Iloperidone-induced Galactorrhea in a Middle-aged Female
A 35-year-old female attended the Psychiatry outpatient department of a tertiary care teaching hospital in eastern part of India with the chief complaints of third person and commanding type auditory hallucination, delusion of persecution, and reference with frequent acting on behavior as well as sudden unprovoked violence, decreased sleep and appetite with marked socio-occupational dysfunction since last two months. Her general physical examination was unremarkable. She weighed 54 kg. Her routine biochemical examinations and computed tomography of brain were normal. Her menstrual cycle was regular and there was no evidence of any hirsutism. On first visit, her Positive and Negative Syndrome Scale for Schizophrenia (PANSS) score was 78. She was prescribed tablet iloperidone, 1 mg twice daily along with tablet clonazepam 2 mg at night. Dose of iloperidone was increased up to 4 mg twice daily within one week. Her symptoms started improving within next two weeks and almost completely resolved within 2 months with the same dose of iloperidone (8 mg/day). Dose of tablet clonazepam were reduced to 0.5 mg at night. Three months after starting Iloperidone, patient developed spontaneous milky discharge from both the nipples and on next menstrual cycle, she missed her date. Patient and her family members became excessively worried because of her new symptoms and wanted to stop all kind of treatment. On liaison with department of Gynecology and General Surgery, detailed work-up was done to search for the causes of galactorrhea and amenorrhea. There was no history of any fever, mastalgia, any visual complaints, and symptoms suggestive of raised intracranial pressure. On systemic examination, there was no tenderness, dimpling, or mass on breast palpation, thyromegaly, adenopathy, hepatosplenomegaly, and no abnormality on examinations of cranial nerve functions. Serum Prolactin was estimated to be 31.70 ng/ml (normal reference range for premenopausal female, 4.79–23.3 ng/mL) and serum TSH was estimated to be 1.26 μIU/ml (normal reference range was 0.27–4.20 μIU/ml). No abnormality detected on renal function test, liver function test, blood glucose levels, lipid profile, mammogram, and MRI brain. Keeping in mind that iloperidone-induced galactorrhea could be the possible reason, tablet iloperidone was stopped and tablet aripiprazole (2.5 mg twice daily) was started. Dramatic resolution of galactorrhea was noted within 1 week of stoppage of iloperidone. Dose of aripiprazole was increased to 5 mg twice daily. Serum prolactin was rechecked, was found to be slightly reduced (25.35 ng/ ml) after one week of stoppage of iloperidone. Her psychotic symptoms remained controlled (PANSS score was 47). Her next menstrual flow was scanty but resumed her normal menstrual bleeding on second month of stoppage of iloperidone when serum prolactin level was rechecked and found to be reverted back to normal range (15.90 ng/ml).