Enzalutamide or abiraterone

[Islandboy2021]

What is the difference between these two drugs. Which one should I use. I know this was discussed in a post recently. My Oncologist would like me to start with one of these. I asked him this question and said abiraterone has less fatigue side effects. I will need to get blood work done every two weeks and monitor potassium levels and kidneys.

[Tall_Allen]

They have never been directly compared in a clinical trial, but they seem to be equally effective.

Abiraterone is an enzyme blocker that prevents the adrenals from manufacturing testosterone and other androgens, and prevents tumors from manufacturing them. Because it prevents steroid synthesis by the adrenals, it prevents them from making cortisol too. That's why you have to take it with a low dose of prednisone to replace the lost cortisol. Too little prednisone will cause high BP, low potassium, and edema.

Enzalutamide is an "anti-androgen." It blocks the androgen receptor so the cancer can't divide and multiply. Even though it differs in how it controls the cancer, there is no advantage in taking both together.

There is a third "hormonal" drug, Erleada (apalutamide) that is also approved in the US for newly diagnosed men with metastases. Unlike enzalutamide, it has increased activity when combined with abiraterone in men who are castration resistant.

They all have different side effects, but most of the adverse effects are caused by ADT.

[Seasid in reply to Tall_Allen]

very interesting

[Schwah in reply to Tall_Allen]

don’t you think Erleada with Zytega might also be better than Zytega alone in hormone sensitive men? Have there been any drugs (or drug combinations) that were shown to work on castrate resistant men that were later shown not to work on hormone sensitive men?

Schwah

[Tall_Allen in reply to Schwah]

Well, Zytiga+Xtandi had no incremental benefit over Zytiga alone in newly diagnosed metastatic hormone sensitive (mHSPC) men. And there was no benefit in combining them in castration-resistant (mCRPC) men either.

MD Anderson is running a trial of Erleada+Zytiga in hormone-sensitive men, but it is not a comparison trial.

Erleada seems to outperform Xtandi (mHSPC) or Nubeqa (non-mCRPC) in indirect comparisons, but has more side effects. Zytiga seems to have the most favorable side-effect profile.

[Seasid in reply to Tall_Allen]

good to know thanks

[Bronzee in reply to Tall_Allen]

thank you for the very clear explanation!

[dhccpa in reply to Tall_Allen]

Excellent summary!

[Islandboy2021 in reply to Tall_Allen]

My PSA has more than doubled in the last couple of months. It’s at 3.36 now and I am still having Zoladex shots every 3 months. I guess I am castrate resistant now. Now I am eligible for double ADT. It’s been almost 5 years with Zoladex only. How long can I go with Zoladex and abiraterone. Will adding the abiraterone bring down my PSA. I have noticed recently that I have more back and rib pain. I have already had chemotherapy at the beginning of this diagnosis. Apparently when this treatment fails I can try chemotherapy again.

[Tall_Allen in reply to Islandboy2021]

When Zytiga fails, you can get Pluvicto.

[bglendi53 in reply to Tall_Allen]

Zytiga has failed me miserablely. Since I started on July 1st, my PSA has went from 24 to over 120. Had bone and CT Scans yesterday, mets are blowing up everywhere. Meet with oncologist Wed. Pretty disappointed.

[VictoryPC in reply to bglendi53]

I hate that drug. I personally thinks it actually is a direct path to CRPC. I feel bad when I hear people taking it.

[MarkBC in reply to Islandboy2021]

My situation is similar to yours. After over 4 years on Zoladex, my PSA climbed to 1.5 in September. My oncologist added abiraterone. This month's PSA dropped quite a bit to 0.13. My oncologist said some men in my situation can get "years" of additional cancer suppression from abiraterone. Hopefully that happens for me.

Based on your profile name, I'm curious whether you are from Vancouver Island? I am.

[Islandboy2021 in reply to MarkBC]

It looks like our treatments have been the same. What was your PSA when you started abiraterone. Have you noticed any more side effects in addition to the SE from the Zoladex. Yes, from the island.

[David1567 in reply to Tall_Allen]

hi Tall_Allen

So do you think if abiraterone stopped working after 3 months (PSA increased from 0.97 to 2.07 in 34 days) ERLEADA could be added now? (Not sure if it’s easily available in Canada) Or is it too late to add erleada?

Also, side note, could the abiraterone have stopped working due to its the 3 month mark for the zoladex shot?

Sorry just trying to figure out hubbys next course of treatment since Fridays PSA of 2.07, before Mondays MO appointment. Only diagnosed in Jan’22 and was hoping for abiraterone to work for a lot longer 🙏

Thank you, Tracey

[Tall_Allen in reply to David1567]

In the US, Erleada is not approved for mCRPC, only for mHSPC or non-mCRPC.

