Current guidelines and their recommendations for prolactin monitoring in psychosis

Guidelines on the use of second-generation antipsychotics and physical health monitoring have begun to include information on hyperprolactinemia, and generally recommend that patients should be queried about possible symptoms related to elevated prolactin: menstrual abnormalities, galactorrhea and sexual dysfunction. However, with only two exceptions, none of the guidelines suggest performing baseline plasma prolactin levels. Although several of the guidelines mention the potential for hyperprolactinemia to be associated with osteopenia and osteoporosis, there is no guidance how to monitor for this. Product labeling for the different antipsychotics inform the clinician about potential risks but are not helpful with precise monitoring recommendations. The internal medicine literature contains important information regarding the pulsatile secretion of prolactin, differential diagnosis of hyperprolactinemia, and plasma levels of prolactin usually associated with certain symptoms that would be useful for the prescriber of antipsychotics to be aware of. The prudent clinician should consider obtaining a baseline plasma prolactin level and at least one follow-up measurement when starting any patient on a new antipsychotic. This will help guide clinical decisions about antipsychotic dosage, switching antipsychotic medications, or considering ancillary treatments to protect bone mass. These decisions would be within the context of considering other adverse events as well as the overall effectiveness of the antipsychotic medication being used.