What is the best approach to manage severe drenching night sweats in a 78-year-old male with metastatic recurrent prostate cancer on Lupron (leuprolide) every 3 months, Zytiga (abiraterone) and prednisone daily?

Management of Severe Night Sweats in Metastatic Prostate Cancer Patient on Endocrine Therapy

The most effective approach for managing severe drenching night sweats in this 78-year-old male with metastatic prostate cancer on Lupron, Zytiga, and prednisone is to consider adding a non-hormonal pharmacologic treatment such as an antidepressant, anticonvulsant, or neuronal inhibitor, as these are recommended first-line interventions for vasomotor symptoms in cancer patients on hormonal therapy.

Understanding Night Sweats in Prostate Cancer Patients

Night sweats are a common menopausal-like symptom experienced by approximately 50-80% of men on androgen deprivation therapy (ADT) such as Lupron 1. These symptoms can significantly impact quality of life and may persist throughout treatment.

Current Treatment Regimen Analysis

• Patient is on Lupron (leuprolide) - an LHRH agonist causing testosterone suppression
• Zytiga (abiraterone) - blocks androgen synthesis
• Prednisone - required with abiraterone to prevent mineralocorticoid excess

This combination therapy is standard for metastatic castration-resistant prostate cancer (mCRPC), but the profound hormonal suppression contributes to vasomotor symptoms like night sweats.

Management Algorithm for Night Sweats

Step 1: Evaluate for Other Causes

First, rule out other potential causes of night sweats:

• Disease progression
• Infection
• Thyroid dysfunction
• Medication side effects beyond hormonal therapy

Step 2: Non-Pharmacologic Interventions

• Sleeping in a cool environment
• Moisture-wicking bedclothes and sheets
• Avoiding triggers (spicy foods, alcohol, caffeine)
• Light, layered clothing

Step 3: Pharmacologic Interventions

First-Line Options:

1. Non-hormonal pharmacologic treatments 1:
   • Antidepressants (SSRIs/SNRIs): Venlafaxine 37.5-75mg daily or Paroxetine 7.5-20mg daily
   • Anticonvulsants: Gabapentin 300-900mg daily (divided doses)
   • Neuronal inhibitors: Clonidine 0.1mg daily

Alternative Options to Consider:

1. Modification of current therapy:

   • Consider switching from prednisone to dexamethasone 0.5-1mg daily while maintaining abiraterone 1
     • The SWITCH study showed this approach improved symptoms in some patients with mCRPC
   • Ensure optimal dosing of current medications

2. If symptoms persist and significantly impact quality of life:

   • Consider discussing with oncologist whether adding enzalutamide instead of abiraterone might provide better symptom control, though this would require careful consideration of disease status and prior treatments 1

Important Considerations and Caveats

• Do not discontinue current cancer therapy: The primary goal remains cancer control, and the current regimen (Lupron + Zytiga + prednisone) is a standard approach for metastatic prostate cancer 1.

• Avoid hormonal treatments for night sweats: Estrogen-based therapies that might help with vasomotor symptoms are contraindicated in hormone-dependent cancers like prostate cancer 1.

• Monitor for drug interactions: When adding medications like antidepressants, be vigilant about potential interactions with the patient's current regimen.

• Regular reassessment: Night sweats may change in intensity over time with disease progression or treatment response, requiring periodic reassessment.

• Quality of life focus: Given the patient's age and metastatic disease status, interventions should prioritize comfort and quality of life alongside disease control.

By following this approach, the severe night sweats can likely be managed while maintaining effective cancer treatment, improving the patient's quality of life during his ongoing therapy for metastatic prostate cancer.