Risperdal and Prolactin Levels

[Blitz2006]

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So I've been doing some reading online and speaking to attendings, getting mixed results.

Some attendings are telling me to check prolactin levels annually if on risperdal. Some are saying only check if symptomatic.

I have a few patients with "high" prolactin levels (>50, range is up to 25), but asymptomatic. Do I decrease dose, or just keep them on it and recheck in 6 months? What is your definition of a high prolactin level?

What do you guys do in the outpatient world? Any guidelines you can refer me to?

Thx,

 

[PistolPete]

This is why you don't check prolactin levels unless your patient is symptomatic. Now you have to do something (whether that's changing the medication and/or dose or do nothing) and justify it.

 

[Indodo]

Anyone use abilify or vraylar to combat high prolactin?

 

[Jules A]

This is why you don't check prolactin levels unless your patient is symptomatic. Now you have to do something (whether that's changing the medication and/or dose or do nothing) and justify it.

And you know if they are on Risperdal their levels are going to be elevated.

 

[Merovinge]

Anyone use abilify or vraylar to combat high prolactin?

Yes, Abilify at low doses works very well for this and faster than bromocriptine. The trick is getting it approved by insurance as its one of the somewhat rare cases where 2 atypicals at the same time makes actual sense.

 

[Merovinge]

What do you guys do in the outpatient world? Any guidelines you can refer me to?

Don't draw unless symptomatic. However in the PP world most attendings Ive spoken to in the past year have said that since 1-800-RISPERDAL late night advertisements for their class action lawsuit that it's better to just avoid the drug altogether. Which is a pain if you are also formulary constricted, particularly in CAP where it has been actually studied for aggression in ASD. I'm still torn on how much I will be prescribing it as an attending.

 

[milesed]

It's use is pretty much mandated here by insurance as first line tx. I check it at baseline and q6 months. I switch to something else if going up and male. For females, I wait until symptomatic to switch.

I'd prefer to avoid use of risperdal completely, but am waiting for Geodon and Abilify generics to get as cheap.

 

[Blitz2006]

This is why you don't check prolactin levels unless your patient is symptomatic. Now you have to do something (whether that's changing the medication and/or dose or do nothing) and justify it.

Fair enough.

I guess I'm thinking along the lines of "prevention is best cure". I wonder if putting a young patient on risperdal, and then never checking a prolactin level because she is asymptomatic, and then 20 years later she gets early onset osteorporosis, could it have been avoided/did I cause it? I'm just playing devil's advocate/thinking out loud.

Of course if a patient is lactating/not having periods, then switching meds is no-brainer. I mean at that point, checking prolactin is purely academic, right?

So am curious if there are any such guidelines, and what is considered "high". I mean a patient could sit at a level of 100 for many years being asymptomatic....

 

[Merovinge]

no it doesn't make sense. abilify acts as a dopamine agonist in the presence of a dopamine antagonist this you can worsen psychosis if using with another neuroleptic. makes much more sense to cross taper to abilify or to use bromocriptine

Our psychosis specialists use this not infrequently, usually at 2mg, and to the best of my knowledge it has been widely well tolerated. That's absolutely a theoretical concern but I have seen folks with severe schizophrenia tolerate Abilify adjunctive tx for hyperprolactinemia.

 

[Salpingo]

2mg is unlikely to destabilize someone of course as it's such a piddly dose.

Sorry, have to comment -- I cringed when I saw that. Unless you've actually taken risperidone, I wouldn't characterize any amount of psychotropic as "piddly", but especially not 2mg. People are cavalier about atypicals, but even at low doses you get pretty substantial D2 receptor occupancy (maybe not enough for EPS, but enough to feel pretty miserable).

Edit: Sorry, didn't realize you were referring to aripiprazole. Still, the point still stands that we shouldn't be casual with neuroleptics.

 

[hamstergang]

I'm a brand new attending, doing outpatient child/adolescent work, so maybe my answer will eventually change. But for now, I won't check prolactin in an asymptomatic patient. I don't think there's good evidence that checking routinely is useful, and the AACAP Practice Parameters supports this. Checking the lab just gives parents another thing to worry about and can mess with the course of treatment without clear benefit.

I inherited a patient who just had the prolactin level checked prior to me coming on board, and the level was mildly elevated. He is asymptomatic, and his family felt very strongly that the Risperdal was very helpful, so we're keeping him on it. Now that we have an elevated level, I plan to continue monitoring for symptoms every visit and prolactin levels every 6 months or so just to be sure it's not creeping up higher. Don't know if this makes sense, but the family likes the idea.

I had one parent so scared of the idea of hyperprolactinemia that I had to check the level and it was slightly high. I suggested a little Abilify given how helpful the Risperdal was and how serious the patient's problems were, but the parents were already so scared of these medications since the Risperdal caused a lab abnormality. Perhaps adult patients would be more open to adding another medication to counter side effects of the first.

