Cabergoline

Cabergoline
Clinical data
Trade names Cabaser, Dostinex
AHFS/Drugs.com Monograph
License data
Pregnancy
category
  • US: B (No risk in non-human studies)
    Routes of
    administration
    Oral
    ATC code
    Legal status
    Legal status
    Pharmacokinetic data
    Bioavailability First-pass effect seen; absolute bioavailability unknown
    Protein binding Moderately bound (40–42%); concentration-independent
    Metabolism Hepatic, predominately via hydrolysis of the acylurea bond or the urea moiety
    Elimination half-life 63–69 hours (estimated)
    Excretion Urine (22%), feces (60%)
    Identifiers
    CAS Number
    PubChem CID
    IUPHAR/BPS
    DrugBank
    ChemSpider
    UNII
    KEGG
    ChEBI
    ChEMBL
    Chemical and physical data
    Formula C26H37N5O2
    Molar mass 451.604 g/mol
    3D model (JSmol)
     NY (what is this?)  (verify)

    Cabergoline (brand names Dostinex and others), an ergot derivative, is a potent dopamine receptor agonist on D2 receptors. Rat studies show cabergoline has a direct inhibitory effect on pituitary lactotroph (prolactin) cells.[1] It is frequently used as a first-line agent in the management of prolactinomas due to its higher affinity for D2 receptor sites, less severe side effects, and more convenient dosing schedule than the older bromocriptine, though in pregnancy bromocripine is often still chosen since there is less data on safety in pregnancy for cabergoline.

    Medical uses

    Off-label

    It has at times been used as an adjunct to SSRI antidepressants as there is some evidence that it counteracts certain side effects of those drugs, such as reduced libido and anorgasmia. It also has been suggested that it has a possible recreational use in reducing or eliminating the male refractory period, thereby allowing men to experience multiple ejaculatory orgasms in rapid succession, and at least two scientific studies support those speculations.[5][6]:e28–e33 Additionally, a systematic review and meta-analysis concluded that prophylactic treatment with cabergoline reduces the incidence, but not the severity, of ovarian hyperstimulation syndrome (OHSS), without compromising pregnancy outcomes, in females undergoing stimulated cycles of in vitro fertilization (IVF).[7] Also, a study on rats found that cabergoline reduces voluntary alcohol consumption, possibly by increasing GDNF expression in the ventral tegmental area.[8]

    Pregnancy and lactation

    Relatively little is known about the effects of this medication during pregnancy and lactation. In some cases the related bromocriptine may be an alternative when pregnancy is expected.

    • Pregnancy: available preliminary data indicates a somewhat increased rate of congenital abnormalities in patients who became pregnant while treated with cabergoline.. However, one study concluded that "foetal exposure to cabergoline through early pregnancy does not induce any increase in the risk of miscarriage or foetal malformation." [9]
    • Lactation: In rats cabergoline was found in the maternal milk. Since it is not known if this effect also occurs in humans, breastfeeding is usually not recommended if/when treatment with cabergoline is necessary.
    • Lactation suppression: In some countries cabergoline (Dostinex) is sometimes used as a lactation suppressant. It is also used in veterinary medicine to treat false pregnancy in dogs.

    Contraindications and precautions

    Side effects

    Side effects are mostly dose dependent. Much more severe side effects are reported for treatment of Parkinson's disease and (off-label treatment) for restless leg syndrome which both typically require very high doses. The side effects are considered mild when used for treatment of hyperprolactinemia and other endocrine disorders or gynecologic indications where the typical dose is one hundredth to one tenth that for Parkinson's disease.

    Cabergoline requires slow dose titration (2–4 weeks for hyperprolactinemia, often much longer for other conditions) to minimise side effects. The extremely long bioavailability of the medication may complicate dosing regimens during titration and require particular precautions.

    Cabergoline is considered the best tolerable option for hyperprolactinemia treatment although the newer and less tested quinagolide may offer similarly favourable side effect profile with quicker titration times.

