Practice Update: Oncology

Q & A 28

Managing mineralocorticoid excess in mCRPC: data review and clinical recommendations Interview with Neeraj Agarwal MD

Dr Agarwal, a specialist in genitourinary cancer, is Associate Professor of Medicine in the Division of Oncology at the University of Utah School of Medicine in Salt Lake City, where he is also the Director of the Genitourinary Oncology Program.

Farzanna Haffizulla MD, FACP, FAWMA, who practices general internal medicine in Davie, Florida, discusses Dr Agarwal’s work with eplerenone in managing mineralocorticoid excess in mCRPC.

Dr Haffizulla : Dr Agarwal, you have previously pub- lished work related to eplerenone in managing mineralocorticoid excess in patients with metastatic castration-resistant prostate cancer after they receive abiraterone. Can you tell us a little bit more about the rationale for some of this work? Dr Agarwal: Absolutely. Abiraterone, as we know, is approved by FDA to be used along with prednisone. That’s how most of the abiraterone trials were done. However, many patients have concerns about long- term use of prednisone, which is a corticosteroid, as you know. Patients who have received prior immu- notherapy drugs, they’re also very concerned about

using corticosteroids for a long time, so why we use prednisone with abiraterone is because abiraterone can cause increased mineralocorticoids, such as aldosterone, causing fluid retention, low potassium, hypertension, and so on. So, how could we have avoided prednisone and still block these side effects. The answer is use a drug which can antagonize high aldosterone, which is eplerenone. The advantage of eplerenone over more traditional antagonists for aldosterone, such as spi- ronolactone, is that it is a nonsteroidal antagonist, so in theory it doesn’t stimulate prostate cancer cells. So, I think that was the rationale behind using eplerenone with abiraterone. And we saw that it was very safe, and we were able to avoid prednisone in these patients. I think it’s a very attractive option for our patients to be able to use abiraterone without using prednisone. Dr Haffizulla: That’s a wonderful option, absolutely. Well, I want to thank you so much for sharing your expertise, and perspective, and for bringing all of this vital infor- mation to us at PracticeUpdate.

Management of aggressive prostate cancer variants

Ana Aparicio MD, Associate Professor at the University of Texas MD Anderson Cancer Centre, shares her management strategies for aggressive prostate cancer. Go to www.practiceupdate.com to watch the full interview.

Dr Haffizulla practices general internal medicine in Davie, Florida, within her own internal medicine concierge practice.

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