Written by: Michelle Phillips, PharmD, BCOP, Wilmot Cancer Center
The purpose of this PQI is a summary of process for initiating and monitoring darolutamide therapy in the treatment of patients with non-metastatic castration-resistant prostate cancer (nmCRPC).
Darolutamide is a next-generation androgen receptor antagonist approved in 2019 for the treatment of nmCRPC.1 It was given a category 1 recommendation by NCCN for patients with nmCRPC and a prostate specific antigen doubling time (PSADT) of ≤ 10 months based on the results of the phase 3 ARAMIS trial.2 This trial demonstrated that darolutamide 600 mg twice daily improved median metastasis-free survival vs placebo in this patient population (40.4 months vs 18.4 months; HR for metastasis or death 0.41; 95% confidence interval 0.34 to 0.50; P < 0.001).3 In addition, patients receiving darolutamide experienced clinical benefits compared to placebo including improved overall survival, reduced time to requirement for cytotoxic chemotherapy and skeletal related events, and increased time to pain progression. Darolutamide is also well tolerated with overall low rates of serious adverse events. The most common adverse events include fatigue, decreased neutrophil count, elevated liver function tests, pain in extremities, and rash (see supplemental information).4
Upon receipt of an order for darolutamide:
- Verify diagnosis of nmCRPC
- Ensure appropriate dose—darolutamide 600 mg (two tablets) twice daily4
- Reduce to 300 mg twice daily for eGFR 15 – 29 mL/min in patients not on hemodialysis or for patients with moderate hepatic impairment (Child-Pugh B)
- Obtain labs—complete blood count (CBC) with differential and comprehensive metabolic panel (CMP), PSA, and testosterone at baseline, monthly, and as needed
- Check for clinically relevant drug interactions
- Darolutamide concentrations may be decreased by combined P-glycoprotein and moderate to strong CYP3A4 inducers
- Darolutamide concentrations may be increased by combined P-glycoprotein strong CYP3A4 inhibitors
- Darolutamide may decrease concentrations of breast cancer resistance protein (BCRP) substrates
- Dose modifications for toxicities—for grade ≥ 3 toxicity or other intolerable adverse event, withhold or reduce to 300 mg twice daily until symptom resolution.
- May resume 600 mg twice daily upon resolution
- Doses < 300 mg twice daily not recommended
- Complete DUDE Access Services Patient Service Request form with patient and provider available at https://www.nubeqahcp.com/
- Provides patient with 2-month free trial while obtaining prior authorization from insurance and assessing for tolerability
- Must be done prior to patient starting treatment to qualify for free trial
- Reminder: This process may assist in your own institution’s benefits investigation
- Obtain provider signatures on pages 1 and 4, and obtain patient signatures on pages 2 and 5
- Be sure to check the box “in office dispensing” on step 3 of page 1 if applicable
Patient Centered Activities:
- Ensure patient receiving concomitant gonadotropin releasing hormone (GnRH) antagonist
- Take twice daily after a meal
- Swallow tablets whole
- Store at room temperature in original container
- Review potential side effects including fatigue, decreased neutrophil count, pain in extremities, increased LFTs, and rash (see Supplemental Information)
- Males with sexual partners of reproductive potential should use highly effective contraception during treatment and for one week after last dose due to risk of embryo-fetal toxicity.
- Monitor for toxicities warranting dose adjustments (see Supplemental Information)
- Bastos DA, et al. Darolutamide for castration-resistant prostate cancer. Onco Targets Ther. 2019; 12: 8769 – 8777.
- National Comprehensive Cancer Network. Prostate cancer. NCCN Clinical Practice Guidelines in Oncology. Version 1.2020 – March 16, 2020. Available at: https://www.nccn.org/professionals/physician_gls/pdf/prostate.pdf
- Fizazi K, et al. Darolutamide in nonmetastatic, castration-resistant prostate cancer. New Eng J Med. 2019; 380: 1235 – 1246.
- Nubeqa (darolutamide) [prescribing information]. Whippany, NJ; Bayer HealthCare Pharmaceuticals Inc: 2019.
- For patients with private insurance, visit https://www.nubeqacopayprogram.com/
- Adverse reactions from ARAMIS trial
|All grades (%)||Grade ≥ 3||All grades (%)||Grade ≥ 3|
|Decreased neutrophil count||20||4||9||0.6|
|Pain in extremities||6||0||3||0.2|