We started our treatment focusing on the affective symptoms with 300 mg of bupropion, a norepinephrine and dopamine reuptake inhibitor. After 3 weeks, affective

symptoms had improved; impulsive and inconsiderate behaviour remained though. Moreover, the patient had lost 1.5 kg of his body weight. At week 6, we added methylphenidate starting with Inhibitors,research,lifescience,medical 18 mg and increasing the dose to 36 mg at week 7. The combined medication was well tolerated, NR reported to have a longer and better ability to focus his attention or organize tasks. We observed less impulsive and more goal-directed behaviour with improved emotional stability. Furthermore, uncontrolled food intake and body weight decreased without any reported or observable effort to take control over the impulse to eat. We discharged NR with a body weight of 133 kg (BMI 47.1) after 10 weeks of treatment. At no point did we apply psychological treatment for obesity nor made the body weight a major issue in the Idarubicin supplier therapeutic sessions and visits. NR clearly refused any efforts in losing weight. We saw the Inhibitors,research,lifescience,medical patient for follow up interviews at weeks 3 and 8 after discharge. NR’s psychopathological status and his weight remained essentially stable, with a slight increase to 134.1 kg

(+1.1). Medication remained unchanged and was well tolerated. Eight weeks after discharge NR’s body weight had even further decreased to 131.8 kg. Inhibitors,research,lifescience,medical Discussion We present, to the best of the authors’ knowledge, the first report on

combined treatment with bupropion and methylphenidate as added to an established therapy with cabergoline Inhibitors,research,lifescience,medical in a patient with a prolactin-secreting pituitary adenoma. We report a subsequent improvement of neuropsychiatric symptoms and a sustained reduction of obesity. This improvement was not observed during a preceding 1 year’s treatment with cabergoline, despite normalization of prolactin, somatotropin and testosterone levels. This observation suggests no direct influence of this D2 agonist on the reward processing system and no indirect influence on weight through normalization of prolactin Inhibitors,research,lifescience,medical levels. Notably, abnormalities of the circadian rhythm of prolactin secretion rather than the baseline prolactin next level has been associated with weight increase [Doknic et al. 2002], which might explain some inconsistencies in the literature mentioned above [Greenman et al. 1998; Delgrange et al. 1999; dos Santos Silva et al. 2011]. As the somatotropin levels were normalized at the point of treatment, we did not substitute this hormone. The normalization of somatotropin levels without any impact on the body weight suggested that a substitution of somatotropin would not have led to a significant impact on the body weight. Furthermore, hyposomatotropinaemia has been rather associated with selectively elevated visceral fat than with obesity. Still, a significant effect of a substitution is clearly possible.