 

[cookymonster]

Don't draw unless symptomatic. However in the PP world most attendings Ive spoken to in the past year have said that since 1-800-RISPERDAL late night advertisements for their class action lawsuit that it's better to just avoid the drug altogether. Which is a pain if you are also formulary constricted, particularly in CAP where it has been actually studied for aggression in ASD. I'm still torn on how much I will be prescribing it as an attending.

Not sure prescribing Abilify for hyperprolactinemia is such a terrific idea then. It's one thing to have a bunch of 12-year-old boys growing breasts and lactating, but a totally different beast when they're blowing they're blowing their weekend allowance while leaking all over the craps table on the riverboat casino.

 

[milesed]

Fair enough.

I guess I'm thinking along the lines of "prevention is best cure". I wonder if putting a young patient on risperdal, and then never checking a prolactin level because she is asymptomatic, and then 20 years later she gets early onset osteorporosis, could it have been avoided/did I cause it? I'm just playing devil's advocate/thinking out loud.

Of course if a patient is lactating/not having periods, then switching meds is no-brainer. I mean at that point, checking prolactin is purely academic, right?

So am curious if there are any such guidelines, and what is considered "high". I mean a patient could sit at a level of 100 for many years being asymptomatic....

This was discussed not too long ago and I remain in the minority as one who checks it regularly. If you search the forum, you'll find the other discussion.

Practice parameters do recommend checking baseline glucose, lipids and following up if on any SGAP. If you are already ordering labs, why not add this one to the order? I feel like those who don't check out of uncertainty about how to deal with the results are just sticking their heads in the sand and hoping for the best. I got flamed for this last time and likely will again now.

Risperdal is well known for causing metabolic issues and the lab recommendation was not added to what is monitored until the med had been out for a long time. I think prolactin will be added at some point with some definite guidelines in using the results. IMO there is no excuse for not checking and dealing with a high result. We have many other meds available now that are good options not to switch away from risperdal. If they have failed all others, then you need to at least have that discussion as to why you are leaving them on the med despite the high prolactin.

I watch it closely, if it is extremely high or steadily heading up and up, I change the med. The levels do come back down to baseline and we have caught it in time to prevent gynecomastia which is not reversible w/o surgery. We all check labs for depakote and Lithium and if the kidneys, liver or blood cells are going down the tubes we do something about it. It's the minimal standard of care and I'm betting it will soon also be with Risperdal- prolactin monitoring. I don't want to harm my patients and I don't want to be sued.

 

[PistolPete]

This was discussed not too long ago and I remain in the minority as one who checks it regularly. If you search the forum, you'll find the other discussion.

Practice parameters do recommend checking baseline glucose, lipids and following up if on any SGAP. If you are already ordering labs, why not add this one to the order? I feel like those who don't check out of uncertainty about how to deal with the results are just sticking their heads in the sand and hoping for the best. I got flamed for this last time and likely will again now.

Risperdal is well known for causing metabolic issues and the lab recommendation was not added to what is monitored until the med had been out for a long time. I think prolactin will be added at some point with some definite guidelines in using the results. IMO there is no excuse for not checking and dealing with a high result. We have many other meds available now that are good options not to switch away from risperdal. If they have failed all others, then you need to at least have that discussion as to why you are leaving them on the med despite the high prolactin.

I watch it closely, if it is extremely high or steadily heading up and up, I change the med. The levels do come back down to baseline and we have caught it in time to prevent gynecomastia which is not reversible w/o surgery. We all check labs for depakote and Lithium and if the kidneys, liver or blood cells are going down the tubes we do something about it. It's the minimal standard of care and I'm betting it will soon also be with Risperdal- prolactin monitoring. I don't want to harm my patients and I don't want to be sued.

Fair points. I could see an autistic boy doing well on risperidone who has failed aripiprazole, then he starts to grow breasts and parents sue you for malpractice because he doesn't complain about them and parents may not notice until it's too late and then he needs surgery.

But what if the autistic boy has an elevated prolactin and no symptoms? What are the odds that he will develop gynecomastia in the future? I just don't think we have clear numbers on this, and you can still be doing harm by taking him off of a medication that has been working perfectly well at controlling aggression and switching to something else that does not, and he ends up hurting himself.

You're damned if you do, and damned if you don't.

 

[Merovinge]

2mg is unlikely to destabilize someone of course as it's such a piddly dose. I question why in most cases it wouldn't just make sense to switch them to abilify and avoid the polypharmacy. obviously in some cases abilify is not going to cut it but it's a reasonable neuroleptic outside of the acute setting

I use a lot of aripiprazole and absolutely agree that it can work well, however these cases tend to be in repeatedly hospitalized, low SES, chronically debilitated individuals with schizophrenia. They happen to be doing good on Risperidone and may have even failed a trial of Abilify already; it is far from a common situation but one that a psychiatrist should have in their armament when faced with good response to risperidone and hyperprolactinemia.

 

[milesed]

Fair points. I could see an autistic boy doing well on risperidone who has failed aripiprazole, then he starts to grow breasts and parents sue you for malpractice because he doesn't complain about them and parents may not notice until it's too late and then he needs surgery.

