Opinion
Video
Managing Steroid-related Effects with Abiraterone Therapy
In this episode, Dr. Christopher M. Pieczonka and Dr. Jose De La Cerda discuss the nuances of prescribing abiraterone acetate related to strategies for patient counseling on prednisone and methylprednisolone use and managing steroid-related side effects, dosing adjustments in patients with liver issues, emphasizing the importance of close monitoring and individualized care in prostate cancer treatment.
Transcript:
Christopher M. Pieczonka, MD: You know, one thing that I wanted to ask you about is you had mentioned earlier that, obviously, the label for the micronized version uses methylprednisolone. The original abiraterone acetate uses prednisone. People worry about prednisone toxicity when you tell the patient they're going to need to be on prednisone or methylprednisolone. So two questions. The first question is, how do you counsel the patients that they're not going to get the type of side effects you get with prednisone or methylprednisolone? The second question, have you noticed any difference in terms of the side effects you do see, maybe bruising the skin or any of those other things?
Jose De La Cerda, MD, MPH: I mean, I really haven't. It's such a low dose. When I tell the patients the reason we're giving it is just essentially we're just replacing what's not being made. And it's at such a low dose that it's just something that we're going to be monitoring with their blood work and we're going to be monitoring with routine physical examinations. But I haven't really seen any worsening glucose intolerance or any worsening control. Well, the one that actually worries me particularly here is sort of worsening of diabetes or glucose intolerance, or they have to go up on their diabetic meds, so that's one thing I'm ensuring that they're also seeing their primary care and calling their primary care physician, saying I'm starting this patient on a steroid for this reason because if they see a steroid, they might just want to stop it altogether and not understand why they're giving a steroid, but it's really just replacement at that point.
Christopher M. Pieczonka, MD: I want to put a pin in that too. So what do you tell your patients regarding prednisone or methylprednisolone itself? Specifically, do you counsel them about the concern about stopping the medicine suddenly? If something happens, you know, they get hospitalized, you know, they go on a trip, they forget their pills, kind of just walk me through what you would tell the patient with the supportive steroids that are necessary for abiraterone.
Jose De La Cerda, MD, MPH: Yeah, absolutely. And I say they go hand in hand. You can't be taking one without the other. So if you go anywhere, if you forget to take your medication, I don't want you doubling up on any medication. The medication has been lost. All we want you to do is give us a call, let us know how long you've been off the med and when you're going to restart. And whenever you take these, they tend to put them in little pill bottles and they kind of put them together. But I don't want them to separate their abiraterone, whether it's their micronized or non-micronized or their prednisones, because we want them to take them together, and we want to ensure that they're not missing those doses. So for me, I tell them one is going to stop the production, but the other one's going to replace it. I'm not giving you anything extra. It's just so we can continue your levels where they are at a standard level and making sure that they are compliant with that.
Christopher M. Pieczonka, MD: Yeah, and you triggered my thought on something that, you know, for my practice, we're doing exactly as you are, exactly, and I'm preparing ahead of time the concept with the patient that the goal is to have them stay on therapy and not drop the therapy, right? So we don't want to, sometimes patients have side effects, they're on a cancer medicine, they're all dying of prostate cancer, unfortunately. But how we phrase that in the right frame of reference so that they don't end up having something that, you know, they have to, they're looking for reasons to drop the therapy rather than stay on it. And what comes to my mind in particular is hepatotoxicity. So, you know, one of the things that I'd like your guidance on is that when somebody does have an LFT elevation, you know, what do you do, you know, is there something you're looking up, you refer into the package insert, you know, how do you manage that? Is there some sort of, you know, pathway that you use or you're just sort of stopping and say, okay, I'm going to use, you know, anti-androgen now. So kind of walk me through that.
Jose De La Cerda, MD, MPH: Yeah. So there's pretty good information, I think, in the package insert. But in general, if a patient does develop some sort of transaminitis and we see their LFTs start going up, it's sort of dose reduced by half and recheck LFTs in two weeks. Once the transaminitis has resolved, I then re-escalate to the standard dosing. In the event that it kind of returns, then I'll go back or if it continues going up or goes above the upper limit of no more like five times, I kind of stop altogether. I've never had a patient that's developed jaundice or anything like that. However, if there were a patient that were to develop jaundice or any sort of symptomatic transaminitis, I just sort of stop it altogether and consider an alternative form of therapy. But the point is, I think what we know is when we see this transaminitis, we see it early on, but we also get a pretty quick resolution with sort of dose de-escalation. And by two months, most of these patients have sort of had that resolved. But if it hasn't resolved or continues rising, that's when an alternative sort of medication might be a better option for these particular patients.
Christopher M. Pieczonka, MD: Yeah, you know, that I think that that's really interesting because I'm thinking about, in my own practice, what happens. And I think I probably self-select for the people who might have liver issues to start with. So you would ask that question earlier about somebody who has some sort of fatty liver disease or, you know, hepatitis or something. That's probably the person that maybe you don't do abiraterone on. And I have the same kind of feedback from my practice that I don't think I've ever had somebody with jaundice. The number of patients are few and far between that can't be dose reduced. You know, I think for a lot of people who may have some sort of fatty liver issue or something that if you settle in on kind of the half dosing or the three-quarter dosing, that might be the right dosing for them. And that seems to be pretty consistent. And I think one of the things that, you know, I think it should be emphasized is that a portion of the dosing may be the right dosing for the patient and the way thatthey metabolize the drug, they're effectively getting 100% dosing with taking part of the medicine. So, back to the conversation we had about the low-fat diet, where even if you're taking a 250 or so, you're going to get that sort of therapeutic effect in the bloodstream. And I think I'm getting a little bit more comfortable with the fatty liver disease because I see so much of it. And there are only so many options we have. So, you know, we want to treat these patients, but we also want to extend their life, but it's also ensuring that when we are treating them, we're kind of really keeping in the back of our mind that we don't forget that they have fatty liver disease, that they have these comorbidities that might make them have a potential issue with any liver dysfunction or transaminitis.
*Video transcript AI-generated and reviewed by Urology Times® editorial staff.
