Enzalutamide

Enzalutamide (Xtandi®) is a type of hormone therapy for men with prostate cancer that has spread to other parts of the body (advanced prostate cancer) and has stopped responding to other types of hormone therapy.

It works by blocking the effect of the hormone testosterone on prostate cancer cells. Without testosterone, the prostate cancer cells can’t grow, even if they have spread to other parts of the body.

Enzalutamide has been shown to help some men live longer. It can also help to treat or delay symptoms, such as pain and bone problems.

Who can have enzalutamide?

Enzalutamide is suitable for men with advanced prostate cancer that has stopped responding to other types of hormone therapy. You can have enzalutamide before or after chemotherapy.

Your hospital doctor may offer you enzalutamide if you can’t have chemotherapy, or you don’t want to have it yet. Enzalutamide may be suitable if your cancer isn’t causing any symptoms or only mild symptoms.

You may be offered enzalutamide if you’ve had chemotherapy with a drug called docetaxel, and your cancer has stopped responding to this treatment.

If you’ve already had a type of hormone therapy called abiraterone, enzalutamide probably won’t be an option. And if you’ve already had enzalutamide, abiraterone probably won’t be an option. This is because research suggests that men who have already had one of these drugs don’t respond so well to the other drug. However, if you get severe side effects from enzalutamide or abiraterone, you may be able to try the other drug.

If you’re having trouble getting enzalutamide, even though your doctor thinks it is suitable for you, please let us know.

Enzalutamide or abiraterone?

Enzalutamide and abiraterone are both types of hormone therapy that treat advanced prostate cancer.

Your hospital doctor will talk to you about which drug is most suitable for you. For example, enzalutamide may be a better option than abiraterone if your cancer has spread to the liver or lungs, or if you can’t take steroids. Abiraterone must be taken with a steroid.

But abiraterone may be a better option than enzalutamide if you’ve had:

  • any falls
  • any seizures (fits) or you have an increased risk of seizures
  • extreme tiredness (fatigue)
  • problems with memory or concentration.

This is because enzalutamide can increase your risk of these problems.

Some men may find enzalutamide easier to take because, unlike abiraterone, you don’t need to take it on an empty stomach and you don’t need to take steroids. But some men want to avoid the tiredness that enzalutamide can cause, and prefer to take abiraterone.

Speak to your doctor or specialist nurse about which treatments might be suitable for you and when to have them. You can also talk things through with our Specialist Nurses.

  • Other health problems and medicines  

    Tell your doctor if you have any heart or kidney problems. Enzalutamide may not be suitable for you if you’ve had seizures, a stroke or injury to your brain in the past, or if the cancer has spread to your brain.

    Enzalutamide may affect how some other medicines work. And some medicines can affect how well enzalutamide works. Tell your doctor if you are taking medicines for any other health problems, including:

    • high cholesterol
    • pain
    • epilepsy
    • severe anxiety or schizophrenia
    • sleep problems
    • heart problems or high blood pressure
    • thyroid problems
    • gout.
  • Other treatment options  

    If enzalutamide isn’t suitable for you, or if you choose not to have it, your doctor may offer you a different treatment. Possible treatments include:

    • abiraterone
    • chemotherapy (docetaxel or cabazitaxel)
    • steroids
    • radium-223
    • less commonly, oestrogens.

    Speak to your doctor about your treatment options. They can also tell you about any clinical trials that might be suitable for you.

    Read more about treatment options after your first hormone therapy.

What does treatment involve?

Enzalutamide is usually taken as four capsules, once a day. You should take the capsules at the same time each day and swallow them whole with water. You can take the capsules with or without food.

You will probably continue with your first type of hormone therapy, even though it’s stopped working so well. For most men, this will be a monthly or three-monthly injection. This will still help to keep the amount of testosterone in your body low and may help enzalutamide to work.  Read more about what happens when your first hormone therapy isn’t working so well.

What are the side effects?

Like all treatments, enzalutamide can cause side effects. These may affect each man differently, and you’re unlikely to get all the possible side effects. Before you start treatment, your doctor or nurse will explain the possible side effects. Knowing what to expect can help you deal with them. You can find more information in the leaflet that comes with your medicine or from the Electronic Medicines Compendium.

Common side effects include:

Less common side effects include:

  • pain in your muscles, bones, back or joints
  • loose and watery bowel movements (diarrhoea)
  • difficulty emptying your bowels (constipation).

