Indications

  • Localized high-risk (plus RT).

  • Locally advanced / metastatic (M1).

  • Biochemical recurrence with rapid PSA doubling time.
    (NCCN Prostate 2025; ESMO Prostate 2024)

Therapeutic approaches

Category Mechanism Examples (Trade) Typical Dose / Route Notes
Medical castration (GnRH agonist) Down-regulate pituitary GnRH → ↓ LH/FSH → ↓ testosterone Leuprolide (Lucrin®) 7.5 mg IM/SC q4wk or 22.5 mg q3mo Goserelin (Zoladex®) 3.6 mg SC q4wk or 10.8 mg q12wk Triptorelin (Decapeptyl®) 3.75 mg IM q4wk / 11.25 mg q3mo Initial testosterone flare → co-start anti-androgen  
GnRH antagonist Direct blockade → immediate testosterone suppression Degarelix (Firmagon®) 240 mg SC loading → 80 mg q4wk Relugolix (Orgovyx®) 120 mg PO daily No flare; better CV profile  
Anti-androgens Block AR binding/translocation Bicalutamide (Casodex®) 50 mg PO daily Enzalutamide (Xtandi®) 160 mg PO daily Apalutamide (Erleada®) 240 mg PO daily Darolutamide (Nubeqa®) 600 mg PO BID with food Combine with ADT in high-volume M1 disease for OS gain (~30–35%)  
CYP17A1 inhibitor Blocks androgen synthesis Abiraterone (Zytiga®) 1000 mg PO daily + Prednisone 5 mg BID Monitor BP, K+, LFTs; avoid on full stomach (↑ absorption × 10)  

Treatment timing & duration

  • Localized + RT: start 2–3 months before, continue during, and extend 18–36 months after.

  • Metastatic: continuous ADT or intermittent in select cases (QoL preservation if PSA nadir < 0.2 ng/mL).

Monitoring & targets

  • Testosterone < 50 ng/dL (“castrate level”).

  • PSA nadir time and velocity predict outcome.

  • Alkaline phosphatase trend (bone disease).

  • DEXA scan q 2 y.

Toxicity mitigation

  • Bone loss → bisphosphonate / denosumab prophylaxis.

  • Metabolic syndrome → screen lipids, glucose, BP.

  • Sexual dysfunction → counseling, PDE-5 inhibitors.

  • Cognitive changes → exercise + sleep hygiene.

Practical pearls

  • Always pair long-term ADT with bone protection.

  • Relugolix reduces cardiovascular events (~50% less vs leuprolide).

  • Never combine two hormone classes without trial support (↑ toxicity no OS gain).

PreviousNext