    Approximately 200 patients with newly diagnosed Parkinson's disease participated in a clinical study of cabergoline monotherapy. Seventy-nine (79) percent reported at least one side effect. These side effects were chiefly mild or moderate:

    In a combination study with 2,000 patients also treated with levodopa, the incidence and severity of side effects was comparable to monotherapy. Encountered side effects required a termination of cabergoline treatment in 15% of patients. Additional side effects were infrequent cases of hematological side effects, and an occasional increase in liver enzymes or serum creatinine without signs or symptoms.

    As with other ergot derivatives, pleuritis, exudative pleura disease, pleura fibrosis, lung fibrosis, and pericarditis are seen. These side effects are noted in less than 2% of patients. They require immediate termination of treatment. Clinical improvement and normalization of X-ray findings are normally seen soon after cabergoline withdrawal. It appears that the dose typically used for treatment of hyperprolactinemia is too low to cause this type of side effects.

    Valvular heart disease

    In two studies published in the New England Journal of Medicine on January 4, 2007, cabergoline was implicated along with pergolide in causing valvular heart disease.[10][11] As a result of this, the FDA removed pergolide from the U.S. market on March 29, 2007.[12] Since cabergoline is not approved in the U.S. for Parkinson's Disease, but for hyperprolactinemia, the drug remains on the market. The lower doses required for treatment of hyperprolactinemia have been found to be not associated with clinically significant valvular heart disease or cardiac valve regurgitation.[13][14]

    Interactions

    No interactions were noted with levodopa or selegiline. The drug should not be combined with other ergot derivatives. Dopamine antagonists such as antipsychotics and metoclopramide counteract some effects of cabergoline. The use of antihypertensive drugs should be intensively monitored because excessive hypotension may result from the combination.

    Pharmacology

    Although cabergoline is commonly described principally as a dopamine D2 receptor agonist, it also possesses significant affinity for the D3, D4, 5-HT1A, 5-HT2A, 5-HT2B, 5-HT2C, α2B- receptors, and moderate/low affinity for the D1 and 5-HT7 receptors. Cabergoline functions as an agonist at all of these receptors except for 5-HT7 and α2B-, where it acts as an antagonist.[15]

    Binding profile[16]

    ReceptorBinding Affinity (Ki [nM])Action
    5-HT1A20.0Agonist
    5-HT1B479Unknown
    5-HT1D8.71Unknown
    5-HT2A6.17Agonist
    5-HT2B1.17Agonist
    5-HT2C692Agonist
    α1A adrenergic288Unknown
    α1B adrenergic60.3Unknown
    α1D adrenergic166Unknown
    α2A adrenergic12Unknown
    α2B adrenergic72.4Antagonist
    α2C adrenergic22.4Unknown
    β1 adrenergic>10,000Unknown
    β2 adrenergic>10,000Unknown
    D1214Agonist
    D2S0.62Agonist
    D2L0.95Agonist
    D30.79Agonist
    D456.2Agonist
    D522.4Unknown

    Pharmacokinetics

    Following a single oral dose, resorption of cabergoline from the gastrointestinal (GI) tract is highly variable, typically occurring within 0.5 to 4 hours. Ingestion with food does not alter its absorption rate. Human bioavailability has not been determined since the drug is intended for oral use only. In mice and rats the absolute bioavailability has been determined to be 30 and 63 percent, respectively. Cabergoline is rapidly and extensively metabolized in the liver and excreted in bile and to a lesser extent in urine. All metabolites are less active than the parental drug or inactive altogether. The human elimination half-life is estimated to be 63 to 68 hours in patients with Parkinson's disease and 79 to 115 hours in patients with pituitary tumors. Average elimination half-life is 80 hours.

    The therapeutic effect in treatment of hyperprolactinemia will typically persist for at least 4 weeks after cessation of treatment.

