Larger Danger of Falls/Fractures With Androgen Receptor Inhibitors


A rise within the danger of falling and fracturing bones was related to using androgen receptor inhibitors (ARIs) for the remedy of prostate cancer, a scientific evaluation and meta-analysis suggests.

“We all know from this meta-analysis that using ARIs is related to a 1.8 instances larger danger of falls and a 1.6 instances larger danger of fracture,” lead writer Zin Myint, MD, Markey Most cancers Heart, College of Kentucky, Lexington, instructed Medscape Medical Information in an e-mail.

“Nonetheless, these are nonetheless uncommon unintended effects, and we additionally know from part 3 research that the ARIs considerably extend total survival, so the advantages of ARIs [still] outweigh the dangers of falls and fractures,” he added.

Within the evaluation, ARI use included enzalutamide (Xtandi), apalutamide (Erleada), or darolutamide (Nubeqa) alone or together with androgen deprivation remedy (ADT), however didn’t embody abiraterone (Zytiga) or bicalutamide (Casodex).

The meta-analysis was published online November 17 in JAMA Community Open.

The findings counsel remedy with ARIs is related to higher danger of falls in males with prostate most cancers, stated Carol Stone, MD, advisor in palliative drugs, Belfast Well being and Social Care Belief and Marie Curie Hospice, Northern Eire, UK, who was requested for remark.

“Nonetheless, the frequency of falls in each energetic and management arms is prone to be an underestimation associated to the exclusion of sufferers with cardiovascular comorbidities, choice bias affecting entry into the unique research, and recall bias that impacts correct reporting of falls,” she stated in an e-mail.

Nonetheless, Stone did agree with the authors that each one sufferers with prostate most cancers ought to be screened to evaluate their danger of falls at every oncology outpatient evaluation.

“These recognized to be in danger [for falls] ought to have a multifactorial danger evaluation and concentrating on of recognized modifiable danger elements,” she stated.  

ARI Remedy vs Controls

The evaluation included 11 research involving a complete of 11,382 males with prostate most cancers. Diagnoses included nonmetastatic castration-resistant prostate most cancers, metastatic hormone-sensitive prostate most cancers, or metastatic castration-resistant prostate most cancers. The median age of sufferers was 72 years.

Sufferers have been categorized into those that had been handled with an ARI (n = 6536), both alone or together with ADT, and people who had not (n = 4846). The management sufferers had obtained placebo, ADT, bicalutamide, abiraterone, or a mixture that didn’t embody an ARI.

Sufferers have been excluded from the 11 research if they’d comorbidities together with myocardial infarction, congestive heart failure, ventricular arrhythmia, unstable angina, heart block, bradycardia, uncontrolled hypertension, and seizure issues.

Using ARIs was related to a 1.8 instances larger danger of all-grade falls and a 1.6 larger danger of grade ≥ 3 falls in contrast with controls (each P < .001), Myint and colleagues report.

Equally, the chance of all-grade fractures was virtually 1.6 instances larger within the ARI group in contrast with controls (P < .001), and the chance of grade ≥ 3 fractures was 1.7 instances larger than controls (P = .01).

Grade ≥ 3 falls and fractures meant that the autumn or fracture was extreme sufficient to require hospital admission for care, and sufferers with decrease grade falls and fractures have been handled as outpatients.

Desk 1. Falls and Fractures within the ARI and Management Teams

Final result ARI group, % Management group, %
All-grade falls 8 5
Grade ≥ 3 falls 1 0.6
All-grade fractures 4 2
Grade ≥ 3 fractures 1 0.5


When it comes to the reported incidence of all-grade falls related to particular person ARIs, apalutamide had the best fee at 12%, adopted by enzalutamide at 8% and darolutamide at 4.2%, Myint and colleagues observe.

“Equally, apalutamide was related to the best all-grade fractures fee at 10%…adopted by enzalutamide at 1.8%…and darolutamide at 4.2%,” the authors report.

Mechanism of Motion

All three medicine — apalutamide, enzalutamide, and darolutamide — are nonsteroidal androgen receptor antagonists.

Enzalutamide and apalutamide share an analogous molecular construction with a excessive affinity for the ligand-binding area of the androgen receptor. In distinction, darolutamide has a singular molecular construction with an energetic metabolite that inhibits testosterone-induced downstream results of DNA activation, prostate most cancers cell development, and survival.

“Up to now, it’s unclear why the ARI drug class is related to a better danger of falls,”  the researchers acknowledge.

One risk is that enzalutamide and apalutamide can cross the blood–mind barrier, and might due to this fact be used to deal with brain metastasis.

Darolutamide doesn’t seem to cross the blood–mind barrier, and thus, has fewer central nervous system hostile results, together with falls, than the opposite two brokers.

“One other doable rationalization is that sarcopenia related to ARIs has a better danger for fall,” investigators counsel.

It has been proven that enzalutamide used alone was related to a significant decrease in mean body mass, and that used along with ADT, the doublet could also be related to a better danger of muscle loss and sarcopenia, the researchers be aware.

One other risk is that different medicine, akin to benzodiazepines or opioid medicine, used to deal with concomitant signs, fatigue from the illness or remedy, poor efficiency standing, and even a historical past of falls might improve the chance of falls and fractures.

Because the authors be aware, there are a number of fall risk-assessment instruments for noncancer sufferers, together with the Hendrich II Fall Danger Mannequin and 12-item Fall Danger Questionnaire. They counsel that “physicians ought to incorporate this fall danger mannequin in scientific observe, particularly in sufferers taking high-risk drugs or sufferers with pre-existing circumstances who’ve a excessive danger of fall.”

“Applicable use of bone-targeted brokers ought to be thought of in these sufferers as per established tips,” they add.

Myint and all coauthors besides one have reported no related monetary relationships; Kolesar has reported receiving possession curiosity from Helix Diagnostics outdoors the submitted work. Stone has reported no related monetary relationships.

JAMA Netw Open. Revealed on-line November 17, 2020. Full text

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