But what if the autistic boy has an elevated prolactin and no symptoms? What are the odds that he will develop gynecomastia in the future? I just don't think we have clear numbers on this, and you can still be doing harm by taking him off of a medication that has been working perfectly well at controlling aggression and switching to something else that does not, and he ends up hurting himself.

You're damned if you do, and damned if you don't.

I was in this situation EXACTLY not long ago. Teen with autism, etc. Prolactin got up over 100 so I stopped the risperdal, abilify didn't work and patient had a severe manic episode before ending up on Haldol and does well now. There is always risk involved when switching meds, but there are other options out there.

 

[MLT2MT2DO]

This was discussed not too long ago and I remain in the minority as one who checks it regularly. If you search the forum, you'll find the other discussion.

Practice parameters do recommend checking baseline glucose, lipids and following up if on any SGAP. If you are already ordering labs, why not add this one to the order? I feel like those who don't check out of uncertainty about how to deal with the results are just sticking their heads in the sand and hoping for the best. I got flamed for this last time and likely will again now.

Risperdal is well known for causing metabolic issues and the lab recommendation was not added to what is monitored until the med had been out for a long time. I think prolactin will be added at some point with some definite guidelines in using the results. IMO there is no excuse for not checking and dealing with a high result. We have many other meds available now that are good options not to switch away from risperdal. If they have failed all others, then you need to at least have that discussion as to why you are leaving them on the med despite the high prolactin.

I watch it closely, if it is extremely high or steadily heading up and up, I change the med. The levels do come back down to baseline and we have caught it in time to prevent gynecomastia which is not reversible w/o surgery. We all check labs for depakote and Lithium and if the kidneys, liver or blood cells are going down the tubes we do something about it. It's the minimal standard of care and I'm betting it will soon also be with Risperdal- prolactin monitoring. I don't want to harm my patients and I don't want to be sued.

My argument to this is, do we have any accepted studies where treating an elevated Prolactin reduces morbidity? You're comparing this to very clear cut thing like Lipids and A1Cs where we do have those studies.

You could theoretically follow any lab and if it changes on a medication you could make an argument to stop. My question is "why?".

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[Merovinge]

I was in this situation EXACTLY not long ago. Teen with autism, etc. Prolactin got up over 100 so I stopped the risperdal, abilify didn't work and patient had a severe manic episode before ending up on Haldol and does well now. There is always risk involved when switching meds, but there are other options out there.

So he has traded hyperprolactinemia with unclear physical sequelle for being on Haldol, potentially indefinitely. Depending on who you ask and what side-effects you care about that could be a good thing but could also be a very bad thing. That and he went through a severe episode to get off the risperidone.

 

[HarryMTieboutMD]

Why do you need PRL levels in the first place? If they have symptoms, and the etiology is pretty clear, just make the pharmacologic changes that you all are debating above. If the patient is amenorrheic or is experiencing decreased libido and changes don't work, then you need to expand your differential (or turf to primary care/OBGYN/whatever to do the workup). Maybe if the patient is having pseudoseizures... (!)

 

[milesed]

Why do you need PRL levels in the first place? If they have symptoms, and the etiology is pretty clear, just make the pharmacologic changes that you all are debating above. If the patient is amenorrheic or is experiencing decreased libido and changes don't work, then you need to expand your differential (or turf to primary care/OBGYN/whatever to do the workup). Maybe if the patient is having pseudoseizures... (!)

I want to catch it as early as possible and stop the offending agent. An ounce of prevention is my approach. You may not start to see symptoms until the levels have been high for a long time. At least that is what I'm seeing clinically. Most patients must have elevated prolactin for at least 6-12 months before gynecomastia starts. If I can catch it before, then I've saved them a lifetime of embarrassment from man boobs or serious surgery.

 

[drprincen]

Just want to add to this - please consider increase in breast cancer risk for your female patients as well. The evidence supports a small but significant increase in risk, and when additional risk factors (like positive family hx for breast ca) are present, please keep this on your radar. I have a family member with schizophrenia, who was fairly stable on risperidone for several decades. She developed metastatic breast cancer, and when her prolactin levels were checked they were elevated (~50). I realize that the prolactin may not have anything to do with it, and the truth is we will never know. But for many patients with schizophrenia, the psychiatrist is the only doc they see - they aren't seeing primary care or obgyn docs with any regularity. So if you have a female patient 35+ y/o who has been on risperdal long term, please check a level, if for no other reason than to help prompt them getting a mammogram earlier rather than later. Additionally, if it is elevated in a post-menopausal female patient, you can consider doing a controlled taper and switch, rather than an abrupt discontinuation, as occurred in my family member's case. For my family, this has been a truly horrific process, in terms of learning her diagnosis and prognosis, dealing with the fallout of trying to do a totally ineffective abrupt switch from risperdal to abilify, and trying to get her to engage with any meaningful cancer treatment. Likewise, trying to get any cancer doc to take her seriously as a patient.

I know gynecomastia is usually the big concern, but please think about this in your older female patients as well.