    Mechanism of action

    Cabergoline is a long-acting dopamine D2 receptor agonist and in vitro rat studies show a direct inhibitory effect on the prolactin secretion in the pituitary's lactotroph cells. Cabergoline decreased serum prolactin levels in reserpinized rats.

    Receptor binding studies indicate a low affinity for dopamine D1 receptors, α1-adrenergic receptors, and α2-adrenergic receptors.[1]

    Research

    Cabergoline was studied in one person with Cushing's disease, to lower ACTH levels and cause regression of ACTH producing pituitary adenomas.[17]

    History

    Cabergoline was first synthesized by scientists working for the Italian drug company Farmitalia-Carlo Erba in Milan who were experimenting with semisynthetic derivatives of the ergot alkaloids, and a patent application was filed in 1980.[18][19][20] The first publication was a scientific abstract at the Society for Neuroscience meeting in 1991.[21][22]

    Farmitalia-Carlo Erba was acquired by Pharmacia in 1993,[23] which in turn was acquired by Pfizer in 2003.[24]

    Cabergoline was first marketed in The Netherlands as Dostinex in 1992.[18] The drug was approved by the FDA on December 23, 1996.[25] It went generic in late 2005 following US patent expiration.[26]

    See also

    References

    1. 1 2 "Dostinex at www.rxlist.com". Archived from the original on 2007-05-06. Retrieved 2007-04-27.
    2. UK electronic Medicines Compendium Dostinex Tablets Last Updated on eMC Dec 23, 2013
    3. Sayyah-Melli, M; Tehrani-Gadim, S; Dastranj-Tabrizi, A; Gatrehsamani, F; Morteza, G; Ouladesahebmadarek, E; Farzadi, L; Kazemi-Shishvan, M (2009). "Comparison of the effect of gonadotropin-releasing hormone agonist and dopamine receptor agonist on uterine myoma growth. Histologic, sonographic, and intra-operative changes". Saudi medical journal. 30 (8): 1024–33. PMID 19668882.
    4. Sankaran, S.; Manyonda, I. (2008). "Medical management of fibroids". Best Practice & Research Clinical Obstetrics & Gynaecology. 22 (4): 655–76. doi:10.1016/j.bpobgyn.2008.03.001. PMID 18468953. http://www.britishfibroidtrust.org.uk/journals/bft_Sankaran.pdf
    5. Krüger TH, Haake P, Haverkamp J, et al. (December 2003). "Effects of acute prolactin manipulation on sexual drive and function in males". Journal of Endocrinology. 179 (3): 357–65. doi:10.1677/joe.0.1790357. PMID 14656205.
    6. Hollander, Adam B.; Pastuszak, Alexander W.; Lipshultz, Larry I. (2016). "Cabergoline in the Treatment of Male Orgasmic Disorder—A Retrospective Pilot Analysis" (PDF). Journal of Sexual Medicine (4).
    7. Youssef MA, van Wely M, Hassan MA, et al. (March 2010). "Can dopamine agonists reduce the incidence and severity of OHSS in IVF/ICSI treatment cycles? A systematic review and meta-analysis". Hum Reprod Update. 16 (5): 459–66. doi:10.1093/humupd/dmq006. PMID 20354100.
    8. Carnicella, S.; Ahmadiantehrani, S.; He, D. Y.; Nielsen, C. K.; Bartlett, S. E.; Janak, P. H.; Ron, D. (2009). "Cabergoline Decreases Alcohol Drinking and Seeking Behaviors Via Glial Cell Line-Derived Neurotrophic Factor". Biological Psychiatry. 66 (2): 146–153. doi:10.1016/j.biopsych.2008.12.022. PMC 2895406. PMID 19232578.
    9. Colao, A; Abs R.; et al. (January 2008). "Pregnancy outcomes following cabergoline treatment: extended results from a 12-year observational study". Clinical Endocrinology. 68 (1): 66–71. doi:10.1111/j.1365-2265.2007.03000.x. PMID 17760883.
