Bromocriptine for Weight Loss

Bromocriptine for Weight Loss

--------------------------------------------------------------------------------

by Karl "NANDI" Hoffman
Editor's note: Given how this piece more or less assails Lyle McDonald's e-book dealing with Bromocriptine, in will by this token be controversial. Lyle will be given the opportunity to retort either in the form of an article, or on our debate board, perhaps both, whatever medium of response as how may he choose.

Bromocriptine, a drug that mimics the action of the naturally occurring neurotransmitter dopamine, has a long history of use by body builders and life extension enthusiasts. The drug originally gained popularity due to its reputation for acting as a mild growth hormone secretagogue. This is paradoxical, since in people suffering from acromegaly, or growth hormone excess, bromocriptine has the opposite effect: it actually lowers GH levels. Bromocriptine has a number of other legitimate medical uses, including treatment of Parkinson's Disease and the lowering of prolactin levels in people suffering from prolactin secreting tumors. It has also been used successfully to treat hyperprolactinemia (elevated prolactin) that often occurs as a side effect of the administration of antipsychotic medications.

Bromocriptine and Weight Loss

Lately however, bromocriptine has gained prominence particularly on the World Wide Web as a weight loss agent. Perhaps no single person is more responsible for this resurgence of interest in the drug than Lyle McDonald, who popularized its anti-obesity properties in his recently published e-book (1). There are studies both in animals (2) and humans (3),(4) that support the ability of bromocriptine to reduce weight and body fat. The exact mechanism whereby dopaminergic agonists induce weight loss has not been elucidated.

Studies in animals have shown mixed effects of dopaminergic agonists on lipid metabolism. When dopamine and SKF 38393, a D2 receptor agonist were administered to genetically obese mice, antilipogenic effects were observed in the liver, but a combination of both lipolytic and antilipolytic effects were demonstrated in adipose tissue. In adipose tissue lipoprotein lipase activity was decreased (an antilipogenic effect) where as beta-agonist stimulated lipolysis was decreased (5). Additionally, obese mice treated with dopaminergic agonists also exhibited reduced de novo lipogenesis (2). This is the process whereby dietary carbohydrates are converted to fat. Interestingly, while de novo lipogenesis is important in animals, its contribution to fat deposition in humans is relatively unimportant (6). When humans ingest excess carbohydrates, rather than being stored as fat, the carbohydrates are preferentially used as fuel, preserving fat stores that would have otherwise been oxidized. Here is a case where the results of animal studies do not necessarily carry the same implications for humans.

Dopamine has also been implicated in appetite control. It has been postulated that dopamine modulates appetite by providing a reward stimulus, and that obese individuals have lower levels of dopamine receptors in certain portions of the brain (7). Hence to achieve the same "reward" from eating as normal individuals, obese individuals must eat more. This would provide some rationale for the treatment of obese individuals with dopaminergic agonists, but it is unclear whether normal body weight individuals possessing a normal density of dopamine receptors and/or normal dopaminergic activity in the brain would benefit from such treatment. The authors of the previously cited paper also acknowledged that it was unclear whether the relative paucity of dopamine receptors in the obese subjects was a cause or a result of their overeating. Since eating elevates dopamine levels, the brain could be compensating for elevated dopamine in chronic overeaters by downregulating the dopamine receptors. This latter possibility could call into question the use of dopaminergic agonists for appetite control. The result of increasing dopamine levels with agonists could lead to a further downregulation of the D2 receptors, leading to an increased desire to eat in order to further elevate dopamine levels. In a review of the above-cited study, Dr. Joseph Frascella of NIDA’s [National Institute of Drug Abuse] Division of Treatment Research commented on this positve feedback effect on D2 receptor downregulation:

“This deficiency could be a double-edged sword that cuts both ways. First, the reduced reward experienced by people with this deficiency may make them more likely to engage in addictive behaviors. Then, the addictive behavior itself could make the deficit worse as the brain further lowers D2 levels in response to constant overstimulation of the reward pathway. “In the end, they could be much worse off biologically than when they started,”

Another mechanism by which dopamine could suppress appetite is by antagonizing neuropeptide Y (NPY). As fat stores decrease during dieting, leptin levels fall. This signals an increase in NPY, which is a potent hunger inducing neuropeptide. Treatment of genetically obese mice with bromocriptine led to a decrease in the elevated levels of hypothalamic NPY in these animals (2). Again, the implications of these observations to normal humans are unclear.

Both obesity and cocaine addiction have been linked to the dopaminergic reward pathway. As we have been discussing, food consumption elevates dopamine level, leading to a reward stimulus. In the case of cocaine, the traditional view has been that cocaine blocks the cellular dopamine transporter, blocking dopamine reuptake and increasing extracellular dopamine levels, again leading to reinforcing reward. However, this view has been called into question by the 1998 publication of a study showing that mice lacking the dopamine transporter develop cocaine addiction (8). According to the dopamine reward model of cocaine addiction, the lack of the dopamine transporter should have maintained chronically elevated dopamine levels, obviating any reward derived from cocaine use. Nevertheless the mice became addicted. The authors suggested that other neurotransmitter pathways, such as those mediated by serotonin may play a more important role in addiction. These ideas are supported by the fact that dopaminergic agonists, including bromocriptine, have not been useful in treating cocaine addiction (9).

