Zytiga Effects On Bloodwork

[Dett]

Hello all,

I would appreciate feedback on interpretation of my husband’s latest blood test results. As background, he was diagnosed with stage 4 PC in July 2019 (Gleason 9, PSA 77, several bone mets). He has been on Casodex since diagnosis, then put on Eligard about a month later, and he’s been taking Zytiga/Prednisone since June or July 2020. He has also had extensive radiation to the pelvic bed and spinal mets.

Husband’s PSA has been undetectable since May 2020 (9 months) and his testosterone has been < 10 during this timeframe. He has mild anemia, but most of his CBC and metabolic panel test results are within normal. His calcium level has decreased to normal range.

What concerns me is that husband’s ALP has been slowly but steadily increasing since early August 2020 (80 to 111). I know that his latest reading is only slightly above normal, but the trajectory is concerning. I also noticed that his bilirubin level has been slowly but steadily rising since last August as well (.4 to 1.1 - barely within normal range). The increase in ALP parallels the increase in bilirubin, and all have occurred since husband started Zytiga. AST and ALT are normal.

My initial concern was that the increasing ALP represented possible progression of bone mets and/or the increasing bilirubin represented potential liver metastasis, but cursory research into Zytiga revealed that it can cause abnormalities in liver tests and ALP and that this must be monitored. Any thoughts?

[Hidden]

What did the MO say? He/she should be on top of this.

[Dett in reply to Hidden]

Nothing yet. Husband has long scheduled teleconference with her on Friday. But I’m wondering if we should message her before then. I know that these numbers must seem trivial to a lot of guys on this site, but I don’t want things to get out of hand.

[4Rosebud in reply to Dett]

my feeling and my own treatment is less is more do alternative to counter side affects of the drug cocktail that they are using.. you have to stay stronger.. than the drugs, milk thistle to cleanse his liver, curcumin to help with inflamation. cbds for immune responses.. no sugar, milk, eggs things like that.I personally don't do more than 1 or 2 meds at once so I know what is causing what...I'm 69..6 years in stage 4 with over 30 1 cm bone and 30 1cm lymph nodes. I was told I had 60-90 days over 3 years ago and very healthy.

I've been on zytiga for about 11/2 years with no side affects so far. no chemo or radiation..nothing hard.

I wish you much success. Do whatever it takes.

[Dett in reply to 4Rosebud]

Thanks. I appreciate your input.

[Tall_Allen]

Progression is possible. A bone scan/CT or even an FDG PET scan may tell you. If so, docetaxel is clearly called for.

[Dett in reply to Tall_Allen]

I recognize that anything is possible with APC, but is it likely with an undetectable PSA and other blood values within mostly normal parameters? MO has been reluctant to prescribe scans, but we may need to press her.

[Tall_Allen in reply to Dett]

Not likely, but possible.

[Dett in reply to Tall_Allen]

Thanks for taking the time to reply.

[dhccpa in reply to Dett]

What's her reason for hesitating to order scans? I've had quite a few done, but ROs seem more willing than MOs.

[Dett in reply to dhccpa]

I have no idea. RO had several focused scans done during radiation (at a different hospital), but he hasn’t had any whole body scans since diagnosis.

[Hidden in reply to Tall_Allen]

TA. How exactly does the docetaxel work? Does it reduce the PSA? Thanks Tom.

[Tall_Allen in reply to Hidden]

It stabilizes microtubules. When microtubules can't collapse, cells can't migrate, divide and replicate, so they die. PSA usually increases with the number of prostate cancer cells.

[Hidden in reply to Tall_Allen]

Thanks TASo that should make the psa and spread go down????

I feel great now - except for hot flashes

Trying to void it because people have said it makes them feel terrible and after docetaxel they never really recover their energy or vigor.

Yu are so helpful!!!!

Tom

[4Rosebud in reply to Tall_Allen]

Why Doceataxel? I'm curious

[Tall_Allen in reply to 4Rosebud]

Because there is cross-resistance between second-line hormonal therapies. Sometimes docetaxel will restore sensitivity.

[timotur]

My ALP followed a similar trajectory from about 75 to 115 while on 18 months ADT (Lupron/Zytiga) Uro/MO couldn’t explain it, and discounted any possible mets or NEPC with PSA <0.01. Since stopping ADT ALP has been dropping back down to 100. All other blood tests were normal. So, thus far, unexplained why this happened.

[Dett in reply to timotur]

Thanks.