    10. Schade, Rene; Andersohn, Frank; Suissa, Samy; Haverkamp, Wilhelm; Garbe, Edeltraut (2007-01-04). "Dopamine Agonists and the Risk of Cardiac-Valve Regurgitation". New England Journal of Medicine. 356 (1): 29–38. doi:10.1056/NEJMoa062222. PMID 17202453.
    11. Zanettini, Renzo; Antonini, Angelo; Gatto, Gemma; Gentile, Rosa; Tesei, Silvana; Pezzoli, Gianna (2007-01-04). "Valvular Heart Disease and the Use of Dopamine Agonists for Parkinson's Disease". New England Journal of Medicine. 356 (1): 39–46. doi:10.1056/NEJMoa054830. PMID 17202454.
    12. "Food and Drug Administration Public Health Advisory". 2007-03-29. Archived from the original on 2007-04-08. Retrieved 2007-04-27.
    13. Bogazzi, F.; Buralli, S.; Manetti, L.; Raffaelli, V.; Cigni, T.; Lombardi, M.; Boresi, F.; Taddei, S.; Salvetti, A. (2008). "Treatment with low doses of cabergoline is not associated with increased prevalence of cardiac valve regurgitation in patients with hyperprolactinaemia". International Journal of Clinical Practice. 62 (12): 1864–9. doi:10.1111/j.1742-1241.2008.01779.x. PMID 18462372.
    14. Wakil, A.; Rigby, A. S; Clark, A. L; Kallvikbacka-Bennett, A.; Atkin, S. L (2008). "Low dose cabergoline for hyperprolactinaemia is not associated with clinically significant valvular heart disease". European Journal of Endocrinology. 159 (4): R11–4. doi:10.1530/EJE-08-0365. PMID 18625690.
    15. Sharif NA, McLaughlin MA, Kelly CR, Katoli P, Drace C, Husain S, Crosson C, Toris C, Zhan GL, Camras C (March 2009). "Cabergoline: Pharmacology, ocular hypotensive studies in multiple species, and aqueous humor dynamic modulation in the Cynomolgus monkey eyes". Experimental Eye Research. 88 (3): 386–97. doi:10.1016/j.exer.2008.10.003. PMID 18992242.
    16. National Institute of Mental Health. PDSD Ki Database (Internet) [cited 2013 Jul 24]. ChapelHill (NC): University of North Carolina. 1998-2013. Available from: "Archived copy". Archived from the original on 2013-11-08. Retrieved 2014-03-04.
    17. Miyoshi, T.; et al. (2004). "Effect of cabergoline treatment on Cushing's disease caused by aberrant adrenocorticotropin-secreting macroadenoma". Journal of endocrinological investigation. 27 (11): 1055–1059. doi:10.1007/bf03345309. PMID 15754738.
    18. 1 2 Council regulation (EEC) no 1768/92 in the matter of Application No SPC/GB94/012 for a Supplementary Protection Certificate in the name of Farmitalia Carlo Erba S. r. l.
    19. Espace record: GB 202074566
    20. US Patent 4526892 - Dimethylaminoalkyl-3-(ergoline-8'.beta.carbonyl)-ureas
    21. Fariello, RG (1998). "Pharmacodynamic and pharmacokinetic features of cabergoline. Rationale for use in Parkinson's disease". Drugs. 55 (Suppl 1): 10–6. doi:10.2165/00003495-199855001-00002. PMID 9483165.
    22. Carfagna N, Caccia C, Buonamici M, Cervini MA, Cavanus S, Fornaretto MG, Damiani D, Fariello RG (1991). "Biochemical and pharmacological studies on cabergoline, a new putative antiparkinsonian drug". Soc Neurosci Abs. 17: 1075.
    23. Staff. News: Farmitalia bought by Kabi Pharmacia. Ann Oncol (1993) 4 (5): 345.
    24. Staff, CNN/Money. April 16, 2003 It's official: Pfizer buys Pharmacia
    25. FDA approval history
    26. FDA generic approvals, December 2005
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