Is it possible that the food driven reward mechanism is also dopamine independent, or at least only partially dependent on dopamine? The successful use of fenfluramine as an anorectic agent suggests this could be the case. Fenfluramine stimulates the release of serotonin and is a potent reuptake inhibitor of serotonin into nerve endings. This increases levels of serotonin in the nerve synapse, increasing levels of serotonergic nerve transmission. In both animals and humans, fenfluramine induces lack of appetite leading to weight loss. Fenfluramine was withdrawn from the market in 1997 due to findings that its use was associated with valvular heart disease.

Side Effects of Bromocriptine Treatment

As with the majority of drugs bromocriptine has a number of well characterized side effects that seem more unpleasant than dangerous, and often abate during treatment. These include nausea, orthostatic hypotension, headaches, abdominal discomfort, nasal congestion, fatigue and constipation. Besides these there are two other potential side effects that are not as well characterized, that are controversial, and that are of particular interest to bodybuilders and other athletes. The first I would like to address is the possibility that bromocriptine may lower testosterone levels in normal men, as well as increase the ovarian aromatization of testosterone to estrogen in women. The second is the potential bromocriptine may have to suppress the immune system in normal humans.

Bromocriptine and Steroidgenesis

It has been appreciated for decades that elevated levels of prolactin in males (hyperprolactinemia) can suppress testosterone production. Hyperprolactinemia disrupts the hypothalamic-pituitary-gonadal axis in women as well, leading to amenorrhea and infertility. Since bromocriptine lowers prolactin levels, when bromocriptine is administered to these patients, normal sexual function is usually restored. What is less well known is that studies done both in vitro and in humans suggest that hypoprolactinemia (low prolactin levels) also leads to suppressed testosterone production. So prolactin appears to exert a biphasic effect: too much or too little can disrupt testicular function. Normal physiological levels of prolactin appear to be necessary for normal gonadal function. (10) (11). To quote from Marin-Lopez et al, (10), where sulpiride and bromocriptine were used respectively to induce hyper and hypoprolactinemia in normal males

"the hyperprolactinemia induced a low basal level of testosterone with a higher response of this steroid to hCG...while the loss of the trophic effect of prolactin on gonadal steroidogenesis, as seen in hypoprolactinemia produces a decrease of basal testosterone levels without any alteration of the response of this steroid to hCG. We conclude that prolactin plays an important role in the steroidogenesis of Leydig cells in normal men.'' (11)

Confusing the issue is the fact that several other studies both in vitro and in vivo have shown either no effect or an increase in testosterone production due to both prolactin and bromocriptine administration (12) (13).

A number of experimental observations have led to several theories that could possibly explain how bromocriptine induced hypoprolactinemia suppresses testosterone production. Kovacevic and Sarac (14) proposed that bromocriptine competitively inhibits androgen production at the level of the testicular enzymes 17 alpha-hydroxylase and/or 17,20-lyase. These enzymes act at intermediate steps in the testicular production of testosterone. Aisaka et al. observed a decrease in luteinizing hormone (LH) levels that was mirrored by a decrease in testosterone after bromocriptine administration, suggesting that bromocriptine directly inhibits LH secretion from the pituitary (15). As we know, luteinizing hormone, or LH, secreted from the pituitary gland acts directly on testicular Leydig cells to stimulate testosterone secretion.

On the other hand Suescun et al. observed a decrease in circulating testosterone after bromocriptine administration in men with no decrease in LH levels (16), consistent with a direct testicular action of bromocriptine, as proposed by Kovacevic.

Other studies have shown that lowering prolactin decreases the binding of LH to the Leydig cell LH receptor, with a concomittent reduction in androgen production (17). These researchers concluded that

These results suggest that under normal conditions, endogenous prolactin plays a key role in maintaining the functional integrity of rat Leydig cells." (16)

So perhaps by either lowering the affinity of the LH receptor to LH, or by directly decreasing LH receptor number, bromocriptine could lower testosterone production.

As is obvious from the conflicting studies, and the variety of proposed mechanisms for bromocriptine induced testosterone suppression, there is much to be learned about the role of prolactin in maintaining normal testicular steroidogenesis.

All of the studies thus far cited have been carried out in men. What about the effects of bromocriptine in normal women? As mentioned earlier in the article, hyperprolactinemia inhibits ovulation in both animals and humans. One interesting study showed that prolactin administered to rats decreased levels of ovarian aromatase. Conversely, when bromocriptine was administered, ovarian aromatase was increased (18). Is this of any relevance to human females? Perhaps, since the same phenomenon is observed during the follicular phase of the menstrual cycle: bromocriptine increases the estradiol/testosterone ratio as a result of increased aromatization of testosterone to estrogen (19).

