Charles Ryan, MD: The Side Effects for Prednisone in Combination With Abiraterone

Are there any side effects for prednisone in combination with abiraterone that are concerning for these patients?

The general side effect profile of abiraterone is fluid retention, hypertension, and potentially electrolyte abnormalities. And elderly patients, because of maybe a reduced cardiovascular reserve or other comorbidities, are simply more likely to have cardiovascular toxicities from anything that would cause fluid retention. So I would say that, for the elderly patient, we need to be particularly concerned about monitoring their cardiac status, their fluid status. Even, for example, having a patient weigh himself once a week or something like that at home is important because that’s probably the most sensitive indicator of whether fluid retention is occurring. And so when I see a patient, elderly or not, I will examine them for fluid retention, edema, pedal edema, and those types of things. If I notice a sudden or a drastic weight gain, or if I notice rales in the bases of their lungs, that would be something that would prompt me to think that they might need, for example, a diuretic or other approaches that could reduce the fluid retention.

The other issue is that it is safe and reasonable to reduce the dose of prednisone from 10 mg or 5 mg twice a day to 5 mg daily if a patient is experiencing prednisone-specific side effects. That obviously can be done, but monitoring needs to continue after that is done as well.

CASE: Metastatic Prostate Cancer (Part 1)

Stanley S is an 83-year-old Caucasian male whose past medical history includes diagnosis of adenocarcinoma of the prostate in 2012 with no evidence of metastasis. At the time, he was started on bicalutamide and his serum PSA levels subsequently decreased to 1.2 ng/ml.

During his most recent follow-up exam, the patient complained of intermittent back pain and increasing fatigue.

• His serum PSA level is 56.9 ng/ml and his alkaline phosphatase is 258 U/L
• CT scan shows enlarged lumbar bone metastasis with associated soft tissue component, as well as symptomatic nodes with lumbar bone metastases
• Biopsies of the prostate and transrectal ultrasound reveal the prostate is 42 grams
• Ten of 14 cores are positive for prostate cancer for a Gleason score of 8 (4 + 4)
• His ECOG performance status score is a 2