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Aripiprazole for Hyperprolactinaemia — MRCPsych Paper B MCQ

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HardSchizophrenia & PsychosisAripiprazole for HyperprolactinaemiaMRCPsych Paper B

A 28-year-old man with first-episode psychosis has remained in remission on risperidone 4 mg daily. He develops reduced libido and erectile dysfunction. Two fasting morning prolactin measurements are 1800 mU/L and 1740 mU/L; other causes of hyperprolactinaemia have been excluded, and he has no headache or visual symptoms. A previous reduction of risperidone to 3 mg daily was followed by the return of attenuated psychotic symptoms. He declines switching antipsychotic. Which pharmacological intervention is most appropriate?

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Correct answer: D — Add aripiprazole 5 mg daily

Explanation lettering: D = shown as A · E = shown as B · B = shown as D · A = shown as E

The correct answer is B. Low-dose adjunctive aripiprazole reduces antipsychotic-induced hyperprolactinaemia through partial dopamine D2 agonism at tuberoinfundibular receptors while the effective antipsychotic continues; this is the Maudsley-endorsed strategy when switching is declined, supported by a double-blind RCT (58% prolactin fall versus placebo without worsening psychopathology) and a 2022 network meta-analysis showing 5–10 mg doses lower prolactin with high certainty. Monitor for akathisia, impulse-control effects and psychotic relapse. Sildenafil may improve erectile function but is purely symptomatic and leaves the endocrine cause, hypogonadism and long-term bone risk untreated. Further dose reduction (D) is inappropriate because 3 mg previously caused re-emergence of psychotic symptoms. Bromocriptine (C) is a full dopamine agonist that risks exacerbating psychosis and is not the preferred approach in antipsychotic-treated patients. Testosterone (E) is not indicated without confirmed androgen deficiency and does not address the drug-induced prolactin elevation.

Reference: Zhu Y et al. Pharmacological treatment strategies for antipsychotic-induced hyperprolactinemia: a systematic review and network meta-analysis. 2022. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9256633/