What is the appropriate workup for an 86-year-old male with chronic obstructive pulmonary disease (COPD), hypertension (HTN), hyperlipidemia (HLD), hypothyroidism, and prostate cancer, presenting with hot flashes, diaphoresis, and imbalance while walking, who recently started Xtandi (enzalutamide) and has fluctuating blood pressure readings, ranging from normal to elevated?

From the Guidelines

For this 86-year-old male with multiple comorbidities, I strongly recommend a comprehensive workup focusing on both his new symptoms and chronic knee pain, prioritizing his morbidity, mortality, and quality of life. Given his complex medical history, including COPD, HTN, HLD, hypothyroidism, and prostate cancer, it is crucial to consider how each condition and its treatment may be impacting his current symptoms. The patient's symptoms of hot flashes, sweating, and feeling off-balance with brisk walking, which started around 6 months ago, coincide with the initiation of Xtandi (enzalutamide) for his prostate cancer. This temporal relationship suggests that these symptoms could be side effects of the medication, as enzalutamide is known to cause hot flashes, fatigue, and dizziness by blocking androgen receptors 1.

Initial Assessment and Laboratory Tests

• Obtain orthostatic vital signs to assess for postural hypotension that might explain his balance issues.
• Laboratory tests should include:
  • Complete blood count
  • Comprehensive metabolic panel
  • Thyroid function tests (particularly TSH and free T4) to evaluate his hypothyroidism management
  • PSA levels to monitor his prostate cancer

Management of Symptoms and Conditions

• For his blood pressure variability, a 24-hour ambulatory blood pressure monitoring would help determine if medication adjustments are needed.
• Regarding his worsening knee pain, order weight-bearing knee X-rays to assess for osteoarthritis progression or other structural changes.
• Consider physical therapy referral for gait assessment and balance training to address his unsteadiness.
• While the patient should continue Xtandi as recommended by oncology, symptomatic management of hot flashes might include low-dose venlafaxine (37.5mg daily) or gabapentin (300mg at bedtime) 1.
• Discuss with his oncologist about possible dose adjustments if symptoms significantly impact quality of life.
• For knee pain, consider topical NSAIDs like diclofenac gel 1% applied to the affected knee four times daily to minimize systemic side effects in this elderly patient.

Considerations for Prostate Cancer Management

• The recent guideline update from the Journal of Clinical Oncology 1 suggests that ADT plus enzalutamide should be offered to men with metastatic noncastrate prostate cancer, which aligns with the patient's current treatment plan.
• It is essential to weigh the benefits of continuing Xtandi against the potential side effects and impact on quality of life, considering the patient's age and comorbidities.

By taking a comprehensive approach to this patient's care, focusing on both the management of his prostate cancer and the mitigation of side effects from his treatments, we can optimize his morbidity, mortality, and quality of life outcomes.

From the Research

Patient Presentation

The patient is an 86-year-old male with a history of COPD, HTN, HLD, hypothyroidism, and prostate cancer, presenting with complaints of hot flashes, sweating, and feeling off-balance with brisk walking for 6 months. He also reports variable blood pressure readings at home.

Medication Review

The patient is currently taking Xtandi (enzalutamide) for prostate cancer, which has been associated with improved overall survival in men with castration-resistant prostate cancer 2, 3. However, enzalutamide has also been linked to an increased risk of hypertension 4.

Symptom Evaluation

The patient's symptoms of hot flashes and sweating could be related to his prostate cancer treatment or other underlying conditions. The feeling of being off-balance with brisk walking may be related to his chronic knee pain or other factors.

Workup

Based on the patient's presentation and medication review, the following workup may be considered:

• Monitor blood pressure regularly to assess for hypertension, given the increased risk associated with enzalutamide 4
• Evaluate the patient's prostate-specific antigen (PSA) levels to assess for disease progression, as changes in PSA can inform treatment decisions 5
• Consider a comprehensive patient history to gather relevant information and inform diagnosis and treatment 6
• Assess the patient's chronic knee pain and consider ordering an x-ray to evaluate for any underlying conditions that may be contributing to his symptoms
• Evaluate the patient's balance and gait to determine if there are any underlying factors contributing to his feeling of being off-balance with brisk walking.

Differential Diagnosis

The patient's symptoms and presentation could be related to various underlying conditions, including:

• Hypertension, given the variable blood pressure readings and increased risk associated with enzalutamide 4
• Prostate cancer progression, given the patient's history and symptoms 2, 3, 5
• Chronic knee pain, given the patient's history and symptoms
• Other underlying conditions, such as COPD, HTN, HLD, or hypothyroidism, which could be contributing to the patient's symptoms.