Initiating ADT: Factors to Consider

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When initiating androgen deprivation therapy (ADT), multiple pharmacologic and clinical factors must be considered to optimize patient outcomes. The mechanism of action differs significantly between oral and injectable formulations, with oral relugolix providing immediate testosterone suppression compared to the delayed effect of injectable agonists. Treatment frequency and delivery method present distinct advantages: While some patients prefer quarterly or semiannual injections to avoid daily pill-taking, others value the control and convenience of oral therapy.

Cardiovascular risk assessment has become increasingly important in ADT selection, with the HERO study demonstrating a 50% reduction in major adverse cardiovascular events in patients with predisposing cardiovascular risk factors who received relugolix compared to leuprolide. This finding is particularly relevant given that ADT is associated with multiple metabolic adverse effects including dyslipidemia, weight gain, bone loss, and cardiovascular complications. For patients with existing coronary artery disease, hypertension, diabetes, or smoking history, the cardiovascular benefit of oral ADT may be a decisive factor.

Patient preference plays a crucial role in treatment selection, with adherence data from the HERO study showing high compliance rates with once-daily oral therapy. The ability to initiate treatment through virtual visits or pharmacy consultation, combined with the reversibility of oral agents, provides patients with greater autonomy over their treatment. The rapid onset (50% of patients achieving castrate levels within 4 days) and quick recovery (testosterone normalization within 30 days of discontinuation) offer significant psychological benefits for patients concerned about long-term commitment to ADT.