LDH Levels of Concern in Pluvicto Treatment for Prostate Cancer
Elevated LDH above the upper limit of normal (ULN) is concerning in patients receiving Pluvicto, with particular attention to rising LDH levels during treatment, as this predicts shorter progression-free survival and overall survival. 1, 2
Baseline LDH Assessment
Before initiating Pluvicto therapy, baseline LDH should be measured and interpreted in the context of metastatic castration-resistant prostate cancer (mCRPC) prognosis:
Elevated baseline LDH (>1× ULN) predicts shorter progression-free survival and overall survival in patients receiving PSMA-targeted radioligand therapy like Pluvicto. 1
Patients with both visceral metastases AND elevated LDH represent the poorest prognostic subgroup, with median progression-free survival of only 1.7 months compared to 7.5 months in those without these features. 1
In the context of mCRPC, elevated LDH indicates high tumor burden, aggressive disease biology, or rapid cell turnover. 1
LDH Monitoring During Treatment
Rising LDH during Pluvicto treatment is a critical red flag:
Rising LDH levels during treatment are associated with significantly shorter clinical progression-free survival and overall survival. 2
LDH can increase during Pluvicto infusions through tumor lysis, as the targeted radiation to PSMA-expressing cancer cells releases intracellular LDH into the bloodstream. 1
Monitor LDH at baseline, before each treatment cycle (every 6 weeks), and when evaluating disease progression. 1, 3
Specific LDH Thresholds
While no absolute LDH cutoff contraindicates Pluvicto use, these thresholds guide prognostic assessment:
Any elevation above the upper limit of normal warrants concern and closer monitoring. 1, 2
In testicular cancer prognostic models (which provide context for LDH interpretation in oncology), LDH >1.5× ULN indicates intermediate prognosis, and LDH >10× ULN defines poor prognosis. 4
The presence of visceral metastases combined with any LDH elevation identifies patients at highest risk for poor outcomes with Pluvicto. 1, 2
Clinical Decision-Making Algorithm
When evaluating LDH in Pluvicto candidates:
Measure baseline LDH before first dose - elevated levels predict worse outcomes but do not contraindicate treatment. 1, 2
Assess for visceral metastases - the combination of visceral disease plus elevated LDH identifies the poorest prognostic group. 1, 2
Monitor LDH before each cycle - rising LDH during treatment signals disease progression or poor response. 2
Consider treatment discontinuation if LDH rises significantly - particularly if accompanied by clinical or radiographic progression. 2
Important Caveats
LDH is non-specific and can be elevated by numerous benign conditions:
Hemolysis (including from blood sample handling), liver disease, myocardial infarction, kidney disease, strenuous exercise, and infections all elevate LDH. 5, 1
Ensure proper blood sample handling to avoid false elevation from hemolysis. 5
Interpret LDH elevation in the full clinical context, including PSA trends, imaging findings, and symptom burden. 1
Tumor lysis during Pluvicto treatment can cause transient LDH elevation; if levels rise between cycles, repeat testing mid-cycle to distinguish tumor lysis from disease progression. 5