Lupron vs Firmagon

[Melaine50]

Firmagon brought my PSA down from 550 to 10.9 in six months. My oncologist is now recommending switching to Lupron . Is this a good change?

[Tall_Allen]

It probably won't make a difference, but the multi-month Lupron shots are a lot more convenient.

[Melaine50 in reply to Tall_Allen]

Thank you

[DW1986 in reply to Melaine50]

We are on Lupron but our oncologist warned us that the multi month shot doesnt work as well for everybody as the one month shot...purely based on different things can affect how fast it is released etc. He had experienced patients who's PSA raised alongside with a heightened testosterone but when put back to the monthly shot the testosterone zerod again alongside lowering the PSA. So one thing to be aware of.

[GP24]

Lupron is more convenient. However, this study reports better results with Firmagon:

medirequests.com/pdfs/Crawf...

[cigafred in reply to GP24]

While I know of studies showing benefits of Degarelix vs. Lupron, the study cited is for going from Lupron to Degarelix, not vice versa. To this amateur, it would not be reasonable to conclude much about the reverse based on this study.

[GP24 in reply to cigafred]

The study concludes: " Over the 5-year period, degarelix resulted in improved PSA PFS [=progression-free survival] compared with leuprolide."

[Tall_Allen in reply to GP24]

I think Cigafred is right. The study had two parts - in the first year, men were randomized to Lupron or Firmagon. After a year, the men on Lupron were switched to Firmagon.

So at the end of the first year, median PSA was actually lower among the men taking Lupron (0.40 for Lupron, 0.50 for Firmagon). After the men on Lupron were switched, their PSAs were virtually identical. However, progression-free survival improved after the switch. From this I conclude that switching itself may have an effect. Because the study did not look at switching from Firmagon to Lupron, we can't really tell. But we have seen where changing the type of androgen deprivation can have a positive benefit (e.g., adding or subtracting Casodex from Lupron, changing steroid used with Zytiga)

[GP24 in reply to cigafred]

The objective in this study was to keep the PSA value below 0.5 ng/ml. Both Degarelix and Lupron achieved this. The authors see the benefit of Degarelix in the reduced risk of PSA progression. They write:

"... patients receiving degarelix 240/80 mg had a significantly lower risk of PSA progression or death than those receiving leuprolide during the first year of treatment. After crossing over from leuprolide to degarelix, the PSA PFS hazard rate decreased significantly (P= 0.002), indicating a decreased risk of PSA progression or death after

switching to degarelix. There was no significant change in the hazard rate for patients who continued to receive degarelix.

As expected, PSA progression in the first year occurred mostly in patients with locally advanced or metastatic disease and exclusively in patients with baseline PSA level >20 ng/mL. The risk of PSA progression in patients with baseline PSA level >20 ng/mL was significantly lower for degarelix 240/80 mg vs leuprolide during the first year (P= 0.019). Patients with baseline PSA level >20 ng/mL who crossed over from leuprolide to degarelix experienced a significant improvement in the PSA PFS hazard rate similar to that in the overall population.

Further benefits of degarelix, both clinical and economic, have recently been reported. A pooled analysis of comparative phase III degarelix trials found that the risk of experiencing a cardiovascular event or death is lower for men treated with degarelix compared with a LHRH agonist, particularly in those patients with a history of cardiovascular disease before starting androgen deprivation. ...."

However, the injection-site reactions "Pain" and "Erythema" were twice as high with Degarelix than Lupron.

[Melaine50 in reply to GP24]

Thanks for the study

[Nachas613]

Did he say why?

[AlanMeyer]

From what I have read, the advantages of Firmagon (degarelix) are that it lowers testosterone more quickly, there is no "testosterone flare" at the outset, and it achieves a lower testosterone level than Lupron and similar drugs achieve. The advantages of Lupron and related drugs (Zoladex, Eligard) are that they can be given in three or four month doses instead of one month, and the injections are simpler (not in the stomach) and less painful. There is some evidence (see GP24's posting above) that Firmagon offers greater long term survival. I presume that is because it gets the testosterone down further than Lupron does, but perhaps there are other factors too.

I am 100% unqualified to give you advice on this but if it were me, and I had an initial PSA of 550, and my PSA was above 10 after six months, and if I were young and healthy enough to believe that I might have some years left in me if I could hold down the cancer, and if the Firmagon injections weren't really too much of a pain with me, and if the side effects weren't too bad, I'd probably want to stay with the Firmagon.

