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Psychiatria Danubina, 2013; Vol. 25, No. 3, pp 266-267 Medicinska naklada - Zagreb, Croatia DULOXETINE-RELATED GALACTORRHEA AND
Hasan Belli, Mahir Akbudak & Cenk Ural
Department of Psychiatry, Bagcilar Education and Research Hospital, Istanbul, Turkey INTRODUCTION
weeks. Six weeks later, she applied to our clinic with the complaints of milky discharge, fullness, breast pain, High prolactin hormone level in the blood is known distressing sensations deep inside the limbs occurring at as hyperprolactinemia. The most common symptom of bedtime and paresthesias consisting in an irresistible hyperprolactinemia is galactorrhea, in which sponta- urge to move the limb. The patient reported that there neous milky discharge is seen from all ducts of the two was not this kind of complaints before duloxetin mammary glands. Dopamine has an inhibitor effect on prolactin, in the tuberoinfundibular tract and inhibition Results of neurological, general physical examina- of dopamine increases the serum prolactin level tion, and laboratory investigation, including blood (Feuchtl et al. 2004). Monoaminoxidase inhibitors, tri- chemistry, thyroid function test, FSH, LH levels, liver cyclic antidepressants, and selective serotonin reuptake and renal functions were normal. Magnetic resonance inhibitors (SSRIs) were identified as a cause of hyper- imaging (MRI) focused on the brain and particularly the prolactinemia (Wieck et al. 2004). However, data pituitary gland, and result of this test was within normal regarding hyperprolactinemia due to duloxetine, a novel limit. Her serum prolactin level was measured as 37.9 serotonin-noradrenaline reuptake inhibitor, are limited ng mL. As repeated serum prolactin levels gave the same results. We sought to eliminate the most likely Restless legs syndrome (RLS) is a sensorimotor causes of galactorrhoea. She was married but was not disorder characterized by distressing sensations deep having menstrual periods. No evidence of any inside the limbs, typically occurring at bedtime or rest. These paresthesias involve an irresistible urge to move Duloxetine treatment was stopped and bupropion the limb, which provides temporary relief but at the was started at the dose of 150 mg per day and the dose expense of sleep and quality of life. RLS may be a was increased to 300 mg per day within 4 weeks. At the primary or a secondary condition. Secondary causes of end of the 2nd week under bupropion treatment, her RLS include iron deficiency, chronic kidney disease, galactorrhea and RLS symptoms improved consider- pregnancy, and various medications (Allen et al. 2003). ably. Six week after initiated bupropion, her serum In a study, RLS was noted as a possible side effect of prolactin level was measured as 20.2 ng mL. At the end the use of fluoxetine, paroxetine, citalopram, sertraline, of 12th week under bupropion treatment, she was also escitalopram, venlafaxine, duloxetine, and mirtazapine In the present paper, we report a case of duloxetine- DISCUSSION
related galactorrhea and restless legs syndrome. It was reported that women are more vulnerable to CASE REPORT
prolactin elevation when using antidepressants (Hal-breich et al. 2003). Our case had been suffering from Ms. P, female, 46 years old. She applied to our clinic depression without any galactorrhea and RLS symp- with the complaints of depression. A screen for symp- toms. Furthermore, patients treated with duloxetine may toms of depression revealed that she had hopelessness, present with galactorrhea and RLS as unwanted side low energy, anhedonia, appetite, poor concentration, a effects of therapy. The mechanism by which antide- strong sense of guilt and insomnia. Beck Depression pressants may cause hyperprolactinaemia is not fully Inventory (BDI) (Beck 1961) was used to screen for understood, though several theories have been postu- depression. BDI scores for depression was determined lated, such as serotonin stimulation of GABAergic as 42. She had become increasingly upset over 2 months neurons and indirect modulation of prolactin release by and noticed depressive symptoms. Her psychiatric serotonin (Coker & Taylor 2010). However, hyper- history did not include previous episodes of depression. prolactinemia may be caused by two distinct mecha- Duloxetine was started with the dose of 30 mg per day nisms, the presynaptic inhibition of dopamine discharge and the dose was increased to 60 mg per day within 4 by serotonergic receptors (Egberts et al. 1997), or the Hasan Belli, Mahir Akbudak & Cenk Ural: DULOXETINE-RELATED GALACTORRHEA AND RESTLESS LEGS SYNDROME: A CASE REPORT Psychiatria Danubina, 2013; Vol. 25, No. 3, pp 266–267 direct stimulation of hypothalamic postsynaptic seroto- and epidemiology workshop at the National Institutes of nergic receptors (Bronzo & Stahl 1993). In one study, Health. Sleep Med 2003; 4:101–19. RLS was noted as a possible side effect of the use of 2. Ashton AK & Longdon MC: Hyperprolactinemia and fluoxetine, paroxetine, citalopram, sertraline, escitalo- galactorrhea induced by serotonin and norepinephrine pram, venlafaxine, duloxetine, and mirtazapine (Rottach reuptake inhibiting antidepressants. Am J Psychiatry 2007; 164:1121-2. et al. 2008). Mechanisms mentioned in here, dopami- 3. Beck AT: An inventory for measuring depression. Arch nergic transmission may also play an important role in 4. Bronzo MR & Stahl SM: Galactorrhea induced by We have prefered switching to bupropion as another sertraline. Am J Psychiatry 1993; 150:1269–70. antidepressant. At the end of the 2nd week under 5. Coker F & Taylor D: Antidepressant-induced hyperpro- bupropion treatment, galactorrhea and RLS symptoms lactinaemia: incidence, mechanisms and management. improved considerably in our case. Bupropion should be considered for depressed patients with galactorrhea and 6. Egberts AC, Meyboom RH, De Koning FH, Bakker A & Leufkens HG: Non puerperal lactation associated with Clinicians need to be aware of these unusual side- antidepressant drug use. Br J Clin Pharmacol 1997; effects of duloxetine, because galactorrhea and RLS may play an important role in compliance with 7. Halbreich U, Kinon BJ, Gilmore JA & Kahn LS: Elevated prolactin levels in patients with schizophrenia: mecha- treatment and can act as an additional stress factor for nisms and related adverse effects. Psychoneuroendo- crinology 2003; 28(suppl 1):53-67. 8. Feuchtl A, Bagli M, Stephan R, Frahnert C, Kölsch H, Kühn KU, et al: Pharmacokinetics of m-chloro- Acknowledgements: None.
phenylpiperazine after intravenous and oral admini-stration in healthy male volunteers: implication for the Conflict of interest: None to declare.
pharmacodynamic profile. Pharmacopsychiatry 2004; 9. Rottach KG, Schaner BM, Kirch MH, Zivotofsky AF, References
Teufel LM, Galwitz T et al: Restless legs syndrome as side effect of second generation antidepressants. J Psychiatr 1. Allen RP, Picchietti D, Hening WA, Trankwalder C, Walters AS & Montplaisi J: Restless legs syndrome: 10. Wieck A & Haddad PM: Antipsychotic-induced hyper- diagnostic criteria, special considerations, and epidemio- prolactinaemia in women: pathophysiology, severity and logy. A report from the restless legs syndrome diagnosis consequences. Br J Psychiatry 2003; 182:199-204. Department of Psychiatry, Bagcilar Education and Research Hospital


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