REVIEW OF: Zhe L et al, Transl Psychiatry2022;12(1):267

STUDY TYPE: Systemic review and network meta-analysis 

Many patients on antipsychotic drugs—up to 70%—face a common side effect: increased levels of prolactin. This condition, which is typically seen when levels exceed 20 ng/mL in patients who are not pregnant, can lead to issues like reduced libido, breast enlargement, and galactorrhea. Men may experience erectile dysfunction, and postmenopausal women may see a decrease in bone density.

A comprehensive review involving 31 randomized controlled trials, with around 2,000 participants in total, investigated ways to lower elevated prolactin levels in patients who were taking antipsychotic medications. The study explored various methods: switching antipsychotic drugs, supplementing with vitamin B6 (200–1200 mg), using dopamine agonists such as bromocriptine and cabergoline, and even an herbal remedy (peony-glycyrrhiza decoction). Researchers also investigated the effectiveness of aripiprazole, a drug known from previous studies to lower prolactin levels, either when added to a patient’s regimen or as a replacement for their current medication.

The findings varied based on patients’ initial prolactin levels. For those whose starting levels were very high (above 100 ng/mL), adding a low dose of aripiprazole (5 mg daily) was the only method that significantly cut prolactin levels. For levels of 50–100 ng/mL, either switching to aripiprazole, adding aripiprazole as an adjunct (in doses of 5–10+ mg daily), or incorporating vitamin B6 significantly helped. When prolactin levels were below 50 ng/mL, none of the strategies made a significant difference. The study didn’t delve into whether these reductions in prolactin also eased the related symptoms or affected psychotic symptoms, nor did it consider differences between genders.

CARLAT TAKE

When prescribing antipsychotics, it’s crucial to keep an eye on your patients’ prolactin levels. For patients with prolactin levels over 100 ng/mL, adding just 5 mg of aripiprazole can be beneficial. For those with prolactin levels of 50–100 ng/mL, adding or switching to aripiprazole are both viable alternatives, as is simply adding high-dose vitamin B6. This study did not investigate reducing the offending antipsychotic, which may also be helpful.