potent
Prednisone—4 times more potent than hydrocortisone
Prednisolone—5 times more potent than hydrocortisone
Methylprednisolone—5 times more potent than hydrocortisone
Dexamethasone—most potent, 30 times more than hydrocortisone
Advantages These drugs are simple to take and have a good safety record.
The catch These drugs serve largely to reduce the side effects of some secondary hormonal drugs (ketoconazole or abiraterone) and chemotherapy drugs. They also suppress the immune system.
What else do I need to know? These medications have at least some anti-prostate cancer effect, probably by lowering adrenal androgen production. They have not received a lot of attention compared to the other secondary hormone therapies because they do not appear to be as effective or have an impact that lasts as long as the other therapies. Regardless, it is important to know that they at least have some impact. There does not seem to be an advantage to using one specific corticosteroid drug or dosage as compared to another, but check with your doctor on the latest research.
ESTROGEN
Also known as DES, estradiol, or by multiple generic names.
How is it taken? pill, patch, or injection.
Dosage Various doses based on the drug and situation.
Advantage Usually inexpensive, and it also has a role in reducing hot flashes and preventing bone loss in very small dosages.
The catch It increases the risk of several cardiovascular problems, particularly blood clots, so the drug is usually given with a prescription blood thinner. It also can cause breast pain and enlargement and fluid retention. The higher the dosage, the higher the risk of serious side effects.
What else do I need to know? The “female” hormone estrogen has been used for more than 50 years to treat prostate cancer. In some countries, it is still used to lower testosterone levels and function as an androgen deprivation treatment (ADT) instead of LHRH therapy. However, in most countries, LHRH drugs replaced estrogen many years ago because estrogen has serious cardiovascular toxicity (blood clots, edema, high blood pressure) in higher doses, especially as an oral drug.
Some doctors still use estrogen for two purposes in treating prostate cancer. First, as mentioned above, it can be used to treat side effects of ADT, such as hot flashes, bone loss, and perhaps even cognitive changes. Secondly, research has shown that estrogen can reduce adrenal androgens, and it also may directly kill some HRPC cells. Lower doses of estrogen seem to cause fewer side effects, and there are now several drugs to reduce these side effects if they still occur. For example, there are blood pressure medications, diuretic drugs, and blood thinners that can reduce the risk of most of estrogen’s side effects.
Newer delivery systems make it easier for some patients to use estrogen, and they may also reduce side effects. For example, some patients use an estrogen patch (estradiol transdermal patch) to reduce hot flashes. The patch appears to reduce the risk of blood clots by bypassing the liver’s ability to increase the clotting production that usually occurs when exposed to oral estrogen.
However, overall, the oral form of estrogen is still very popular as a secondary hormone treatment. One of the most popular is diethylstilbestrol or DES. This drug is quite inexpensive and is prescribed in a range of doses (less than 1 mg to 2 or 3 mg/day). Most doctors prefer patients to be on a prescription blood thinner, such as Coumadin (warfarin), to counteract the blood clotting concerns.
Other notable side effects of estrogen are breast pain (mastalgia) and breast enlargement (gynecomastia). These conditions can mostly be prevented by taking an oral (pill) dose of tamoxifen daily, or more simply by getting a dose of radiation to each breast (just once, taking seconds). Some studies suggest that oral tamoxifen daily is a little more effective at preventing breast pain and enlargement as compared to radiation, but radiation works with just a single treatment. Regardless, there are many issues to consider if you and your doctor decide that estrogen is an option for you in preventing ADT side effects or as a secondary hormonal treatment.
There are also other estrogen-derived treatments that you may hear about, and they are just as effective as DES for cancer treatment or for treating side effects. Several common ones are listed below:
• EMCYT (pill, also known as estramustine phosphate)
• Ethinyl estradiol (pill)
• Estradurin (injectable, also known as polyestradiol phosphate)
• Fosfestrol (pill)
• Vivelle-Dot and others (patch)
FIVE-ALPHA REDUCTASE INHIBITORS (5AR INHIBITORS)
Also known as 5AR inhibitors, finasteride, and dutasteride (brand name Avodart).
How is it taken? pill.
Dosage A single pill, taken daily. There are two options, namely finasteride (dosage 5 mg per day) and dutasteride (dosage 0.5 mg per day).
Advantages Easy to take, with minimal side effects. Finasteride now has a generic option, but dutasteride remains in your body for a longer time (a 5-week half-life) as compared to finasteride (an 8-hour half-life). Therefore, it is possible to take dutasteride just once a week (or simply not daily), save money, and still potentially get the same benefit.
The catch With these drugs, reductions in sex drive and overall sexual function are possible, as are breast tenderness and enlargement. Hot flashes and liver toxicity are also potential side effects. A recent large study of prostate cancer prevention regimes found that dutasteride slightly, but significantly, increased the risk of heart failure as compared to a placebo. This possible side effect needs to be further investigated to be sure that it is an actual concern.
What else do I need to know? These medications, particularly dutasteride, are receiving a lot of attention in the area of prostate cancer prevention and beyond. The drugs have been shown to reduce the risk of non-aggressive prostate cancer, but could rarely increase the risk of an aggressive tumor. Still, these drugs (especially dutasteride) have been tested for men on active surveillance (REDEEM clinical trial) and for men with a rising PSA after localized treatment (ARTS clinical trial), with beneficial results and some controversies. Discuss those results with your doctor.
Over the past several years, a small study of men with a rising PSA after localized prostate cancer treatment showed interesting results. These men did not have HRPC, but they were hormone sensitive and did not go on LHRH injections. Men took twice the daily dose of finasteride (10 mg total daily) and an anti-androgen (flutamide at 125 mg twice a day). They were compared to a group of men taking just flutamide. The researchers found greater PSA reductions and a lower chance of disease progression in the combination group (finasteride and flutamide) as compared to those taking flutamide alone. The side effects experienced by the groups were similar. This suggests that a combination approach using the 5-alpha reductase inhibitor may be a potential option in the future, even for some men with HRPC.
HIGH DOSE ANTI-ANDROGEN REPLACEMENT
Also
