2017 Resarch Forum

PSY: C-2

Applicant & Principal Investigator: Sarayu Vasan MD MPH

A case of galactorrhea associated with citalopram in a Hispanic American woman Sarayu Vasan MD MPH, Kelsey Stevens MD, Sara Abdijadid DO MS

INTRODUCTION : An elevated prolactin level with resultant galactorrhea as a side effect of antidepressants is not well understood, although it has been well documented with a multitude of physiological and pathological causes. However, with the increased use of antidepressant medications, there has been a rise in the frequency of these rare reported symptoms, leading to interest in the mechanism of hyperprolactinemia associated with Selective Serotonin Reuptake Inhibitors (SSRIs). We report a rare case of elevated prolactin levels and subsequent galactorrhea while on treatment with citalopram, which resolved after discontinuation of the medication. PURPOSE: The goal of this case study is to have the medical community aware that hyperprolactinemia with galactorrhea can be associated with citalopram and this should be screened for among patients treated with SSRIs. Also, the exact mechanism of high prolactin levels with galactorrhea due to SSRIs is not well understood and this calls for future research. CASE: A 39 year old Hispanic female who was diagnosed with major depressive disorder was treated with citalopram. However, she developed hyperprolactinemia with galactorrhea after three months of treatment. Prolactin level was ordered and found to be elevated at 207 ng/mL (reference range: 3-23 ng/mL). Given there were no abnormalities in any other laboratory values including negative pregnancy and negative imaging with isolated finding of elevated prolactin levels with galactorrhea following treatment with citalopram, it was hypothesized that galactorrhea was an adverse effect of the medication. Citalopram was eventually tapered off and a repeat prolactin level after six weeks was found to be to be 3.30 ng/mL (reference range: 3-23 ng/mL). Subsequently galactorrhea also resolved with discontinuation of citalopram. DISCUSSION: Citalopram is a combination of two enantiomers, R and S. It is believed that the efficacy of this drug is due to high affinity binding to serotonin receptors. The neurotransmitters responsible for prolactin release include serotonin and dopamine. Serotonin works directly by stimulating postsynaptic 5HT receptors, releasing neuropeptides known as prolactin releasing factors located in the paraventricular nucleus, regulating the transcription of prolactin. Serotonin also indirectly leads to prolactin release by inhibiting dopaminergic transmission at tuberoinfundibular dopaminergic neurons. However, the mechanisms and interactions between dopaminergic and serotonergic systems are complex and not well understood. Long-term serotonergic and subsequent antidopaminergic effects due to citalopram therapy could be a plausible cause in this case as she developed galactorrhea after three months. CONCLUSION: Few case reports suggest galactorrhea associated with escitalopram, sertraline, fluoxetine, and fluvoxamine. However to the best of our knowledge this is the first report of hyperprolactinemic galactorrhea in association with citalopram. These findings signify a strong association of SSRIs with prolactin abnormalities. This calls for future research and confirmation studies to further illustrate the prevalence and precise mechanisms of hyperprolactinemia and galactorrhea due to SSRIs.