If you are tempted to try the Lupron, and assuming you can always go back to Firmagon, here's what I would do.

I'd get my PSA and testosterone levels tested and make notes on my side effects. That would be the benchmark that I'd be measuring Lupron against. After a couple of months on Lupron (waiting long enough to be sure the Firmagon was no longer significant in my blood stream), I'd get my PSA and testosterone retested and compare my Lupron side effects with my Firmagon notes. If the numbers were climbing and the side effects were not a lot better on Lupron, I'd go back to the Firmagon. Otherwise, I'd probably stay on the Lupron but keep testing over time.

I mentioned the PSA numbers of 550 and >10 because your cancer is pretty serious and your response to Firmagon, while very good, was not wildly fantastic (e.g., undetectable PSA). It's possible that the Lupron will be less good and very unlikely that it will be more good. Maybe it's best not to take chances.

But, as I say, I'm 100% unqualified to give advice.

Best of luck.

Alan

[Melaine50 in reply to AlanMeyer]

Appreciate your advice . thanks

[sammamish]

I believe there is recent evidence to suggest Firmagon has a slightly lower cardiac risk profile than Lupron. Specifically DVT clot formation. I also recall reading how Firmagon may have an additional mode of action that may make it more effective...blocking FSH or LH receptors. which apparently may be a backdoor stimulant for cancer cells..going from foggy memory here..so check NCBI for yourself.

[Melaine50 in reply to sammamish]

Thank you.

[Hidden]

The Lupron is more convenient that's why I switched.

[Melaine50 in reply to Hidden]

Thank you

[hansjd]

As for switching from Firmagon to Lupron, personally I would not do it. Numerous comparative studies have shown Firmagon to be superior to Lupron and have switched people from Lupron to Firmagon during the studies for that reason.

Having said that, I have a different scenario you might want to consider.

I've been on Firmagon monthly injections since I was diagnosed in February this year. My MO said as an antagonist it was superior to an agonist such as Lupron. Everything I read said he was right. My PSA was 168 at diagnosis and dropped to 0.4 in 6 months when I last had it tested. I did have 6 rounds of docetaxel in that time though as well.

Now my MO wants me to switch to diphereline / triptorelin 3 monthly injections. As it's an agonist and as I've had no issues at all with the Firmagon, I questioned him about switching. He said it's a good ADT and he has switched many of his patients to it after being on Firmagon for 6 to 8 months.

As I was still sceptical I tried to find comparative studies / trials for Firmagon vs Diphereline, but couldn't find much. What I did find was the following:

"A mixed treatment comparison meta-analysis of a total of six studies of the selected agents revealed that leuprolide and goserelin were associated with increased mortality compared with degarelix (odds ratio [OR] 1.8 and 1.9, respectively). In contrast, mortality with triptorelin was lower than with degarelix (OR 0.5), leading the NICE Evidence Review Group to consider that the treatment effect of triptorelin on overall survival may differ from that of leuprolide and goserelin"

ncbi.nlm.nih.gov/pmc/articl...

I thought that sounded pretty good, but then I realised that the studies were mainly a year or less in length. So I kept searching. I found this article about a 3 year trial using triptorelin which, while not directly on topic, seemed to indicate that it's a good ADT.

'Factors predicting progression to castrate-resistant prostate cancer in patients with advanced prostate cancer receiving long-term androgen-deprivation therapy.'

ncbi.nlm.nih.gov/pubmed/269...

So I'm about to make the switch and I hope I'm doing the right thing. My MO is highly regarded and I did ask for a second opinion from an MO at another major cancer centre, and they agreed with him.

Maybe you should consider diphereline / triptorelin if you're going to switch.

All the best

[Melaine50 in reply to hansjd]

Thanks! I will mention it MO this coming week

[GeorgeGlass in reply to hansjd]

Great research Hans,

1. Does this, "In contrast, mortality with triptorelin was lower than with degarelix (OR 0.5)" mean that triptorelin mortality was half that of Firmagon?

2. Does triptorelin fall into the same category as Firmagon (antagonist) or Lupron (agonist)?

Thanks,

George

[hansjd in reply to GeorgeGlass]

Hi George

Not sure about the answer to your first question. Maybe someone else can answer that.

Triptorelin is an agonist.

