Cabergoline, sold under the brand name Dostinex among others, is a dopaminergic medication used in the treatment of high prolactin levels, prolactinomas, Parkinson's disease, and for other indications. It is taken by mouth.

Cabergoline
Cabergoline.svg
Clinical data
Trade namesDostinex, others
AHFS/Drugs.comMonograph
License data
Routes of
administration
Oral
ATC code
Legal status
Legal status
Pharmacokinetic data
BioavailabilityFirst-pass effect seen; absolute bioavailability unknown
Protein bindingModerately bound (40–42%); concentration-independent
MetabolismHepatic, predominately via hydrolysis of the acylurea bond or the urea moiety
Elimination half-life63–69 hours (estimated)
ExcretionUrine (22%), feces (60%)
Identifiers
  • (6aR,9R,10aR)-N-[3-(dimethylamino)propyl]-N-(ethylcarbamoyl)-7-prop-2-enyl-6,6a,8,9,10,10a-hexahydro-4H-indolo[4,3-fg]quinoline-9-carboxamide
CAS Number
PubChem CID
IUPHAR/BPS
DrugBank
ChemSpider
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KEGG
ChEBI
ChEMBL
CompTox Dashboard (EPA)
ECHA InfoCard100.155.380 Edit this at Wikidata
Chemical and physical data
FormulaC26H37N5O2
Molar mass451.615 g·mol−1
3D model (JSmol)
  • [H][C@]12C[C@@H](C(=O)N(CCCN(C)C)C(=O)NCC)CN(CC=C)[C@]1([H])Cc3c[nH]c4cccc2c34
  • InChI=1S/C26H37N5O2/c1-5-11-30-17-19(25(32)31(26(33)27-6-2)13-8-12-29(3)4)14-21-20-9-7-10-22-24(20)18(16-28-22)15-23(21)30/h5,7,9-10,16,19,21,23,28H,1,6,8,11-15,17H2,2-4H3,(H,27,33)/t19-,21-,23-/m1/s1 checkY
  • Key:KORNTPPJEAJQIU-KJXAQDMKSA-N checkY
 ☒NcheckY (what is this?)  (verify)

Cabergoline is an ergot derivative and a potent dopamine D2 receptor agonist.[1]

Cabergoline was patented in 1980 and approved for medical use in 1993.[2]

Medical usesEdit

Cabergoline 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 bromocriptine is often still chosen since there is less data on safety in pregnancy for cabergoline.

Off-labelEdit

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.[6][7]: 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).[8] Also, a study on rats found that cabergoline reduces voluntary alcohol consumption, possibly by increasing GDNF expression in the ventral tegmental area.[9] It may be used in the treatment of restless legs syndrome.[citation needed]

Pregnancy and lactationEdit

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.[citation needed]

  • Pregnancy: available preliminary data indicates a somewhat increased rate of congenital abnormalities in patients who became pregnant while treated with cabergoline.[citation needed]. 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."[10]
  • 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.

ContraindicationsEdit

Side effectsEdit

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.[citation needed]

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.[11] Seventy-six (76) 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 diseaseEdit

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.[12][13] As a result of this, the FDA removed pergolide from the U.S. market on March 29, 2007.[14] 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.[15][16]

InteractionsEdit

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.

PharmacologyEdit

PharmacodynamicsEdit

Activities of cabergoline at various sites
Site Affinity
(Ki [nM])
Efficacy
(Emax [%])
Action
D1 214–32,000 ? ?
D2S 0.5–0.62 102 Full agonist
D2L 0.95 75 Partial agonist
D3 0.80–1.0 86 Partial agonist
D4 56 49 Partial agonist
D5 22 ? ?
5-HT1A 1.9–20 93 Partial agonist
5-HT1B 479 102 Full agonist
5-HT1D 8.7 68 Partial agonist
5-HT2A 4.6–6.2 94 Partial agonist
5-HT2B 1.2–9.4 123 Full agonist
5-HT2C 5.8–692 96 Partial agonist
5-HT3 >10,000
5-HT4 3,000 ? ?
5-HT6 1,300 ? ?
5-HT7 2.5 ? Antagonist
α1A 288–>10,000 0 Silent antagonist
α1B 60–1,000 ? ?
α1D 166 ? ?
α2A 12–132 0 Silent antagonist
α2B 17–72 0 Silent antagonist
α2C 22–364 0 Silent antagonist
α2D 3.6 ? ?
H1 1,380 ? ?
M1 >10,000
SERT >10,000
Notes: All sites are human except α2D-adrenergic, which is rat (no human counterpart).[17] Negligible affinity (>10,000 nM) for various other receptors (β1- and β2-adrenergic, adenosine, GABA, glutamate, glycine, nicotinic acetylcholine, opioid, prostanoid).[18] Sources: [17][19][20][18][21]

