Is ADT causing anemia?

@stragale Stagale, I hope that you have success in resolving your blood count issues.

I too have low hemoglobin, not as severe as you have, but troublesome to me. Your problem appears to be loss of red blood cells after they have been created. My problem is that the production of red blood cell is not sufficient to maintain hemoglobin above anemia levels.

In the first 2 years of ADT my hemoglobin dropped from 13.5 to an average of 12.6, which I find from research is the normal effect of ADT. It then proceeded on down to 11.2. I brought this to the attention of my oncologist and he referred ma to a hematologist on the staff of the provider group. A test indicated that the kidneys were not producing sufficient Erythropoietin to stimulate the bone marrow to make an adequate number of red blood cells. I attribute the damage to the kidneys to the ADT treatment, although I found there is little information on this in the literature.

The plan of the hematologist is to monitor the hemoglobin levels and when if falls below 10, and I am symptomatic for anemia, to use erythropoiesis-stimulating agents (ESAs) to raise the hemoglobin level modestly. The hematologist warned the ESAs can cause blood clots and other cardiac events. The FDA black box for an EAS drug has this at the beginning;

WARNING: ESAs INCREASE THE RISK OF DEATH,
MYOCARDIAL INFARCTION, STROKE, VENOUS
THROMBOEMBOLISM, THROMBOSIS OF VASCULAR ACCESS
AND TUMOR PROGRESSION OR RECURRENCE

Not a very good indication.

Recently I saw some articles that mentioned that patients with chronic kidney disease and or diabetics have modest increases in hemoglobin from the use of Sodium-Glucose Transport 2 (SGLT2) Inhibitors. The increase is about 0.7 g/dL, admittedly small but any gain in my book is good. I showed the articles to the oncologist, he asked if I was willing to take the medication, and when I said yes he refereed me to the endocrinologist on the staff of the group. The endocrinologist said he never prescribed the medication for the purpose of raising the hemoglobin, but if I was willing to try it, he would prescribe it.. Now I am in my first week of taking Dapagliflozin (Farxiga®) 5 mg tablets. I won't know the results for at least a month and perhaps 4 months.

Since the SGLT2 Inhibitors require prior approval by my insurance plan I may not be reimbursed for the cost of this medication. Since I am outside of the United States the cost per month is about $30, whereas in the United States the cost would be several hundred dollars per month.

I was rereading the original comment by @waynerl and was struck by the comment that you may be on ADT therapy until you die of something else. If a prostate cancer oncologist actually tells a patient that, it seems to me that indicates a lack of current knowledge/ understanding of PC, IMHO. ADT therapy works well at suppressing testosterone production and binding of the hormone to androgen receptors. However, eventually, after a few years, the cancer cells evolve such that they become hormonally insensitive and will start growing again and potentially metastasizing. In that case, oncologists move on to other treatment options that may include chemo, PARP inhibitors, radiation, Pluvicto, etc.

When I asked my oncologist back in February how long I would be on ADT (in my case, Orgovyx/Abiraterone/Prednisone), he said probably 24 months. This was based on best evidence from the literature at that time. I just saw a video from the Prostate Cancer Research Institute that discussed what may become a landmark paper published earlier this year that suggests that the recommended time on ADT can be tailored to the patient's cancer aggressiveness, PSA number, Gleason Score, etc. Here's a link to the video: https://www.youtube.com/watch

All of this is to say that it is really important to get a second or maybe even a third opinion from another medical center, preferably one that sees a large number of PC patients to see what they recommend for a patient's specific health issues.

@waynerl
A few questions if I may:

Have you had any of the labs done that I had listed in my post? Basically, they're to rule out (or in) other possible causes of your low RBCs etc., such as hemolytic anemia.

You mentioned having GI issues. Is it possible you have a GI bleed that's contributing to your low numbers? My PCP referred me to a GI specialist. I don't have an appointment set up yet but expect to get one soon.

If RBCs are low enough and you're having breathing problems, maybe a transfusion is in order?

Finally, have you sought a second opinion from another center? I think you mentioned that you see physicians at VA in Seattle? Maybe see if you can get in to the Hutchinson Cancer Center for a second opinion. I have seen experiences from friends and others who have seen docs who are "behind the times" in their knowledge.

Hugs and warm wishes
Gale

@overage SGLT2 inhibitors are a primary treatment for CKD. Allowing glucose to flow increases efficiency of kidneys filtering other items. Dapagliflozin went generic in USA this year; 3 months is less than $30 generic and is $105 brand. Competing SGLT2s are still expensive. I had anemia but levels slowly increased after I was off Orgovyx.

@waynerl
A few questions if I may:

Have you had any of the labs done that I had listed in my post? Basically, they're to rule out (or in) other possible causes of your low RBCs etc., such as hemolytic anemia.

You mentioned having GI issues. Is it possible you have a GI bleed that's contributing to your low numbers? My PCP referred me to a GI specialist. I don't have an appointment set up yet but expect to get one soon.

If RBCs are low enough and you're having breathing problems, maybe a transfusion is in order?

Finally, have you sought a second opinion from another center? I think you mentioned that you see physicians at VA in Seattle? Maybe see if you can get in to the Hutchinson Cancer Center for a second opinion. I have seen experiences from friends and others who have seen docs who are "behind the times" in their knowledge.

Hugs and warm wishes
Gale

wayneri, yes, testosterone deprivation lowers the body's production of erythropoietin (EPO), a hormone necessary for the production of rbcs. Ask your physician to prescribe EPO to bypass the need for testosterone.
Abiraterone can also lower blood sugar levels. Make sure they are testing you frequently. I'd want testing for iron, b12, blood sugar, and oxygen levels in addition to the CBC. Lower RBCs are common with ADT but are often mild. You might benefit from oxygen supplementation for now.
Sorry for your struggle. I think you'll get help.

Did they say why. There might be an excellent reason.
Were you offered any other remediation.