The Use of High-Dose Daily Cabergoline in an Adolescent Patient With Macroprolactinoma

Abstract

Prolactinomas are rare in children and adolescents but well studied in adults. Dopamine agonists are the treatment of choice for all ages. Bromocriptine is the only agonist approved for use in pediatric patients by the FDA. Cabergoline, a second-generation ergot derivative with a longer half-life, has been used in resistant prolactinomas and as first-line treatment in adults. The authors describe an adolescent boy with a pituitary macroadenoma with an initial prolactin level of 73,777 ng/mL. After failing to respond to bromocriptine and standard-dose cabergoline, he responded well to very high daily doses of cabergoline (1.5 mg daily), with a current prolactin level of 726 ng/mL and notable reduction in tumor size. Escalating doses of cabergoline should be considered in pediatric patients with dopamine-resistant prolactinomas.

Clinical Features and Response to Treatment of Prolactinomas in Children and Adolescents: A Retrospective Single-Centre Analysis and Review of the Literature

“…1.5 mg/day) [25]. Amenorrhea disappeared and tumour size shrank on MRI, but the prolactin level remained elevated.…”

“…Mann [24] reviewed the following treatment strategies: cabergoline should be started at 0.25–0.5 mg once weekly with a monthly increase by 0.5 mg; 0.5 mg twice per week up to 3.5 mg per week is suggested as a medium dose. In individual cases, higher doses are possible and tolerable [25, 26]. Cabergoline should be taken in the evening because of better tolerance.…”

THERAPY OF ENDOCRINE DISEASE: The challenges in managing giant prolactinomas

“…Among 16 cases collected from the literature and fulfilling all definition criteria of a true giant prolactinoma (55,56,72,95,105,106,107,108,109,110,111,112,113,114), there were 15 boys with a mean age of 10.8 years (range: 6-14 years) and a mean tumour diameter of 65 mm (range: 40-99 mm) and only one 14.5-year-old girl (95). These giant tumours may also lead to the same various neurologic complications as in adults, such as blindness and cranial nerve palsies (106), hydrocephalus (56,72), proptosis (56,105,108) or nasopharyngeal symptoms (71,114), and they should be considered in the differential diagnosis of every large and erosive paediatric skull base tumour.…”

“…In the absence of complications requiring immediate surgery, such as apoplexy or CSF leak, DAs should be considered as first-line treatment, irrespective of the size of the tumour and the presence or not of severe visual defects. Both BRC and CAB have demonstrated a very good efficacy in children with giant prolactinomas, although experience remains so far limited (56,95,106,108,109).…”

Management of resistant prolactinomas

“…Isolated cases of patients requiring 1.5 and 3.0 mg daily have also been reported. 59,60 In general, high doses of cabergoline are well tolerated. If necessary, the dose of cabergoline can be increased, as long as the patient is monitored for adverse effects and closely checked to assure that a clinical response is obtained.…”