[tango65]

Even when progression of the cancer may be possible, since his PSA has remained undetectable it is unlikely the increase in bilirubin and ALP is caused by progression of the cancer.

Zytiga is hepatotoxic:

accessdata.fda.gov/drugsatf...

He has a simultaneous increase in the bilirubin and in the ALP along with undetectable PSA.

There are several isoenzymes of ALP, mainly liver and bone isoenzymes. Consequently, ALP can increase if there is liver damage or bone lesions. Bilirubin could also increase if there is liver damage.

It is possible the simultaneous increase of these 2 parameters are caused by the effects of Zytiga on the liver. Discus studying liver enzymes and the isoenzymes of the ALP.

[Dett]

Thanks! I’m hoping that the increase in bilirubin and corresponding increase in ALP are side effects from the Zytiga. But I’m still trying not to freak out.

[tango65 in reply to Dett]

Best of luck!!

[dhccpa in reply to Dett]

Is he taking the full dose of Zytiga on empty stomach or 1/4 dose after a meal?

[Liggs69 in reply to dhccpa]

I was taking 4 zitiga pills at 2-4am for a month. Battling for 9 years and needed break for Xmas. Should get blood test today. On elligard and other hormones.

[dhccpa in reply to Liggs69]

Thanks. Some (still a minority) docs are now recommending a 1/4 dose with food. Less cost and SEs, but still effective.

[Dett in reply to dhccpa]

Full dose on empty stomach.

[LearnAll]

First the basic fact: Bilirubin is an enzyme released by Liver. ALP is an enzyme released by Liver, Bones and Intestines. If both are rising simultaneously, it indicates possible liver origin. Most likely due to ADT drugs.How do we know for sure ? Check Bone Specific Alkaline Phosphatase and if it comes below 20 mcgm/L , it means the source of increased ALP is not the bone mets....(it has to be liver or intestine) I would not rush to scans yet.

[Dett in reply to LearnAll]

Thanks.

[ctflatlander]

Suggest you talk with your MO and stop Zytiga. It may only take a couple weeks for your liver to recover and restart it with smaller dose. Good wishes.

[Dett in reply to ctflatlander]

I’d love to talk to her. We sent a message to the MO requesting feedback, but her nurse responded that we’ll talk at our scheduled online meeting on Friday. I don’t doubt that the MO is busy, but would it kill her to provide a quick response in the interim?

[Cmdrdata]

I have been on Zytiga+5mg of prednisone for 35 months (no Lupron). My PSA has been <0.1 and T <50 during the entire time. Blood works are within normal range, however my BP (systolic) has been in the 150s during all those months. Diastolic is between 80-90 range.

[winkoliu]

Talk to your doctor, try to take "MILK Thistle" a supplement that would help with you liver.

[NotAlwaysSunshine]

Wow - I feel like I am living in your shoes. Exact same reaction to Zytiga. Husband has same dx as well. He met with a liver specialist and found nothing alarming. Thankful for that! He started taking Xtandi - The liver issues all went back to normal levels. My husband was diagnosed in May 2019. Still Having trouble getting his PSA down. It's currently around 9.0 We are constantly doing scans every 3 months.

[Dett in reply to NotAlwaysSunshine]

Thanks for the feedback. I’ve heard that the side effects of Xtandi can be pretty bad, which is concerning. Best wishes to you and your husband for continued reduction of PSA.

[GoBucks]

Dett, no reason to worry although we do all worry about everything. My AST & ALP kept rising. My MO kept watching(went from monthly testing to biweekly) When my numbers got to just under 5 times normal I stopped Zytiga. But only for 7 weeks until my liver numbers came back to normal. By the way this rise started in my 7th month of taking Zytiga. When I restarted Zytiga I took 1/2 dose. When I tolerated that ok I went to 3/4 dose. Been there ever since and my PSA has been <0.01 the whole time, even when off Zytiga. So your hubby's numbers have a long way to go before worry sets in. I am now 3 years <0.01 after surgery, G9, multiple mets.

[Dett in reply to GoBucks]

Your input is much appreciated. One thing I don’t understand is why husband’s AST and ALT are perfectly normal, but his bilirubin keeps rising. Most people seem to have problems with AST and ALT, not bilirubin. I’ve read that prednisone can also cause liver problems, so that could be a contributor. Also, I’ve been conditioned to think that rising ALP is a hallmark of cancer progression, so it is reassuring to know that that may not always be the case. Guess we’ll find out more on Friday when we talk to the MO.

[NotAlwaysSunshine]

Thankful that Xtandi has not had any side effects.