Maybe discuss Jevtana (+ carboplatin, if allowed) now and rechallenge with Xtandi later. Probably, Canada will allow Pluvicto at some point.

If he was late for his Zoladex shot, he PSA increase may be attributable to that if his testosterone increased.

Has he had any metastases biopsied?

[David1567 in reply to Tall_Allen]

thanks Tall_Allen for your reply. T results should be in on Monday but always has been <0.5 so far. His zoladex shot wasn’t late, but due on Oct 30. MO was thinking to make it every 10 weeks because it tapers off. Pluvicto (lu-177?) is only in trials I believe here, I think as are most drugs. Will ask about jevtana, thank you I think the MO was thinking enzalutamide next but we are not covered for it, And the falling side effect is a concern. He was taking to abiraterone well and we were really hoping to be on it for awhile, do you think a switch from prednisone to dexamethasone would work? Or also to late?

Thanks for all your calming wisdom!

[Tall_Allen in reply to David1567]

Good idea to try switching to dexamethasone.

[David1567 in reply to Tall_Allen]

oh- and he only had his liver lesions biopsied. They were prostate origin. He has not had the bone Mets done. Should he? He had a few genetic tests done on prostate tissue and were inconclusive.

[Tall_Allen in reply to David1567]

Liver metastases is fine.

[Seasid]

are you also considering Apalutamide?

[Seasid]

my oncologist wants to see me on Abiraterone plus Prednisone,

but would be ok to prescribe Enzalutamide if I really want to

i am thinking about Enzalutamide as it is milder on the liver but could cause falls (not very desirable)

[Shooter1 in reply to Seasid]

I was on Enzo for years. I fell a lot. I was only injured once, broken ribs. Full dose made me a complete invalid. 1/2 dose and I recovered to work 2 more years and retire... Lots of us can't handle full dose Enzo, don't be strong and delay cutting dose.. An Enzo zombie is no good for anyone.

[Seasid in reply to Shooter1]

i will ask for Nubequa as all my bone mets gone and now I only have remaining cancer left in my prostate and left seminal vesicles.

[Shooter1 in reply to Seasid]

Mine is only in bones and spreading. No soft tissue mets since first year chemo.. 5 1/2 years in and counting..

[Seasid in reply to Shooter1]

can you get a Guardant360 liquid biopsy to see if Olaparib or Keytruda would be effective for you?

[Seasid in reply to Shooter1]

dr google about Guardant 360 cdx

google.com/search?q=guardan...

[Seasid in reply to Seasid]

How much does Guardant360 cost?

For patients without insurance, the cash pay rate for Guardant360 TissueNext is $5,000 effective the first day of commercial launch June 22, 2021. In the event the test is not fully covered by insurance, patients may be eligible for financial assistance based on medical and financial need.

guardanthealth.com › products

Tests for Patients with Advanced Cancer - GuardantHealt

[Seasid in reply to Shooter1]

more comprehensive information about Guardant 360 available in Heidelberg Germany:

therapyselect.de/en/guardan...

[Pops78 in reply to Seasid]

What treatments killed your bone mets? Been on Nubeqa 9 months, even though he has bone mets, and have new met at Sacrum now. Had Orch last year not long after dx. Have not had Chemo or Radiation but MO wants radiation now I think, seeing her next week to go over liquid biopsy results and treatments. RO thinks Nubeqa not working. This is the wife and I'm really scared so all input is appreciated.

[Seasid in reply to Pops78]

i don't know what killed the bone mets. Maybe they just converted into a PSMA negative mets.

i asked for an appropriate PET scan to check for concordance between the PSMA positive and the PSMA negative cancer but professor Anthony Joshua said no to check for concordance.

i am not a doctor or an oncologist.

we should always put our faith in a doctors hands

I will ask him this question about checking for concordance again next week on Thursday when I see him again.

i can't communicate with professor Joshua very well. I am thinking about to change Medical oncologists.

i am visiting him for more than 4 years now and never succeeded to have any meaningful conversation with him about my cancer.

He denied my request for a PSMA PET scan on the ground that I I don't need a PSMA PET scan as we already know that I am metastatic.

I had to move to see an RO at genesis care with my urinary system symptoms in order to have attention.

my early chemotherapy was also pushed by my RO professor Izard and the board of urologists at the st Vincent's Hospital otherwise I would not get the early Docetaxel chemotherapy 6 cycles.

professor Anthony Joshua registra believe that I am doing well because of the early Docetaxel chemotherapy.

[Seasid in reply to Pops78]

Could you please fill out your profile information?

It would help to others to respond more appropriately. Not everyone has a time to go through all your posts before replying to you.

[Seasid in reply to Pops78]

what was your PSA at the time of the liquid biopsy?

when did you have a liquid biopsy?

what is your PSA now?

did they receive a results of your liquid biopsy?

you may be eligible for Olaparib or Keytruda.

why didn't they recommend early chemotherapy treatment?

urotoday.com/journal/everyd...

grandroundsinurology.com/dr...

