two surveys of medical practice on this topic in UK have been published. Three studies have evaluated the use of pharmaceutical agents in WLWH. Two of these studies evaluated cabergoline and reported it to be an effective method of lactation inhibition in this population. The third study evaluated ethinyl estradiol and bromocriptine use and showed poor efficacy. Cabergoline is a long‐acting dopamine D2 agonist and ergot derivative that inhibits prolactin secretion and suppresses physiologic lactation when given as a single oral dose of 1 mg after delivery. Cabergoline is at least as effective as bromocriptine for lactation inhibition with success rates between 78% and 100%. Transient, mild to moderate adverse events to cabergoline are described in clinical trials. Few drug interactions exist as cabergoline is neither a substrate nor an inducer/inhibitor of hepatic cytochrome P450 isoenzymes. There are no reported clinically significant drug–drug interactions between cabergoline and any antiretroviral medications including protease inhibitors. Conclusions Cabergoline is a safe and effective pharmacologic option for the prevention of physiological lactation and associated physical symptoms in non‐breastfeeding women. Future studies should focus on its safety, efficacy and acceptability among WLWH.

Evaluation of cabergoline for lactation inhibition in women living with HIV

“…The cabergoline product monograph recommends administration during the first day postpartum, 8 and clinical trials have all established single-dose cabergoline efficacy when administered up to 50 h postdelivery. 15 This is consistent with our findings of greater efficacy in participants who received cabergoline earlier in the postpartum period.…”

“…Until recently, the majority of the available guidelines regarding perinatal management of WLWH did not provide guidance about lactation inhibition, 15 except the British HIV in Pregnancy Guidelines. 28 Cabergoline use has been added in the last update of the US guidelines.…”

“…[11][12][13][14] There is however limited published information about the safety and efficacy of postpartum use of cabergoline in WLWH. 15 Moreover, the acceptability and satisfaction of using cabergoline for lactation suppression in WLWH has not been adequately assessed. 15 The primary objective of this study is to determine the efficacy of a cabergoline 1 mg single oral dose taken within the first 48 h postpartum for lactation inhibition in WLWH.…”

“…15 Moreover, the acceptability and satisfaction of using cabergoline for lactation suppression in WLWH has not been adequately assessed. 15 The primary objective of this study is to determine the efficacy of a cabergoline 1 mg single oral dose taken within the first 48 h postpartum for lactation inhibition in WLWH. Secondary objectives include the evaluation of the frequency of adverse events within two weeks and assessment of womens' satisfaction related to this medication.…”

HIV Infection in Pregnant Women: A 2020 Update

“…57 However, prospective studies are needed regarding the safety, efficacy, and acceptability in women living with HIV before it can be incorporated into perinatal guidelines and practice. 58 Further, perinatal transmission rates have dramatically decreased from one in three newborns infected to less than one in a hundred, 35,59 with elimination of mother to child transmission of HIV in a growing number of countries worldwide. 9 However, gaps remain, in that 1. interventions appear promising as strategies to improve adherence.…”