Apalutamide

How it works

It binds the androgen receptor ligand-binding domain and inhibits receptor nuclear translocation, DNA binding and transcription, suppressing androgen-driven prostate cancer growth.

Prescribing in practice

• Severe cutaneous reactions including Stevens-Johnson syndrome and DRESS have been reported, so warn the patient and stop treatment for serious skin reactions; falls, fractures, seizures and ischaemic cardiovascular events are also recognised risks.
• It is a potent enzyme inducer affecting CYP3A4, CYP2C9 and other pathways, causing numerous interactions, so review all co-medications including anticoagulants.
• It must be continued together with androgen deprivation therapy, and the SPC advises effective contraception measures for partners of childbearing potential.

Monitoring

Monitor for skin reactions, falls and fractures, seizure activity and cardiovascular events, alongside disease response and relevant blood tests.

Counselling the patient

• Report any rash, blistering, or mouth ulcers promptly, and continue your hormone injections alongside these tablets.
• Take care to reduce your risk of falls, and report any blackouts, fits, or chest pain.
• Do not stop the medicine without advice.

Evidence & guidelines

Apalutamide's benefit in castration-resistant and hormone-sensitive prostate cancer is established by the SPARTAN and TITAN trials, the SPC and NICE guidance.