<p><strong> </strong><strong>Clinicians should not offer first generation antiandrogens (bicalutamide, flutamide, nilutamide) in combination with LHRH agonists in patients with mHSPC, except to block testosterone flare. (<em>Strong Recommendation; Evidence Level: Grade A</em>)</strong></p>
Discussion
Discussion
<p>With compelling level A evidence supporting the use of abiraterone acetate plus prednisone, apalutamide, enzalutamide or darolutamide in combination with ADT in men with newly diagnosed mHSPC, the Panel believes that long-term use of first generation antiandrogens bicalutamide, flutamide, nilutamide in lieu of the above noted agents cannot be supported.</p>
<p>In the first week after LHRH agonists are administered, there is typically a surge in luteinizing hormone resulting in an increase in circulating testosterone. This may cause clinical “flares,” which may be associated with worsening of disease symptoms (e.g., bone pain, urinary tract obstruction) in approximately 10% of patients. This surge can be “blocked” by short term (e.g., 4 weeks or less) of a first-generation antiandrogen, although there is limited evidence of significant clinical utility.<sup>105</sup></p>