Taking enzalutamide can increase your risk of falling, which could mean you’re more likely to break a bone. You can help keep your bones strong and reduce your risk of severe bone thinning (osteoporosis) by making changes to your lifestyle. If you already have osteoporosis, your doctor may suggest taking medicines, such as bisphosphonates, to help reduce the risk of broken bones.

There is also a small risk of having a seizure (fit). This is rare, and may be more likely if you:

  • have had seizures before
  • drink large amounts of alcohol
  • have had other health problems, such as a head injury, some types of stroke or cancer in the brain.

Some medicines increase the risk of having a seizure, including medicines to treat asthma, depression, schizophrenia and pain. Speak to your doctor about whether you have an increased risk of having a seizure and whether it’s safe for you to drive and operate machinery.

Speak to your doctor or specialist nurse if you have any side effects from taking enzalutamide, even if they’re not listed here. They may offer you other treatments to help manage any side effects.

  • Contraception  

    If you’re sexually active and there is a chance your partner could become pregnant, use a condom together with another form of contraception while you are taking enzalutamide and for three months after. If your partner is pregnant, you should use a condom if you have sex, as enzalutamide could harm the baby.

What happens next?

You may have a prostate specific antigen (PSA) blood test at least every two or three months while you’re taking abiraterone. You may also have blood tests and blood pressure checks about once a month. Ask your doctor which tests you will have and how often you’ll have them.

Your PSA levels alone aren’t usually enough to know if your treatment is working. Your doctor will use your PSA level and any other test results, along with information about how you’re feeling, to check how well the treatment is working. Tell your doctor or nurse about any side effects you’re having, as there may be ways of managing these.

If your PSA level falls, this usually suggests your treatment is working. How quickly the PSA level falls, and how low, will vary from man to man.

In some men, the PSA level won’t fall. This alone doesn’t mean that enzalutamide isn’t working. Your doctor will also ask you about any symptoms you’re having. You may have scans, such as MRI or CT scans, particularly if your PSA level is rising. Your doctor may suggest you keep taking enzalutamide or, if they’re concerned the cancer is growing, they may talk to you about other treatment options.

For more information about enzalutamide, speak to your hospital doctor or specialist nurse, or call our Specialist Nurses.

