What is Lupron?
Let's go over some basics of Lupron and why it would be prescribed to you
So for the purpose of this post, I’m gonna talk about Lupron in the context of prostate cancer. Now, I’m picking Lupron (leuprolide acetate) because that is what Dr. Jafri’s office has but there are many cousins of Lupron and your urologist may prescribe a different shot. These are all in the class of LHRH agonists.
Lupron is a shot that you get in the office. The purpose of this shot is to lower testosterone levels in the body and comes in different formulations that can be given at 1 month, 3 month, 4 month, or even 6 month intervals.
Why would I be getting this prescribed to me?
Alright, in general there are three indications for Lupron
- In combination with radiation therapy
- When there is concern that prostate cancer has come back based on your PSA level
- When there is concern that prostate cancer has spread or metastasized
Why do I need Lupron if I am getting radiation treatment?
Sometimes based on your stage or level of prostate cancer, the radiation oncologist and urologist will recommend a course of hormone therapy, or Lupron shots, in combination with the radiation therapy. If you want more information about radiation treatment in general, click over here.
The reason for this is that there have been, in certain instances, a survival benefit with the addition of Lupron shots to the radiation. The addition of Lupron to your radiation may be recommended based on your stage. For intermediate-risk prostate cancer, you may be recommended hormone treatment for 6 months. For high-risk prostate cancer, this may be recommended up to 2 years.
This is why I tell my patients that when you see the urologist you need to make sure you know exactly how long this treatment is recommended for because they sometimes forget and extend the treatment unnecessarily.
When would I need to start Lupron if my PSA has risen after treatment?
Now let’s look at #2 on the list. After prostate cancer treatment, we should see a response in the PSA level.
Let’s look at how we define cure between treatment with a prostatectomy versus radiation because the PSA response is different.
- After prostatectomy: your PSA should become undetectable or less than 0.1.
- After radiation: your PSA will go down to a nadir or bottom level. This level is different for each patient. Failure after radiation therapy is a PSA that is your “nadir +2”.
After a prostatectomy, we want that level to be less than 0.2 or even 0.1. You will commonly hear the word “undetectable”. If that number ever rises, then there is concern that there could be prostate cancer cells back.
After radiation, the way we interpret the PSA level is different because the prostate is still there. The PSA level commonly doesn’t get all the way down to 0.1. If the PSA rises above these levels, we call this biochemical recurrence, which basically means that from a bloodwork standpoint there is a concern that the prostate cancer has recurred or come back.
Let’s talk about radiation treatment and the PSA response in a little more detail. Even though the PSA oftentimes doesn’t go down less than 0.1 after treatment, that is not usually a big deal, it just means that there is some normal prostate tissue still left behind that is producing the PSA. So, the PSA number will typically go down slowly until it reaches a nadir, or a low point.
For example, for patient John Doe we can sometimes see the PSA after radiation over the course of a year or so to go from 5.7 to 1.4 to 0.4 to 0.9. Now in this example his PSA nadir is 0.4 because that is his lowest level. Even though the PSA for his last level went up to 0.9, we don’t worry about this because the rise is not enough to define recurrence. So for Mr. Doe, we would say that he has ‘biochemical recurrence’ when the PSA is 2 points greater than nadir or in this case when the PSA goes above 2.4.
When we see biochemical recurrence, this will not always indicate the need to start Lupron. Oftentimes, the urologist will calculate what is called the PSA doubling time. This is a number showing how quickly the PSA doubles and the shorter the number, the more concerning it is.
In this instance, if the PSA is going up to fast, the urologist will often consider starting Lupron. Now to be clear, this medicine doesn’t prolong life in this setting. But it can help manage the prostate cancer and delay potential side effects.
Why would I need Lupron if there are signs of prostate cancer spread or metastasis?
In the last instance, there has been documented signs of prostate cancer spread. This is termed metastatic prostate cancer. There have been loads of new treatments that are now available to treat this.
However, the backbone of all those treatments includes the use of Lupron shots. Sometimes, the Lupron shots will be given alone, but now, most of the time, we will give the Lupron in combination with some other treatment.
There are many patients who have been on Lupron and the PSA has started to climb and/or there are signs of spread that have developed. Even if you are started on other treatment, we will still continue the Lupron. Now why is this? This is due to the fact that as mentioned above, Lupron is the backbone of all other treatments. Even though the cancer is not completely responding to the Lupron treatment, there is still a role for it as there are cancer cells that are being affected by the Lupron shot.
How will I feel after the treatment?
Well let’s take a step back. Your urologist will really need to evaluate your situation carefully. In some instances, it is NOT appropriate to start you on Lupron right away. Lupron is a LHRH agonist. This means it is a gonadotropin hormone releasing hormone agonist. An agonist is something that turns a process on.
In this instance, the Lupron is actually turning on the testosterone production pathway. Now, if you were paying attention above I told you that we give Lupron to lower testosterone but now I’m telling you its function is to raise testosterone. What the heck, this is so confusing. I know, I know. Imagine how I felt in medical school trying to learn this.
So even though this turns on the testosterone production pathway, it disrupts the normal process that the body has for this. So over time, by messing up the process, it shuts the system down.
Now, why is this important to know. The reason this is important to know is that for some patients Lupron can temporarily make things worse—flare. So for patients with prostate cancer that has spread to critical places, like the spine bones or hip bones, we will need to give a different medication temporarily to help blunt this effect for a couple weeks. So sometimes you doc will prescribe a different kind of prostate cancer medication—bicalutamide, flutamide, etc—for several weeks before you get your shot.
People overall react to the medication differently. The most bothersome potential side effect is hot flashes and happens about 50% of the time. There are medications that can help lessen this side effect and anecdotally I see this become less bothersome as patients get used to the medication.
Are there other side effects?
Oh boy, yes. Now remember we are talking about a medication to treat cancer. So there are several other side effects to discuss.
Diabetes and other cardiovascular diseases
Being on Lupron can increase the risk of high blood sugar, the development of diabetes, and the development of a heart attack or stroke. This is why its really important to followup with your primary care physician to keep a close eye on these things. This is also why your other medical history will factor into the decision about whether to even start Lupron in the first place.
Sexual Side Effects
Now all prostate cancer treatment will affect the quality of your erections. But Lupron will significantly lower your sex drive or interest in sex.
Bone health
Lupron can lead to the development of osteoporosis. Periodically, the urologist will order a DEXA scan which is a nuclear medicine test to evaluate for osteoporosis. Calcium supplementation is controversial but I do recommend all my patients on Lupron to supplement with vitamin D. There are also bone health medications that can be given via an injection or an infusion and you can ask your urologist if this would be beneficial. These are all important, because being on Lupron increases your risk of a fracture. So its important to get in the sun and get natural vitamin D as well as to stay relatively active to make sure your overall bone and muscle health is strong.
Body changes
When you are on Lupron for an extended period of time, this will cause testicular atrophy or shrinkage. Sometimes patients will get headaches or joint pains.
The Dr. Jafri Wrapup
So this is a general overview of Lupron and why it may be a cornerstone for your prostate cancer treatment. If you have more questions, please review with your urologist or ask your pharmacist.
Click here if you want to see the full prescribing information for Lupron.
Lupron (or other hormone shots) are frequently given as a part of your prostate cancer treatment and it is important to understand why it is given as well as what side effects that you might have. Make sure to ask your urologist how they are going to follow your symptoms, if there are any lifestyle changes that he/she recommends for you, and also how long do they anticipate that you will need that treatment.