[Pops78 in reply to Seasid]

<0.1 at time of liquid biopsy (9/2/22) No blood work since so don't know what it is now?

Liquid biopsy done 9/7/22.

No PSA done since 9/2/22.

They received results of liquid biopsy at least 10 days to 2 wks ago.

I asked for the report from the foundation, impossible for me to understand,

but did see Olaparib mentioned as a treatment.

Don't know why chemo was not an option when first dx last year but current MO said

he was too weak to do it the first of this year.

[john4803 in reply to Seasid]

Apalutamide is working well for me with no side effects. PSA has gone from 7.3 to 0.1 in 5 months. I had mets throughout skeleton, too numerous to count.

My MO has 20 patients on it because of less se's. He says it is casodex 2.0, which was the major drug of choice for many years.

I should add that I am on Lupron & Xgeva, also.

[Seasid in reply to john4803]

yes, i can recall you are keep saying

[Janhpr in reply to Seasid]

my husband took Abiraterone for 6 years low PSA good quality of life, but had to stop as become very toxic to his Liver

[Seasid in reply to Janhpr]

i am in Australia and our PBS pays only for one drug in your lifetime.

if the drug like Abiraterone fails you could do chemotherapy or something to make it work again but I am not sure if the PBS would pay again for the drug after for example chemotherapy even if it would work again.

i really don't know what should we do ones the drug fails and we are not eligible according to the PBS.

maybe we could than by generic Abiraterone?

that is why prefer to start Enzalutamide or maybe Nubeqa.

Here are the PBS rules for Nubeqa:

Restriction

Authority Required

Castration resistant non-metastatic carcinoma of the prostate

Clinical criteria:

The condition must have evidence of an absence of distant metastases on the most recently performed conventional medical imaging used to evaluate the condition,

AND

The condition must be associated with a prostate-specific antigen level that was observed to have at least doubled in value in a time period of within 10 months anytime prior to first commencing treatment with this drug,

AND

Patient must have a World Health Organisation (WHO) Eastern Cooperative Oncology Group (ECOG) performance status score no higher than 1 prior to treatment initiation,

AND

Patient must not receive PBS-subsidised treatment with this drug if progressive disease develops while on this drug,

AND

Patient must only receive subsidy for one novel hormonal drug per lifetime for prostate cancer (regardless of whether a drug was subsidised under a metastatic/non-metastatic indication); OR

Patient must only receive subsidy for a subsequent novel hormonal drug where there has been a severe intolerance to another novel hormonal drug leading to permanent treatment cessation.

Treatment criteria:

Patient must be undergoing concurrent treatment with androgen deprivation therapy.

Prescribing instructions:

Retain the results of all investigative imaging and prostate-specific antigen (PSA) level measurements on the patient's medical records - do not submit copies of these with this authority application.

The PSA level doubling time must be based on at least three PSA levels obtained within a time period of 10 months any time prior to first commencing a novel hormonal drug for this condition. The third reading is to demonstrate that the doubling was durable and must be at least 1 week apart from the second reading.

Nubeqa

Brand name: Nubeqa

Form & strength: darolutamide 300 mg tablet, 112

Manufacturer: Bayer Australia Ltd

Dispensed price for max qty: $3536.92

Max recordable value for PBS Safety Net: $42.50

General Patient Charge: $42.50

[Janhpr in reply to Seasid]

Had diagnosed in 2008, RT after stopping Ab in 2019, not eligible in UK after Ab for Enza, bad side effects RT, Proctitis, rising PSA in 2021, had GA PSMA PET Scan showed widespread Bone mets, just had privately 5th treatment Lutetium 177 very expensive but doing a good job, PSA 2.54 chemo nearly killed him last time in 2010 so want to avoid, DVT/multi pulmonary embolisms, on warfarin for life and that causes excessive bruising just with a touch. Hope Lutetium 177 licensed in UK in November so if needed later can have further treatments on NHS. We did contact Michael Hofmann in Australia following his webaire, his hospital offers Lutetium 177 free to some patients and PSMA Pet Scans + FDG scans routinely. It’s a long and stressful road Prostate Cancer, not only for the men who have this disease but for their families as well, seeing what this disease does to them, but we continue love each other + our two Cavalier King Charles Spaniels who always keep us on our toes. A good dose of humour is also very beneficial and kept us going to be able to enjoy the good times as they come

[Seasid in reply to Janhpr]

i am not sure in this (as my registra said that maybe more than 6 Lutetium PSMA infusions are possible under certain condition) but TA said because of the radiation side effects only 6 Lutetium 177 PSMA therapies are possible.

therefore you can only receive one more as you already had 5 infusions of Lutetium 177.

