How is the second generation ADT like xtandi , zytiga etc decided ?

[Tinkudi]

What determines which second line ADT will be given to whom ? I see there is zytiga , xtandi , nubeqa and others.

Is it just left to the MO to decide ?

[Magnus1964]

Difficult question. There are a lot of factors. The patient's condition, side effects to the drug, staging, etc. These are points that cannot be changed.There are things that can be changed. For instance government regulations and doctor's protocols influenced by the pharmaceutical industry.

My advice is to do your own research. I realize that is a dirty word I'm some corners of this forum, but leaving it to your doctor is bad advice.

[Tall_Allen]

In the US, the choices for triplet therapy are Zytiga or Nubeqa. Without docetaxel, the choices are Zytiga, Xtandi, or Erleada. There have been no randomized comparative trials.

[Tinkudi in reply to Tall_Allen]

Allen , have you known patients in 80’s who have tolerated triple therapy ?

[Tall_Allen in reply to Tinkudi]

Are his doctors ageist as well as incompetent?

[Tinkudi in reply to Tall_Allen]

The doctors are saying for double therapy. Lupron and xtandi or abi. Will push for chemo but I am scared of it too

[hansjd]

From my understanding, Xtandi (Enzalutamide), Nubeqa (Darolutamide) and Erleada (Apalutamide) all act in much the same way. Xtandi has a reputation with some of causing extreme fatigue. Darolutamide doesn't cross the blood-brain barrier so apparently it doesn't have the same effect.

Zytiga (Abiraterone) acts differently from these three and for many has fewer side effects than Xtandi especially, but cardiac issues need to be considered.

In reality you may not have a choice because of lack of availability, government regulation or prohibitive cost. As someone else said, best to do your own research and then ask the appropriate questions. Cheers.

[Tinkudi in reply to hansjd]

Thank you. Any resources you can recommend to research ?

[vintage42 in reply to hansjd]

I don't think that crossing the blood brain barrier (BBB) is the cause of fatigue, and my urologist says that Nubeqa does cross the barrier, but much less than Xtandi and Erleada. I cannot find the percentage for Nubeqa to compare, but I also cannot find any source that says it does not cross at all.

My urologist offered me Xtandi and Erleada, pushing Erleada for milder side effects. I wanted Nubeqa because of the BBB and my seizure history, which he dismissed. But I did not qualify for Nubeqa without the chemo Taxotere (docetaxel), which at age 81 I did not want. So I asked for old Zytiga (now generic abiraterone).

My uro's in-house pharmacy says their patients on Xtandi have a lot of problems compared to Erleada. A friend on Xtandi was so fatigued that his MO halved his dose. My abiraterone has had easily-tolerated side effects so far.

[hansjd]

This forum is a good place to start. But searching for relevant studies / trials on Google is also possible.

[vintage42]

For the second-line ADT, the doctor proposes the drug, and you either follow his recommendation or research why you might not.

[RoseDoc]

often the insurers determine which drug one receives as they will only pay for certain ones.

[Clippedwingz]

I’ve been on Xtandi plus Orgovyx for about 6 weeks and have no noticeable fatigue. I’m 55, so perhaps age impacts fatigue with Xtandi?

The “new” NHT options (Xtandi, Erleada, and Nubeqa) all have the same MOA, so I would assume you’re splitting hairs in terms of both efficacy and side effects.

In the US, most insurers cover all 3 equally.

[treedown]

My insurance company had a say in the decision.

[Explorer08]

My urologic oncologist gave me a choice of either Zytiga or Xtandi added to the Orgovyx I was already taking. I chose Xtandi to avoid the prednisone that goes along with Zytiga. I’ve had increased fatigue but somehow my continued workout sessions have helped a great deal. I feel significantly better on the days I workout. I’ve noticed that if I miss workouts for several days in a row then the fatigue becomes quite noticeable.

[dhccpa]

From reading this forum for years, some do better on one vs the others. But every option presents it's own problems. Best to try one and see how you do, but I'm not sure you can predict the right one in advance. But others may differ.