Apalutamide & Relugolix

[sturn]

My husband will soon have to start back on meds for his recurrent PC. (PSA back up to 4.8, doubling every 4 months.) His preference is a combo of apalutamide and relugolix but his MO seems reluctant because he "hasn't seen any data." Anyone out there on this combo? How long? Results? Unusual side effects? Thanks to all.

[JamesAtlanta]

I am literally just starting both. They were prescribed to me by my oncologist at MD Anderson last week. I am on Relugolix because I have some heart trouble and it is supposed to be easier on the heart. ( I had to get a pacemaker a couple of years ago due to electrical issues … likely caused by radiation to my spine - had a met at the T8 vertebra.)

Before my “holiday”, I was on Trelstar, Zytiga and dexamethasone for 4 1/2 years. Relugolix was not an approved medication until, I believe, late 2020.

Hope this helps. I’m sure others can offer more technical support. I just know I’m taking both.

[sturn in reply to JamesAtlanta]

Thanks, James. Hope it works well for you. Looks like you had a good long run on Zytiga.

[Tall_Allen]

Here's the evidence so far:

apalutamide+ADT:

meetinglibrary.asco.org/rec...

Abiraterone+ADT:

ejcancer.com/article/S0959-...

[sturn in reply to Tall_Allen]

Thanks, TA, but that’s with Lupron. We’re hoping to find data on relugolix with apalutamide. Can we assume relugolix can be used interchangeably with Lupron? Our dr doesn’t seem sure of that. Do you know of drs who are doing that specifically?

[Tall_Allen in reply to sturn]

Relugolix is brand new. But the class of drug, GnRH antagonist, has been around for awhile as Firmagon. GnRH agonists (like Lupron) are interchangeable with GnRH antagonists. They may differ in some side effects but they do the same thing - stop testosterone production. Doctors use them interchangeably if insurance will cover them.

[sturn in reply to Tall_Allen]

We do understand that, as I’m sure our dr does also. I guess he just wants to hear that others use that specific combination. Good to hear that M D Anderson is doing it. I hope insurance will approve it.

[Tall_Allen in reply to sturn]

The relugolix is not the issue. The issue is adding a 2nd line hormonal to ADT for men who are recurrent. It is not standard of care. You may have to get it on one of these clinical trials:

clinicaltrials.gov/ct2/show...

clinicaltrials.gov/ct2/show...

[sturn in reply to Tall_Allen]

He is scheduled for a PSMA scan on Nov. 5. In early 2020 he had one and they found one lymph node and he did SBRT. Now we need to know what they find this time. If one has actual mets, as opposed to just rising PSA, does that make a difference? He has actually been through a lot in the past year--diagnosed with pancreatic cancer in March 2021, had a Whipple, and then post-surg pathology determined it was NOT pancreatic ca, it was cancer of the duodenum, stage III, which spread to pancreas. So he had FOLFOX chemo for 9 sessions and he stopped a little short of 12 doses because of his rising PSA, as he felt it was important to start treating that. All drs involved (there are several!) agreed that prostate ca could now take precedence.

[Tall_Allen in reply to sturn]

The "non-metastastic" designation is based on a bone scan/CT, not on a PSMA PET scan. I'm not sure what treatment decision you will make based on a PSMA scan. It seems unnecessary at this time.

[sturn in reply to Tall_Allen]

After reading that first study more closely, the one with apa + ADT, I realize that's the study my husband was on! He did that trial at UCSF and tolerated the side effects of the combination pretty well, so that's why he's now thinking he'd like to do it again. He felt apalutamide didn't add any additional SEs to the ones he was already used to with Lupron. The study was one year on drug and one year on observation.

[Tall_Allen in reply to sturn]

OK, so he is now non-metastatic and castration resistant. He can get Nubeqa, Erleada, or Xtandi. He may be better off switching to Nubeqa or Xtandi this time.

[sturn in reply to Tall_Allen]

No, he is still hormone sensitive, as far as we know.

[Tall_Allen in reply to sturn]

So when his PSA went up to 4.8, he wasn't taking any kind of ADT?

[sturn in reply to Tall_Allen]

No, not for quite a while. He did that study several years ago. Then they eventually found the lymph node with PSMA scan (took PSA a while to get to 2.0) and he did SBRT. So now a year later it has been rising every month. Chemo wouldn’t have caused that, would it? Now that he stopped chemo it just went from 5.6 to 4.8. He likes to find it early and deal with it.

[Tall_Allen in reply to sturn]

Now I understand. I'm not sure if insurance will cover the Erleada, but you can try to get it. I don't know of any clinical trials that cover intermittent Erleada.

[sturn in reply to Tall_Allen]

Many thanks for all your expertise! We had email tonight from his MO and he’s willing to give it a try and see if they will cover it. As for the scan, he’d like to do SBRT again if he is oligometastatic and dr is onboard with plan.

[Tall_Allen in reply to sturn]

Sounds good!

[JamesAtlanta]

Thanks, Allen!

[Boywonder56]

Lupron / erleada 4.5 years.....bio has dx...

[sturn in reply to Boywonder56]

Thanks for your input. We are really looking for experience with the oral drug, Orgovyx (Relugolix) with abi. I know it is probably interchangeable with abi, but just wondered if many have actually used that combination. I hope your combo has worked well for you!

[j-o-h-n]

Tall_Allen sure knows his shit!!! Great asset........

Good Luck, Good Health and Good Humor.

j-o-h-n Wednesday 10/27/2021 11:05 PM DST

[GoLowPSA]

Hello Sturn-

I found a study that may be of interest to you......not sure if the centers are still recruiting or not.

Study of Relugolix in Men With Metastatic Castration-Sensitive Prostate Cancer or Non-Metastatic or Metastatic Castration-Resistant Prostate Cancer

ClinicalTrials.gov ID NCT04666129

Best wishes for your husband.

[sturn in reply to GoLowPSA]

Thanks for the info. We'll check it out.