Hyperprolactinemia Secondary to Paliperidone: Considerations for Women of Childbearing Age

Abstract

CASE DESCRIPTION: A 27 year old female with past medical history significant for schizoaffective disorder, borderline personality disorder, major depressive disorder, and catatonia was admitted following a suicide attempt. During her admission, she revealed that she has had a persistent delusion of believing she was pregnant despite not being sexually active in several months and having multiple negative pregnancy tests. After the patient was started on paliperidone, she stopped menstruating, further perpetuating this delusion. The patient also expressed concerns for infertility in the future. CONCLUSION: Paliperidone has a high incidence of hyperprolactinemia which can lead to reproductive concerns including menstrual irregularity and infertility. These side-effects highlight the critical need for shared decision making in discussions about fertility in patients with psychotic disorders. Further complicating this issue is the significant increase in psychosis risk during the perinatal period. There are other alternatives that exist and may be better options for some patients but changing medications to oral options should be balanced with medication adherence needs. CLINICAL SIGNIFICANCE: Through shared decision-making, the selection of antipsychotic maintenance therapy should consider a variety of patient and physician goals. A younger age of initial psychotic break has strong indications for reproductive counseling, which should remain consistent with patients’ goals and be reassessed as goals evolve throughout their lifetime. Patients who struggle with medication adherence may benefit from long acting injectable antipsychotic medications. However, some of these injections, like paliperidone, can cause hyperprolactinemia and contribute to infertility. Prolactin levels can be monitored and lowering medication doses can be effective for mitigating hyperprolactinemia. There are oral medications available that have a lower chance of causing hyperprolactinemia. However, oral only medication options must be balanced with patient medication adherence concerns.