References

Updated: March 2018 | Due for Review: March 2020

  • List of references  

    • Mottet et al. EAU-ESTRO-ESUR-SIOG Guidelines on prostate cancer. European Association of Urology; 2017.
    • Galletti G et al. Mechanisms of resistance to systemic therapy in metastatic castration-resistant prostate cancer. Cancer Treatment Reviews 2017; 57: 16-27.
    • Beer TM et al. Enzalutamide in Men with Chemotherapy-naïve Metastatic Castration-resistant Prostate Cancer: Extended Analysis of the Phase 3 PREVAIL Study. European Urology. 2017 Feb;71(2):151–4.
    • Scher HR et al. Increased Survival with Enzalutamide in Prostate Cancer after Chemotherapy. N Engl J Med 2012; 367: 1187-97.
    • Litwin M, Tan H-J. The diagnosis and treatment of prostate cancer: a review. JAMA 2017; 317(24): 2532-2542.
    • Ritch CR, Cookson MS. Advances in the management of castration resistant prostate cancer. BMJ 2016; 355: i4405.
    • Loriot et al. Effect of enzalutamide on health-related quality of life, pain, and skeletal-related events in asymptomatic and minimally symptomatic, chemotherapy-naive patients with metastatic castration-resistant prostate cancer (PREVAIL): results from a randomised, phase 3 trial. The Lancet Oncology. 2015;16(5):509–521.
    • Cella et al. Impact of enzalutamide on quality of life in men with metastatic castration-resistant prostate cancer after chemotherapy: additional analyses from the AFFIRM randomized clinical trial. Annals of Oncology. 2015 Jan;26(1):179–85.
    • National Institute for Health and Care Excellence. Enzalutamide for treating metastatic hormone-relapsed prostate cancer before chemotherapy is indicated. Technology appraisal guidance [TA377]. 2016.
    • Scottish Medicines Consortium. Enzalutamide 40mg soft capsules (Xtandi®) SMC No. (1066/15). 2016. Available from: https://www.scottishmedicines.org.uk/SMC_Advice/Advice/1066_15_enzalutamide_Xtandi/enzalutamide_Xtandi_IRP [Accessed 20 September 2017]
    • National Institute for Health and Care Excellence. Enzalutamide for metastatic hormone‑relapsed prostate cancer previously treated with a docetaxel‑containing regimen. Technology appraisal guidance [TA316]. 2014.
    • Scottish Medicines Consortium. Enzalutamide 40mg soft capsules (Xtandi®) SMC No. (911/13) 2013. Available from: https://www.scottishmedicines.org.uk/files/advice/enzalutamide_Xtandi_FINAL_October_2013_Amended_08.11.13.pdf [Accessed 20 September 2017]
    • Zhang W et al. Indirect comparison between abiraterone acetate and enzalutamide for the treatment of metastatic castration‑resistant prostate cancer: a systematic review. Asian Journal of Andrology 2017; 19: 196–202.
    • National Institute for Health and Care Excellence. Enzalutamide for treating metastatic hormone-relapsed prostate cancer before chemotherapy is indicated. Technology appraisal guidance [TA377]. 2016.
    • National Institute for Health and Care Excellence. Enzalutamide for treating metastatic hormone-relapsed prostate cancer before chemotherapy is indicated. Technology appraisal guidance [TA377]. 2016.
    • National Institute for Health and Care Excellence. Enzalutamide for treating metastatic hormone-relapsed prostate cancer before chemotherapy is indicated. Technology appraisal guidance [TA377]. 2016.
    • Gillessen S et al. Management of patients with advanced prostate cancer: the report of the advanced prostate cancer consensus conference APCCC 2017. Eur Urol 2017 (In press)
    • Electronic medicines compendium. Patient information leaflet: Xtandi 40mg soft capsules. 2017. Available from: https://www.medicines.org.uk/emc/medicine/27913 [Accessed 21 September 2017]
    • National Institute for Health and Care Excellence. Enzalutamide for metastatic hormone‑relapsed prostate cancer previously treated with a docetaxel‑containing regimen. Technology appraisal guidance [TA316]. 2014.
    • Electronic medicines compendium. Patient information leaflet: Xtandi 40mg soft capsules. 2017. Available from: https://www.medicines.org.uk/emc/medicine/27913 [Accessed 21 September 2017]
    • Electronic medicines compendium. Patient information leaflet: Xtandi 40mg soft capsules. 2017. Available from: https://www.medicines.org.uk/emc/medicine/27913 [Accessed 21 September 2017]
    • Electronic medicines compendium. Patient information leaflet: Xtandi 40mg soft capsules. 2017. Available from: https://www.medicines.org.uk/emc/medicine/27913 [Accessed 21 September 2017]
    • Mottet N, Bellmunt J, Briers E, Bolla M, Bourke L, Cornford P, et al. EAU-ESTRO-ESUR-SIOG Guidelines on prostate cancer. European Association of Urology; 2017.
    • Electronic medicines compendium. Patient information leaflet: Xtandi 40mg soft capsules. 2017. Available from: https://www.medicines.org.uk/emc/medicine/27913 [Accessed 21 September 2017]
    • Beer TM et al. Enzalutamide in Men with Chemotherapy-naïve Metastatic Castration-resistant Prostate Cancer: Extended Analysis of the Phase 3 PREVAIL Study. European Urology. 2017 Feb;71(2):151–4.
    • Electronic medicines compendium. Patient information leaflet: Xtandi 40mg soft capsules. 2017. Available from: https://www.medicines.org.uk/emc/medicine/27913 [Accessed 21 September 2017]
    • Graff JN et al. Efficacy and safety of enzalutamide in patients 75 years or older with chemotherapy-naive metastatic castration-resistant prostate cancer: results from PREVAIL.Annals of Oncology 2016; 27(2): 286–294.
    • Ritch CR, Cookson MS. Advances in the management of castration resistant prostate cancer. BMJ 2016; 355: i4405.
    • Electronic medicines compendium. Patient information leaflet: Xtandi 40mg soft capsules. 2017. Available from: https://www.medicines.org.uk/emc/medicine/27913 [Accessed 21 September 2017]
    • Electronic medicines compendium. Patient information leaflet: Xtandi 40mg soft capsules. 2017. Available from: https://www.medicines.org.uk/emc/medicine/27913 [Accessed 21 September 2017]
    • Mottet et al. EAU-ESTRO-ESUR-SIOG Guidelines on prostate cancer. European Association of Urology; 2017.
    • Galletti G et al. Mechanisms of resistance to systemic therapy in metastatic castration-resistant prostate cancer. Cancer Treatment Reviews 2017; 57: 16-27.