Letters to the Editor
Risperidone-Induced Galactorrhoea: A Case Series
Dear Editor:
Although galactorrhea induced by atypical antipsychotics, particularly risperidone, has been reported (1–5), the clinical course of this adverse effects has not been adequately described. This report addresses the issue.
Case Report 1
A 31-year-old woman suffering her fourth affective episode (specifically, amitriptyline-precipitated mania) was started on risperidone 4 mg daily, along with ongoing carbamazepine 800 mg daily and lithium 900 mg daily. During the seventh week of treatment, she developed galactorrhea without other features of hyperprolactinemia. At that time, because she was found to have hypothyroidism (triiodothyronine [T3], 30.0 µg/dl; thyroxine [T4], 2.5µg/dl; thyroid-stimulating hormone [TSH], 3.9 µU/ml), thyroxine 25µg daily was added. Simultaneously, trifluoperazine (5 mg daily) was started in place of risperidone, with which her galactorrhea and manic symptoms disappeared over 2 months.
Case Report 2
A 26-year-old woman suffering from major depression with catatonia received 7 doses of electroconvulsive therapy and then began haloperidol 5 mg daily and fluoxetine 20 mg daily. However, haloperidol was later discontinued, owing to extrapyramidal symptoms (EPS), and she began taking risperidone 2 mg daily and trihexyphenidyl 2 mg daily. Her depression and EPS improved after 3 weeks, but after 1 month of treatment, she developed galactorrhea without other hyperprolactinemic features. Her thyroid profile was normal. Consequently, her risperidone was discontinued, and within 2 weeks and while on fluoxetine, her galactorrhea remitted.
Case Report 3
A 24-year-old woman was treated with sertraline 50 mg daily and risperidone 3 mg daily for major depression with psychotic features and comorbid obsessive–compulsive disorder (OCD). During week 3, she developed galactorrhea without other hyperprolactinemic features; consequently, risperidone was stopped. She was euthyroid. Despite improvement in her symptoms, except for galactorrhea, she discontinued medications during week 6 of therapy. This led to exacerbated depressive, psychotic, and OC symptoms, and her galactorrhea persisted. She was then given sertraline 100 mg daily, along with chlorpromazine 100 mg daily, and within 2 weeks, despite only partial improvement in her psychopathology, her galactorrhea disappeared.
Case Report 4
A 34-year-old woman was taking carbamazepine 800 mg daily and haloperidol 5 mg daily to treat bipolar affective disorder diagnosed according to DSM-IV criteria. Because she developed signs of tardive dyskinesia, her haloperidol was stopped and risperidone 4 mg daily was started. After 3 months of treatment, she gradually developed amenorrhea and, 5 months later, galactorrhea. Having had a normal thyroid profile and prolactin level (that is, 1.006 ng/ml, where a normal level is < 20.0 ng/ml), she had no other hyperprolactinemic features. Owing to the distressful galactorrhea, risperidone was discontinued, and both amenorrhea and galactorrhea had vanished 1 month later.
Discussion
Although all patients had clinical galactorrhea, 3 were unwilling to have prolactin levels measured. Apart from hypothyroidism (6), fluoxetine, sertraline, fluvoxamine, and paroxetine therapy have been reported to cause galactorrhea (7–10). However, given that this patient’s galactorrhea had a definite onset and offset with risperidone therapy, risperidone appears to be the main etiological agent for galactorrhea in this series.
There are 3 noteworthy observations in this report. First, galactorrhea can occur after many weeks of risperidone treatment (in 1 patient, it appeared during the seventh week). Second, even small dosages of risperidone (2 to 4 mg daily) can cause galactorrhea—a finding documented earlier (3)—but whether such effect is caused by potent D2 antagonism, by drug interaction between risperidone and specific serotonin reuptake inhibitors, or by an idiosyncratic reaction needs investigation. Third, galactorrhea usually persists during risperidone treatment, and at times even after risperidone discontinuation. All these observations need further exploration.
References
1. Turrone P, Kapur S, Seeman MV, Flint AJ. Elevation of prolactin levels by atypical antipsychotics. Am J Psychiatry 2002;159:133–5.
2. Popli A, Gupta S, Rangwani SR. Risperidone induced galactorrhea associated with a prolactin elevation. Ann Clin Psychiatry 1998;10:31–3.
3. Yong-Ku K, Min-Soo L. Risperidone and associated amenorrhea: a report of 5 cases. J Clin Psychiatry 1999;60:315–7.
4. Dickson RA, Dalby JT, Williams R, Edwards AL. Risperidone-induced prolactin elevations in premenopausal women with schizophrenia. Am J Psychiatry 1995;152:1102–3.
5. Potenza MN, Wasylink S, Epperson CN, McDougle CJ. Olanzapine augmentation of fluoxetine in the treatment of trichotillomania. Am J Psychiatry 1998;155:1299–300.
6. Wilson JD. Endocrine disorders of the breast. In: Fauci AS, Martin JB, Braunwald E, Kasper DL, Isselbacher KJ, Hauser SL, and others, editors. Harrison’s principles of internal medicine. 14th ed. New York: McGraw-Hill; 1998. p 2116–7.
7. Arya DK, Taylor WS. Lactation associated with fluoxetine treatment. Aust N Z J Psychiatry 1995;29:697.
8. Branzo MR, Stahl SM. Galactorrhea induced by sertraline. Am J Psychiatry 1993;150:1269–70.
9. Jeffries J, Bezchlibnyk BK, Remington G. Amenorrhea and galactorrhea associated with fluvoxamine in a loxapine treated patient. J Clin Psychopharmacol 1992;12:296–7.
10. Gonzalez E, Minguez L, Sanguino RM. Galactorrhea after paroxetine treatment. Pharmacopsychiatry 2000;33:118.
Subhash Chandra Gupta, DPM
K Jagadheesan, MD
Soumya Basu, DPM
Sarita E Paul, MD
Jharkhand, India
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