Veozah (fezolinetant) for hot flashes (and what to do in breast or gynecologic cancers)
Vasomotor symptoms (hot flashes and night sweats) are not just a nuisance but can impact significantly pain, fatigue, mental health, sleep, quality of life and more. Some people may also experience palpitations (rapid heart beat) and chills as part of vasomotor symptoms. Endocrine therapies for breast cancer (and occasionally for some gynecologic cancers) - specifically tamoxifen or aromatase inhibitors - are notorious for causing vasomotor symptoms. We do have medications that we can use to treat for hot flashes but these medications are really approved for other uses (for example venlafaxine (Effexor) is an antidepressant that can also be used to treat hot flashes also). Veozah, however, is a hormone-free option specifically approved for treating moderate to severe hot flashes and night sweats due to menopause.
Veozah is a neurokinin 3 (NK3) receptor antagonist. In the hypothalamus (a structure deep in the brain that regulates various bodily functions including body temperature, hunger, thirst, mood, blood pressure and sleep wake cycle), KNDy neurons (nerve cells) are inhibited by estrogen and stimulated by the neuropeptide NKB, which contributes to temperature regulation. In a low/declining estrogen state (such as menopause or perimenopause), the balance is disrupted and there is unopposed NKB signaling. This results in increased KNDy activity and altered signaling in the thermoregulatory center, causing hot flashes and night sweats.
Veozah works by binding to NK3 receptors and blocking NKB. This action reduces heat signaling, helps to restore balance in the thermoregulatory center and reduces frequency and intensity of hot flashes. It is a completely non-hormonal treatment option.
Clinical trials have shown a 50–60% reduction in the frequency of hot flashes, with additional improvements in sleep disturbances.
The most common side effects include abdominal pain (4.3%), diarrhea (3.9%), insomnia (3.9%), back pain (3%), hot flush (2.5%), and liver enzyme elevation (2.3%). All of these side effects were actually reported in patients taking a placebo pill on the trials but at lower rates. Veozah carries a black box warning for potential liver enzyme elevations. It is recommended to check liver enzymes at baseline and every 3 months for the first year on treatment.
Patients with breast cancer (or other cancers) were originally not included in the study. This does not mean that patients with cancer are not able to take Veozah. We just don’t know how well it work. One of the reasons they were not included is because patients with breast cancer (or other cancers) can be on medications that can also cause hot flashes and be a confounder to the study such as tamoxifen or aromatase inhibitors. It would have been hard to tell whether the medication was effective in lowering hot flashes if someone was on another medication also causing hot flashes.
The HIGHLIGHT-1 study is currently evaluating Veozah in patients with stage I-III HR+ breast cancer who are on tamoxifen or aromatase inhibitors. This will help answer the question about whether Veozah will reduce hot flashes in patients on endocrine therapy. More info here on the study: https://clinicaltrials.gov/study/NCT06440967?rank=1. Right now, only open in Canada but plans to open in other countries.
The contraindications to using Veozah at this time are patients with known cirrhosis or severe kidney disease. There are some medications that may interact as well (based on their metabolism- CYP1A2 inhibitors) so always check with your doctor to make sure there are no medication interactions.
Caffeine can increase the effect of Veozah so avoid very heavy caffeine intake. We don’t know how much caffeine is safe so just be mindful. Veozah can be taken at any time of day, but it is generally recommended to take it at the same time each day.
If insurance does not cover Veozah, check with the manufacturer, Astellas, for patient assistance programs or copay savings cards. Your doctor may help with appeals/prior authorizations or recommend alternative therapies if it is not covered. Sometimes, you may have to try a different medication for hot flashes first.
Let me know your questions on Veozah or hot flashes in general! Have you been on this medication? Did it help you?
This has been a game changer and finally found relief. My night sweats affected my sleep and my doctors and I had to try a couple of other options before i got approved for Veozah, although expensive my insurance covered after showing other alternatives did not work. I am taking with Tamoxifen and my VSM symptoms all but disappeared. I get them intermittently and must to remember to take it same day daily.
This has been a game changer and finally found relief. My night sweats affected my sleep and my doctors and I had to try a couple of other options before i got approved for Veozah, although expensive my insurance covered after showing other alternatives did not work. I am taking with Tamoxifen and my VSM symptoms all but disappeared. I get them intermittently and must to remember to take it same day daily.