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Casodex with Lupron?

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Posted 12/29/2016 12:13 PM (GMT -5)
Thanks to all who have shared advice with us this week. In looking at threads and your treatment descriptions I see that many (most?) have taken casodex with lupron. John wasn't given casodex when he got the lupron. Is there literature or advice on this? I asked the med onc about this before J's last taxotere appointment but didn't get an adequate response.

thanks - and here's to 2017 being a whole lot better than 2016! Tamara
Posted 12/29/2016 1:01 PM (GMT -5)
I'm sure there is literature on it.

Maybe google can help.

When I go on HT (I am currently off for another month), I take Casodex (1 50 mg tablet daily) for 2 weeks before the Lupron shot. This prevents a flare. The problem with Lupron is that the body's immediate reaction to it is to produce MORE T. This can cause an increase in the PC, especially if it is in the bones, and result in some damage/pain. Anyway, I have to stay on the Casodex, in addition to the Lupron. The Lupron prevents the testicles from producing T. The Casodex prevents the PC receptors from taking in the T. Hence, they work together and help on two fronts. Of course, the SE increase, too.

I am sure some more knowledgeable than I can comment on the above. I think I've explained it correctly.

Are you seeing an MO specializing in PC?

Mel
Posted 12/29/2016 9:58 PM (GMT -5)
No one is sure if adding Casodex at the start of Lupron therapy really does anything. The way Lupron works is by forcing the testes to produce a huge increase in testosterone. That causes the pituitary gland to shut them down entirely by a process called negative feedback. If there are many painful metastases, the extra testosterone might cause them to grow and become more painful for a little while. Others argue that the androgen receptors on the metastases are already saturated with testosterone, so it doesn't matter if the testosterone level goes up for a few days - the important thing is that it soon drops to very low levels.
Posted 12/29/2016 10:14 PM (GMT -5)
TA:

Thanks for clarifying the mechanism. But you said:

>>>>>>>>>>>>>>>>>>
No one is sure if adding Casodex at the start of Lupron therapy really does anything.
>>>>>>>>>>>>>>>>>>>

Are you referring to the flare of using Casodex with Lupron (ie: ADT2)

Mel
Posted 12/29/2016 10:27 PM (GMT -5)
I mean that no one is sure if it accomplishes any benefit to take Casodex at the start of Lupron therapy. Most doctors add it for a brief period - 1-2 weeks at the start. Of course, Firmagon directly lowers testosterone without causing a testosterone flare first, so Casodex is unnecessary. In fact, some start patients on Firmagon and migrate them to longer lasting Lupron injections.

It's also true that the benefit is unclear for keeping patients on both Lupron and Casodex for extended periods. I think most MOs wait to see if Lupron alone gives an excellent PSA response before adding Casodex. Some docs only prescribe Casodex. There are probably as many ways to give hormone therapy as there are doctors who give it. I think it's a good idea to see how each patient responds.
Posted 12/30/2016 3:38 PM (GMT -5)
I started on Lupron alone, for 2 months before radiotherapy. After six weeks, it had dropped down to less than 1.0, but we'd hoped for lower by then. We finally added Casodex to be more aggressive. Due to the G9 5+4 situation, and the wild mustang character of such a preponderance of Grade 5 cells, I just stayed on both Lupron and Casodex for nearly 3 years. My PSA was undetectable the whole time from the end of radiation therapy.

Whether adding Casodex in this situation is useful or not seems unproven, but we wanted to hit it as hard as we could. My insurance is good, but otherwise even the generic bicalutamide version of Casodex was $500/month. At $6000/year, you want to only prescribe something useful, but it's just not apparently a well proven protocol.
Posted 12/30/2016 3:52 PM (GMT -5)
Redwing:

I remember when I first got on Casodex, I had to go through some hoops for my insurance to approve it. At that time, I had a cadillac plan and my cost was $10 for 90 days. I think now it's $40 for 90 days. But when I was unsure if my insurance will cover it, I really shopped around. There were huge differences in prices. I think the highest was maybe $900 for a month. The cheapest was at Costco, if you had some kind of super membership. That Costco price was $250 or so, and the nearest Costco was about 100 miles away! Second was Sam's Club, but again I would have had to upgrade to a premium membership.

I'm hoping that my newer MediCare Advantage Plan does not give me a hassle with my probable upcoming Lupron shot at Dr. Lam's office and my upcoming probable SBRT!

Mel
Posted 12/30/2016 8:41 PM (GMT -5)
My take is that adding Casodex to Lupron-based hormone therapy serves no purpose when the testosterone is at castrate level.
Posted 12/31/2016 11:39 AM (GMT -5)

Sr Sailor said...
My take is that adding Casodex to Lupron-based hormone therapy serves no purpose when the testosterone is at castrate level.

Maybe. They work on two very different principles, and may have some benefit in parallel. It's not just testosterone suppression.

A good analogy might be Lupron sucks the air out of the room, while Casodex strangles the bad guys. So, is strangling any use if there's no air? Depends on just how little air there is, perhaps.
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