Cabergoline is a long-acting dopamine D2 receptor agonist. In-vitro rat studies show a direct inhibitory effect of cabergoline on the prolactin secretion in the lactotroph cells of the pituitary gland and cabergoline decreases serum prolactin levels in reserpinized rats.[citation needed] Although cabergoline is commonly described principally as a D2 receptor agonist, it also possesses significant affinity for the dopamine D3, and D4, serotonin 5-HT1A, 5-HT2A, 5-HT2B, and 5-HT2C, and α2-adrenergic receptors, as well as moderate/low affinity for the dopamine D1, serotonin 5-HT7, and α1-adrenergic receptors.[17][18][22] Cabergoline functions as an partial or full agonist at all of these receptors except for the 5-HT7, α1-adrenergic, and α2-adrenergic receptors, where it acts as an antagonist.[19][20][18] Cabergoline has been associated with cardiac valvulopathy due to activation of 5-HT2B receptors.[23]

PharmacokineticsEdit

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.

HistoryEdit

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.[24][25][26] The first publication was a scientific abstract at the Society for Neuroscience meeting in 1991.[27][28]

Farmitalia-Carlo Erba was acquired by Pharmacia in 1993,[29] which in turn was acquired by Pfizer in 2003.[30]

Cabergoline was first marketed in The Netherlands as Dostinex in 1992.[24] The drug was approved by the FDA on December 23, 1996.[31] It went generic in late 2005 following US patent expiration.[32]

Society and cultureEdit

Brand namesEdit

Brand names of cabergoline include Cabaser, Dostinex, Galastop (veterinary), and Kelactin (veterinary), among others.[33]

ResearchEdit

Cabergoline was studied in one person with Cushing's disease, to lower adrenocorticotropic hormone (ACTH) levels and cause regression of ACTH-producing pituitary adenomas.[34]

ReferencesEdit

  1. ^ J. Elks; C. R. Ganellin (1990). The Dictionary of Drugs: Chemical Data: Chemical Data, Structures and Bibliographies. Springer. pp. 204–.
  2. ^ Fischer, Jnos; Ganellin, C. Robin (2006). Analogue-based Drug Discovery. John Wiley & Sons. p. 533. ISBN 9783527607495.
  3. ^ UK electronic Medicines Compendium Dostinex Tablets Last Updated on eMC Dec 23, 2013
  4. ^ 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.
  5. ^ 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
  6. ^ 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. CiteSeerX 10.1.1.484.4005. doi:10.1677/joe.0.1790357. PMID 14656205.
  7. ^ Hollander, Adam B.; Pastuszak, Alexander W.; Lipshultz, Larry I. (2016). "Cabergoline in the Treatment of Male Orgasmic Disorder—A Retrospective Pilot Analysis". Journal of Sexual Medicine. 4 (4): e28–e33. doi:10.1016/j.esxm.2015.09.001. PMC 4822480. PMID 26944776.
  8. ^ 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.
  9. ^ 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.
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  16. ^ 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.
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  25. ^ Espace record: GB 202074566
  26. ^ US Patent 4526892 - Dimethylaminoalkyl-3-(ergoline-8'.beta.carbonyl)-ureas
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  30. ^ Staff, CNN/Money. April 16, 2003 It's official: Pfizer buys Pharmacia
  31. ^ FDA approval history
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External linksEdit