How to manage intolerance to dopamine agonist in patients with prolactinoma

PurposeDopamine agonists (DA) are the gold-standard for prolactinoma and hyperprolactinemia treatment. Intolerance to DA leading to drug drop out occurs in 3 to 12% of cases. We provide here a review of published data about DA intolerance and present a case report concerning the use of intravaginal cabergoline.MethodsWe review the literature on the definition, the pathogenesis, frequency and management of DA intolerance. In addition, the review provides strategies to enhance tolerability and avoid precocious clinical treatment withdrawal.ResultsCabergoline is often cited as the most tolerable DA and its side effects tend to ameliorate within days to weeks. Restarting the same drug at a lower dose or switching to another DA can be used in cases of intolerance. The vaginal route can be tried specifically if there are gastrointestinal side effects in the oral administration. Symptomatic treatment could be attempted, although mainly based on a strategy used in other diseases.ConclusionsDue to limited data, no guidelines have been developed for the management of intolerance in DA treatment. The most frequent management is to perform transsphenoidal surgery. Nevertheless, this manuscript provides data derived from published literature and expert opinion, suggesting new approaches to this clinical issue.

Automated summary

Dopamine agonists (DA) are the preferred treatment for prolactinoma and hyperprolactinemia. However, intolerance to DA can occur in 3 to 12% of cases, leading to treatment discontinuation. This review discusses the definition, pathogenesis, frequency, and management of DA intolerance, as well as introduces a case report on the use of intravaginal cabergoline.