However, I have some follow up information to what I posted earlier: I did do the switch to Triptorelin after 8 months on Firmagon, but after 9 months on Triptorelin I asked to be switched back to Firmagon and have now been on it again for 7 months.

Why? A couple of reasons. I had always had some doubts about an agonist vs an antagonist, even Triptorelin, so I continued to do research. I’m pretty convinced that Firmagon is the better ADT. One definite advantage is that, in addition to lowering testosterone, it lowers FSH more than an agonist, and that’s a good thing.

Secondly I started to experience stiffness in my hands beginning a few months after starting Triptorelin. Not sure if that was the cause, but it continued to get worse until I switched back to Firmagon. Since then it has improved somewhat.

As for the Firmagon injections - yes they are more frequent and they do cause s bit of local reaction, but if they are done properly (slowly and at the right angle) then the symptoms are minimal - definitely better than the worsening hand stiffness. I do all my own injections so It isn’t a problem if I want to travel, which we do pretty regularly.

My PSA rose a bit (to 0.7) a few months after starting Triptorelin (related ?) so my new MO suggested adding Bicalutamide. PSA dropped again to about 0.4 where it has remained for the past year.

Hope this is of some help / interest to you : )

Cheers from OZ.

[GeorgeGlass in reply to hansjd]

Thanks Hans,

I appreciate your thorough reply. Useful information. How do you get authorization to inject yourself? You would have to have the Firmagon delivered to you in the mail or picked up at a pharmacy?

What is FSH? I'm fairly good with acronyms but can't recall that one.

Does Firmagon lower Free testosterone more than Lupron shots?

George

[hansjd in reply to GeorgeGlass]

Hi George

Either my GP or my MO writes me a script for Firmagon, usually with about 3 repeats. which I take to the pharmacist. I order a couple each time, sometimes up to three if we’re going to be away.

I’ve had various people do the injections at various times. Some do it well, some not so well. I think I do it best of all. I have a vested interest and lots of practice : ) . Both the GP and the MO are fine with me doing it myself. I inject horses too, from time to time, for what it’s worth. Haha.

FSH is ‘follicle stimulating hormone’ - usually of more significance to women and their ovaries, but also important for prostate cancer. The lower the better and Firmagon does it best. You can check it out by Googling it.

As for testosterone, I believe both Firmagon and Lupron lower it to about the same extent, but Firnagon does it quicker and for longer (if my memory serves me right) .

All the best Jürgen

[GeorgeGlass in reply to hansjd]

Thanks jurgen. Good info!

George

[CalBear74]

I have been on Lupron for six years this month. I am not yet resistant. Time elapsed to resistance in any clinical study would be an interesting data point. I do not have that statistic but if I were in you situation, that would be one of the more important statistics to ponder.

[Melaine50 in reply to CalBear74]

I will keep tabs on resistance data before considering a switch- thanks

[GeorgeGlass in reply to CalBear74]

have you thought about switching based on the studies that hansjd cited above?

George

[larry_dammit]

Was on lupron for about a year, PSA was .005. Switched to eligard monthly no change in the PSA. Not sure about the firmagon. Sorry

[Melaine50 in reply to larry_dammit]

Thanks

[Hidden]

Well, for me, Lupron (6 month shot), took down my PSA from 1000+ to 62 in one month. But, of course, PCa is specific with our biology, what was the rationale given to the change?

[Melaine50 in reply to Hidden]

If my PSA stays at 10 - I will probably switch. Thanks

[charlesmeyers1964]

i've been on lupron/eliguard and for me its a very painful shot. remember it also effects ones bone density after some time. once u get it down to lets say 3 or 4 like all prostrate cancer meds when there down and for this particular one, give your body a break and get a test on psa and testosterone and find out what the level is, quit for awhile.

[Melaine50 in reply to charlesmeyers1964]

Thanks for your advice

[Break60 in reply to charlesmeyers1964]

taking prolia while on Lupron helps with the bone density issue.

[Melaine50 in reply to Break60]

Will check prolia

[Melaine50]

Are the best - thanks.

[JoelT]

If you have any heart or cardio-vascular issues Firmagon is a safer drug:

If you move from Firmagon to Lupron please be aware that you still might be subject to a PSA flare. This is little known and most doctors do not make the transition in the safest way for the patient

Joel

[Melaine50 in reply to JoelT]

Thanks!

[Jstn]

Hi, I'm new here. Does anyone taken bisphosphonate to reduce pain and prevent bone fracture? Would appreciate your advice. Thanks.