What to do if having trouble swallowing abiraterone (abiraterone acetate) for metastatic castration-resistant prostate cancer?

Management of Swallowing Difficulty with Abiraterone Acetate

If you cannot swallow abiraterone tablets, switch to enzalutamide as the preferred alternative hormonal therapy, as it provides equivalent survival benefits without requiring tablet manipulation and does not need concurrent steroid administration. 1

Why Tablet Manipulation is Not Recommended

• Abiraterone tablets must be swallowed whole and cannot be crushed or chewed 2
• The FDA label explicitly states that tablets should not be broken, crushed, or damaged, as this alters drug absorption and can cause unpredictable pharmacokinetics 2
• Crushing tablets creates safety hazards for caregivers and pregnant women who should not handle damaged tablets without gloves 2

Primary Alternative: Enzalutamide

Enzalutamide (160 mg daily) is the first-line alternative for patients unable to take abiraterone, offering comparable efficacy with a simpler administration profile 1

Key Advantages of Enzalutamide:

• No requirement for concurrent steroid therapy, eliminating the complexity of dual medication management 1
• Can be taken with or without food, providing greater flexibility 1
• Strong evidence base with demonstrated survival benefits in metastatic castration-resistant prostate cancer 3

Monitoring Considerations:

• Watch for fatigue, hypertension, and rarely seizures (particularly in patients with seizure history) 1
• Regular PSA monitoring and blood pressure checks are essential 1

Secondary Alternatives Based on Clinical Context

For Patients Unable or Unwilling to Use Enzalutamide:

Ketoconazole with steroids can serve as a viable alternative, particularly if cost or access issues prevent use of newer agents 3

For Symptomatic Patients with Poor Performance Status:

Docetaxel chemotherapy should be considered if the poor performance status is directly cancer-related rather than from comorbidities 3

• Docetaxel demonstrates both survival and palliative benefits in symptomatic disease 3
• This option is particularly appropriate for patients with visceral metastases or rapidly progressive disease 1

For Patients with Symptomatic Bone Metastases:

Radium-223 is specifically indicated for patients with symptomatic bone metastases without visceral disease 1

• Improves overall survival while targeting bone pain 1
• Can be used in patients who have not received prior docetaxel 1

Critical Pitfalls to Avoid

• Do not attempt low-dose abiraterone with food as a solution to swallowing difficulties - while 250 mg with low-fat breakfast has been studied in research settings, this approach is not FDA-approved for the non-castrate setting and requires intact tablets 3, 4
• Do not add spironolactone if attempting to continue abiraterone, as it interferes with the drug's mechanism of action 1, 5
• Avoid sipuleucel-T in symptomatic patients requiring narcotics, as survival benefits do not appear until 6 months after therapy 3

Monitoring Requirements for Any Alternative

Regardless of which alternative you choose:

• Monthly monitoring of blood pressure, liver function, and potassium levels 5
• Regular PSA assessments, though treatment decisions should not be based solely on PSA changes 1
• Cardiac monitoring in patients with pre-existing cardiovascular disease 1