[MateoBeach in reply to Seasid]

That is a harsh policy Seasid. One drug then done. Disposable soma theory being enforced economically.

Yes, would go for apalutamide or darolutamide and reserve abiraterone which is generic and inexpensively available from India, etc. BTW, is not Nubequa now also approved for metastatic HSPC (in the USA anyway)? Hard to keep up.

[Seasid in reply to MateoBeach]

and our PBS in Australia is almost a clone of the British NHS system.

the only big difference is that in UK Xofigo is free while in Australia it cost 60000 A $ for 6 infusions.

but if you think that in Britain you can get it for free you will probably find out soon that they are not going to give you prolia (denosumab) making the whole possibility of getting the Xofigo infusions dangerous as it could result with broken bones especially if you start your treatment with Zytiga plus Prednisone. Plus probably no oncologist in UK will refer you to get Xofigo even if you develop bone pain.

to be honest I don't really know but that is what I believe following a journey of our members.

[tango65]

There are both effective. In general one could say abiraterone is better tolerated than enzalutamide. Enzalutamide crosses the blood brain barrier and it could affect the central nervous system. It can even cause seizures.

Some info from the FDA

accessdata.fda.gov/drugsatf...

accessdata.fda.gov/drugsatf...

Abiraterone had a median of 6.6 years overall survival in the STAMPEDE trial

urotoday.com/conference-hig...

[Seasid]

very useful information for me. Why don't you have an experience with Nubeqa?

I will ask for Nubeqa as my latest scan show that I have only cancer in my prostate and my PSA doubled in a last less than 10 months.

i am eligible for Nubeqa according to the PBS in Australia:

m.pbs.gov.au/medicine/item/...

[Seasid]

This is my latest scan result. My bone mets gone.

Page 2. Of my PSMA PET scan report by professor Emmett.

[cesces]

Take a look at this:

Xtandi Superior to Zytiga? Maybe Yes? Xtandi prevents resistance to Testosterone because it upregulates the AR while inhibiting its activity

Https://healthunlocked.com/advanced-prostate-cancer/posts/148614871/xtandi-superior-to-zytiga-maybe-yes-xtandi-prevents-resistance-to-testosterone-because-it-upregulates-the-ar-while-inhibiting-its-activity

[Seasid]

i don't understand this:

" I don't picked enzalutamide and Zytiga for pBAT.,"

can not you just replace Enzalutamide with Darolutamide?

i thought that they are similar Darolutamide and Enzalutamide? Only that Darolutamide is not crossing the blood brain barrier therefore less side effects?

Maybe the biological half life is different?

[Gl448 in reply to Seasid]

Darolutimide is in my future. My MO stressed that it is two doses daily and very important to remember to take the second dose.

[Seasid]

healthunlocked.com/advanced...

thanks Cesces.

you can just klick on the link

[Seasid]

do you have any link to the clinical trials you are keep saying about?

i would like to see for myself if you could provide the link

[winkoliu]

You can take Casodex first to see what happen. Both xtandi and zytiga have much side effects than Casodex. I took Casodex for more than 10 years without any side effect.

[Seasid in reply to winkoliu]

casodex is very toxic to the liver and it is like a drop in the ocean in comparison with enzalutamide.

[cesces]

hmmm I don't think I disagree. And to the extent I do disagree I am highly confident I am wrong. LOL

The conclusion I came to is, current evidence indicates that there's no outcome difference between choosing Xtandi or Zytiga.

But they do work differently so with time there will become clear evidence based outcome differences.

One area where that might occur in the near future would be for patients who expect to be using BAT treatment subsequent to treatment with either Xtandi or Zytiga.

At the moment that is just conjecture, but a reasoned one. One that will be first tested by clinicians practicing in multiple one off situations.

Do I have that right?

[winkoliu]

I don't know. Please refer to some posts by one of our member " LearnAll".

[Seasid in reply to winkoliu]

thanks. I already concluded that my liver health is very important for me and that i am not using Casodex.

my other potential problem with casodex (but I don't really know

know) is that I am afraid that early use of casodex could interfere with the effectiveness of Enzalutamide later.

enough reason for me to avoid casodex.

liver toxicity, low effectiveness and potentially (maybe) interfering with the effectiveness of Enzalutamide.

[cesces]

Dumb question:

Isn't it best to do Xtandi prior to bat in order upregulate the androgen receptors prior to doing Bat?

As opposed to doing Zytiga prior to bat?

[cesces]

Between the two, which clears out it's effects most quickly when you stop.

I recollect you said that it was xtandi.

[MateoBeach]

And I will be another adding Xtandi (or Nubequa) to mBAT soon.

[anonymoose2]

All I will say is Enzalutamide worked extremely well for me. Cheers 🍻

[Seasid in reply to anonymoose2]

i agree , exactly.