Other medication
Men with PC who experience erectile dysfunction can be offered phosphodiesterase type 5 (PDE5) inhibitors or devices to aid with erections.34
Side effects of anti-androgen therapy include hot flushes which may respond to medroxyprogesterone (off-label use) or cyproterone acetate. Weight gain and gynaecomastia (breast enlargement) is likely, and if troublesome, options include breast radiotherapy or tamoxifen.34
The risk of anti-androgen related osteoporosis can be reduced by giving high dose calcium with vitamin D. However, if osteoporosis is developing a bisphosphonate may be added, or if contraindicated or not tolerated then denosumab may be considered.34
Zoledronic acid may be considered for hormone-relapsed metastatic PC, to prevent or reduce skeletal-related events. Pain relief may also be supported by bisphosphonate therapy, especially when analgesics and palliative radiotherapy are not giving satisfactory pain relief.34
The MHRA has issued several safety warnings about denosumab and bisphosphonates including around increased risk of jaw osteonecrosis (patients require good dental hygiene and regular dental checks), the possibility of hypocalcaemia and hypercalcaemia, and other problems on discontinuation.45,46