In this episode, Dr. Christopher M. Pieczonka and Dr. Jose De La Cerda explores the differences in dosing and administration of abiraterone acetate products, including the impact of food effects, and optimizing therapy for special populations with comorbidities like diabetes, hypertension, and obesity. They share insights from their clinical experience on patient compliance, tolerability, and quality of life improvements with micronized abiraterone.
Christopher M. Pieczonka, MD: What's your take about somebody adhering to a low-fat meal when they're taking their pills? I mean, are you pretty sure that they're not gonna run into a problem? And the fault to that would be what if somebody doesn't have a low-fat meal and they have a huge fat meal and they take the original abiraterone? What's your concern with that?
Jose De La Cerda, MD, MPH: I live in San Antonio. So a low-fat meal is not really low-fat in San Antonio. I think that's one of the biggest things that's an issue here. I mean, obesity is a real problem. Diabetes, hypertension, CAD, and all these go hand in hand with cardiovascular comorbidities. And any patient that's on ADT or an NHD or any other agent or therapy for prostate cancer already has a higher risk of a MACE event. So one of the things that we harp on and we kind of ensure is that all these comorbidities are being sort of taken care of by their primary care physician, that they're maximizing their glucose controls or cardiac health around a low weight-bearing exercise program. Ensuring that low fat is truly a low-fat meal, something that's standard breakfast, a standard lunch without the risk of having a lot of these comorbidities get uncontrolled, especially the diabetes and obesity. We see a whole lot of that down here, and it's tough to deal with.
Christopher M. Pieczonka, MD: Yeah, and I think, you know, we haven't experienced that yet, what I've found is I think a request would you be willing to do that by the different PBMs and so I haven't been forced into doing that yet, but I share the same concerns. I would worry that people are not going to follow the regimen for a diet. People are going to want to live their lives, they're going to go out with their family, who knows what, holidays, etc. And I think that the concern with taking it with more than a low-fat diet would be effective overdose, that might be, maybe that's the right term, but the right concept that the amount of abiraterone that comes into the bloodstream when you're taking it with a high-fat meal shoots way up, and arguably, the side effect profile might be higher. What I really worry about would be like hypokalemia or something that might develop. So that's really sad that you're being forced into that by the pharmacy managers.
Jose De La Cerda, MD, MPH: Oh yeah, absolutely. That's why I personally, if possible, and I can use something that's easy to take, like the non, excuse me, like the micronized version, the micronized version of abiraterone, and I find that it's just kind of patients can incorporate it easier into their lifestyle with their regular diet, with their routine, and that might kind of at least keep this sort of plateau or stability of the concentration of the drug within their bloodstream.
Christopher M. Pieczonka, MD: So is there anyone that you would not consider the micronized version? Is there any medical condition that you think that you might want to use the sort of the original version?
Jose De La Cerda, MD, MPH: Couple of them. You know, if anybody with a history of Cushing's or adrenal insufficiency, I'd try to avoid it just because I don't want to be dealing with the electrolyte dysfunctions. Other slight populations where I would avoid would be those that have moderate to severe hepatotoxicity. If you look at the drug labels, you can probably get away with doing half doses, but I think there are just so many other things that go into sort of liver dysfunction, including other concomitant meds and SIP, three interactions and things like that that I just want to mitigate those altogether. So I might just avoid that altogether. And just to ensure that I'm checking that LFT is kind of frequent if I am placing somebody on this. Do you often give them, if they have any liver disease or liver mets, anything of that nature?
Christopher M. Pieczonka, MD: Yes, good point. I think that you're talking about who may not give it to, that's one. I think the other thing that, you know, I'm pretty fastidious in my practice about checking the blood work a la... the label, and it's very tempting to maybe fall a little bit far from the tree where you may have a desire for the patient to be seen less frequently. And I think with the micronized version of abiraterone, arguably you should continue to check blood work monthly, you know, once you get past the initial sort of treatment. In my neck of the woods, we have snowbirds. So people this time of year or right around the holidays end up heading south... they usually go to Florida for a couple of months. And it's a little challenging to kind of get their monitoring done if they're not on-site here. So that's more of a practical thing, not so much a medical thing. And the other thing that I would tell you that I get leery about is not so much of the refunction testing issue, but I worry about hypokalemia. Particularly if somebody's on a non-potassium solution... diuretic of some sort, if they're on Lasix. And, you know, I think the number of people that have hepatic dysfunction in, you know, because I don't think you're really getting into trouble with hepatic dysfunction right away, but you can get really burned if somebody has bad hypokalemia. You know, so, so those are kind of for me a couple of things that I think about when choosing the type of novel hormonal agent. I don't think that there's any literature to say that the micronized version is better than the original version as it relates to those side effects or toxicity. I think they're kind of, you know, along the same, the same things.
Christopher M. Pieczonka, MD: But are there other, you know, you touched on something in terms of, you know, Cushing's, and I wanted to kind of get your take on fluid overload and whether or not, you know, how does that play into your mindset when you're using or thinking about abiraterone, the micronized version for your prescriptions on your patients. If you could just walk me through...
Jose De La Cerda, MD, MPH: Yeah, so, you know, a lot of these patients that come in, you know, two plus pitting edema, they're going be on some sort of potassium-wasting diuretic. Hypokalemia is a big concern that you want to ensure is not occurring, especially with the addition of something like abiraterone. The two-week visits when you initially start can be challenging, and it's hard to incorporate that into your schedule. So making that happen, seeing patients every two weeks, and ensuring that they're not losing their electrolytes and that everything remains stable is essential. One way to assist with this is by involving advanced practice providers (APPs) who can help schedule these visits. They work alongside you, seeing these patients and monitoring their progress. At the same time, they conduct early work to ensure that patients are not losing any of their electrolytes, particularly potassium, during that time. However, not all practices have APPs, and that's where it gets challenging. When you're dealing with patients with advanced disease, metastasis, and the potential for edema and other issues, you need to be aware of the medications they are taking and potential drug interactions. This underscores the importance of medical assistants (MAs) obtaining a comprehensive medical history when patients walk in and documenting any new medications they might be taking. This way, you can identify and address potential interactions and ensure comprehensive care for the patient, not only treating their cancer but also considering the whole patient and minimizing the risk of worsening toxicity alongside their existing disease.
*Video transcript AI-generated and reviewed by Urology Times® editorial staff.