UNASSIGNED: Prolactinoma, the most common pituitary adenoma, is usually treated with dopamine agonist (DA) therapy like cabergoline. Surgery is second-line therapy, and radiotherapy is used if surgical treatment fails or in relapsing macroprolactinoma.
UNASSIGNED: This study aimed to provide economic evidence for the management of prolactinoma in Italy, using a cost-of-illness and cost-utility analysis that considered various treatment options, including cabergoline, bromocriptine, temozolomide, radiation therapy, and surgical strategies.
UNASSIGNED: The researchers conducted a systematic literature review for each research question on scientific databases and surveyed a panel of experts for each therapeutic procedure\'s specific drivers that contributed to its total cost.
UNASSIGNED: The average cost of the first year of treatment was €2,558.91 and €3,287.40 for subjects with microprolactinoma and macroprolactinoma, respectively. Follow-up costs from the second to the fifth year after initial treatment were €798.13 and €1,084.59 per year in both groups. Cabergoline had an adequate cost-utility profile, with an incremental cost-effectiveness ratio (ICER) of €3,201.15 compared to bromocriptine, based on a willingness-to-pay of €40,000 per quality-adjusted life year (QALY) in the reference economy. Endoscopic surgery was more cost-effective than cabergoline, with an ICER of €44,846.64. Considering a willingness-to-pay of €40,000/QALY, the baseline findings show cabergoline to have high cost utility and endoscopic surgery just a tad above that.
UNASSIGNED: Due to the favorable cost-utility profile and safety of surgical treatment, pituitary surgery should be considered more frequently as the initial therapeutic approach. This management choice could lead to better outcomes and an appropriate allocation of healthcare resources.

BACKGROUND: This guideline (GL) is aimed at providing a reference for the management of prolactin (PRL)-secreting pituitary adenoma in adults. However, pregnancy is not considered.
METHODS: This GL has been developed following the methods described in the Manual of the Italian National Guideline System. For each question, the panel appointed by Associazione Medici Endocrinologi (AME) has identified potentially relevant outcomes, which have then been rated for their impact on therapeutic choices. Only outcomes classified as \"critical\" and \"important\" have been considered in the systematic review of evidence and only those classified as \"critical\" have been considered in the formulation of recommendations.
RESULTS: The present GL provides recommendations regarding the role of pharmacological and neurosurgical treatment in the management of prolactinomas. We recommend cabergoline (Cab) vs. bromocriptine (Br) as the firstchoice pharmacological treatment to be employed at the minimal effective dose capable of achieving the regression of the clinical picture. We suggest that medication and surgery are offered as suitable alternative first-line treatments to patients with non-invasive PRL-secreting adenoma, regardless of size. We suggest Br as an alternative drug in patients who are intolerant to Cab and are not candidates for surgery. We recommend pituitary tumor resection in patients 1) without any significant neuro-ophthalmologic improvement within two weeks from the start of Cab, 2) who are resistant or do not tolerate Cab or other dopamine-agonist drugs (DA), 3) who escape from previous efficacy of DA, and 4) who are unwilling to undergo a chronic DA treatment. We recommend that patients with progressive disease notwithstanding previous tumor resection and ongoing DA should be managed by a multidisciplinary team with specific expertise in pituitary diseases using a multimodal approach that includes repeated surgery, radiotherapy, DA, and possibly, the use of temozolomide.
CONCLUSIONS: The present GL is directed to endocrinologists, neurosurgeons, and gynecologists working in hospitals, in territorial services or private practice, and to general practitioners and patients.

METHODS: We studied a group of 36 fertile women affected with moderate-to-severe cyclical mastalgia (mean age: 26.0 years) showing a normal menstrual history and normal basal levels of circulating hormones, including prolactin (PRL), luteinizing hormone (LH), follicle-stimulating hormone (FSH), estradiol (E2), progesterone (P), testosterone (T), dehydroepiandrosterone sulphate (delta HEAs), androstenedione (A). Using serial measurements of PRL plasma levels after an intravenous injection of thyrotropin-releasing hormone (TRH), (TRH test), patients were divided in two groups: 19 patients with abnormal PRL response to TRH and the remaining 17 with normal response.
RESULTS: Bromocriptine treatment, 2.5 mg b.i.d. for 3-6 months, was effective in 73.6% of patients with abnormal TRH test and in 23.5% of patients with normal TRH test: the difference was statistically significant. On the other hand, 76.9% of patients with either normal TRH test or resistant to bromocriptine therapy had a favourable response to percutaneous progesterone and systemic non-steroidal antiinflammatory drugs (NSAIDs).
CONCLUSIONS: These results seem to confirm the hypothesis that PRL response to TRH could be used to identify patients affected with cyclical mastalgia that are likely to benefit by bromocriptine treatment.

The neuroleptic malignant syndrome (NMS) is a dangerous, often fatal, idiosyncratic disorder presumably of the basal ganglia and hypothalamus. It is usually associated with neuroleptic medications, and it is believed to be related to blockage of dopamine receptors in the brain. The NMS has also been reported in patients with Parkinson\'s disease after withdrawal of antiparkinsonian agents during \"drug holidays.\" Cardinal features include fever, muscular rigidity, an elevated serum level of creatine phosphokinase, changes in mental status, and autonomic dysfunction. Although treatment has been largely supportive, dopamine agonists, such as bromocriptine, and a direct-acting muscle relaxant, dantrolene, have been used with good clinical outcome. Guidelines for reinstitution of neuroleptics are suggested.