Bromocriptine and the Immune System

A number of studies have shown that prolactin stimulates certain aspects of immunity, and that by lowering prolactin with bromocriptine many of the symptoms of autoimmune diseases such as rheumatoid arthritis and systemic lupus erythematosus can be ameliorated. A recent review by McMurray (20) provides an excellent overview of this topic. While this is certainly hopeful news for people suffering from these diseases, what are the implications for the immune lowering effects of bromocriptine in healthy people?

One possibility is that by suppressing the prolactin mediated immune response, an individual could become more susceptible to tumor formation. (21). As Matera et al pointed out (22), prolactin specifically heightens the response of the cellular arm of the immune system. Recalling some basic immunology, the immune system has two components, the cellular arm and the humoral arm. The former is responsible for the direct attack on pathogens, while the latter involves the production of antibodies that mark pathogens for destruction, as well as creating a class of "memory" B cells that once primed by exposure to a pathogen, will respond vigorously the next time the body encounters the same invader. The cellular response is orchestrated by so called Th1 helper cells. The humoral response on the other hand is governed by another T cell subclass, the Th2 helper cells. These two T cell subclasses keep each other in check by controlling the production of cytokines that are mutually suppressive. So any immune stimulus that activates Th1 cells will suppress the Th2 response, and vice versa. So by suppressing prolactin (which heightens the cellular immune respons), cellular immunity is weakened.

One point of possible concern is that many persons who are using or contemplating the use of bromocriptine also use anabolic-androgenic steroids (AAS). Like bromocriptine, AAS suppress the cellular arm of the immune system. They do so by stimulating Th2 cells, which as we discussed above, suppress the Th1 driven cellular response. So users of both AAS and bromocriptine could receive a double dose of immune suppression, leaving the body open to attack by pathogens, or conceivably more susceptible to the development of tumors. This latter possibility is potentially heightend by the fact that many AAS elevate IGF-1 levels, which have been implicated in tumorogenesis.

It has also been demonstrated that prolactin opposes the immunosuppressive effects of glucocorticoids (21). Bromocriptine, by virtue of prolactin suppression, therefore may leave an overtrained or stressed individual more prone to the deleterious effects of elevated cortisol levels, including increased muscle catabolism, and an impaired immune response to exercise induced muscle damage, which is essential to growth.(Post exercise muscle damage is a powerful catalyst for growth. The muscles repair and rebuild so that they are bigger and stronger that before training. Suppressing this post exercise inflammation, whether with cortisol or NSAIDS, hinders growth.)

Bromocriptine and Cognitive Impairment

Dopaminergic agonists including bromocriptine exhibit mixed effects on cognitive ability when used to treat Parkinson’s patients, as well when administered to normal subjects. Swainson et al (23) showed that when administered to Parkinson’s patients, bromocriptine improved working spatial memory, while at the same time impairing so called “reversal learning” skills. This effect was subsequently reproduced in normal volunteers (24). In a reversal task, subjects have to learn that a previously rewarded stimulus now lacks reward, while the formerly neutral or negative stimulus now receives reward. This involves two stages: ceasing to respond to the former stimulus, while simultaneously learning to respond to a new stimulus.

A real world example of working spatial memory is learning to adapt and respond to changing situations, as one would face during a chess game. An example of a reversal learning skill is the ability of a child who is repeatedly reprimanded for chatting to classmates to realize that it is expected of her to participate in classroom discussions.

In the experiment carried out by Swainson et al (24) mentioned above, normal volunteers were administered 1.25 mg of bromocriptine. One aspect of the study that is interesting is that only the subjects who showed relatively poor working spatial memory before bromocriptine administration showed an improvement after being given the drug, whereas no such correlation existed for reversal learning. Bromocriptine impaired reversal learning independently of a subject’s pre-administration reversal learning skills. The bromocriptine treated subjects performed better on the second round of reversal learning testing, which suggested to the researchers that bromocriptine impairs this aspect of cognition in novel situations more strongly than in familiar ones.

Although there is no concrete explanation for the bromocriptine induced cognitive impairment, the authors theorize it is due to dopamine overload of the neural circuitry involved in reverse learning. Jentsch et al (25) showed that monkeys exhibited a similar impairment in reversal learning after cocaine administration. In this experiment food was placed under one of three novel objects and the monkeys learned to lift that object to obtain the food. When the food was subsequently placed under a different one of the three objects, placebo treated monkeys quickly learned to lift the new object to get the food, while the cocaine treated monkeys continued to lift the original object in search of food.

The parallels between this experiment and the human reversal learning experiment are not surprising since cocaine elevates dopamine levels in certain portions of the brain, just as bromocriptine acts as a dopaminergic agonist in the brain. Dopaminegic overload is likely the cause of the impaired reverse learning in both experiments.

Summary

Just as users of AAS owe it to themselves to become familiar with the impact these drugs can have on a person's health, so should users, or potential users, of bromocriptine be aware of the possible health implications of its use. I've tried to point out some of the potential benefits of bromocriptine use (e.g. weight loss, treatment of autoimmune diseases) as well as some possible drawbacks (impaired gonadal function; immunosuppression). Like just about every other agent used to improve performance or lose weight, bromocriptine has its potential dark side as well.