Safety of Veozah (Fezolinetant) in Patients with History of Stroke
Veozah (fezolinetant) should not be used in patients with a history of stroke due to lack of safety data in this specific population and potential risks that outweigh benefits.
Background and Mechanism
Veozah (fezolinetant) is an FDA-approved neurokinin 3 (NK3) receptor antagonist indicated for the treatment of moderate to severe vasomotor symptoms (hot flashes and night sweats) associated with menopause. It works by crossing the blood-brain barrier and modulating neural activity within the thermoregulatory center 1, 2.
Safety Concerns in Stroke Patients
Lack of Specific Safety Data
None of the available guidelines or research specifically addresses the use of Veozah in patients with a history of cerebrovascular accident (CVA) or stroke. This absence of data is concerning, as stroke patients represent a high-risk population that requires careful medication management.
Stroke Risk Management Considerations
The American Heart Association/American Stroke Association guidelines emphasize several key principles in managing patients with prior stroke:
Antiplatelet and Anticoagulant Therapy: Patients with prior stroke are often on antiplatelet agents such as aspirin (75-325 mg daily) or anticoagulants, which are cornerstone therapies for secondary stroke prevention 3.
Medication Interactions: Any new medication introduced to stroke patients must be carefully evaluated for potential interactions with established stroke prevention therapies 3.
Risk Factor Management: Aggressive management of modifiable risk factors is essential in stroke patients, including hypertension, diabetes, and dyslipidemia 3.
Risk-Benefit Analysis
Potential Risks
Unknown Drug Interactions: Potential interactions between Veozah and commonly prescribed stroke prevention medications have not been well-studied.
Cerebrovascular Effects: As Veozah crosses the blood-brain barrier to exert its effects 2, there are theoretical concerns about its impact on cerebral blood flow or neuronal function in patients with already compromised cerebrovascular systems.
Cardiovascular Safety: Stroke patients often have underlying cardiovascular disease, and the cardiovascular safety profile of Veozah in this specific population is not established.
Benefits vs. Alternatives
While Veozah offers a non-hormonal option for treating menopausal vasomotor symptoms, the potential risks in stroke patients likely outweigh the benefits when safer alternatives exist.
For menopausal women with a history of stroke who cannot use hormone therapy, other non-hormonal approaches with established safety profiles in stroke patients should be considered first.
Recommendations for Clinical Practice
Avoid Use: Given the lack of safety data in stroke patients and the availability of alternative treatments, Veozah should generally be avoided in patients with a history of stroke.
Alternative Approaches: Consider other non-hormonal approaches for managing vasomotor symptoms in patients with stroke history.
Risk Stratification: If considering Veozah in a patient with remote stroke history and minimal residual effects:
- Ensure the patient is neurologically stable
- Evaluate for potential drug interactions with existing stroke prevention medications
- Monitor closely for any neurological changes or symptoms
Consultation: Obtain neurology consultation before considering Veozah in any patient with stroke history.
Common Pitfalls to Avoid
Underestimating Stroke Risk: Do not minimize the significance of a prior stroke when considering new medications.
Overlooking Drug Interactions: Be vigilant about potential interactions between Veozah and antiplatelet/anticoagulant therapies commonly used in stroke patients.
Inadequate Monitoring: If Veozah is deemed necessary despite stroke history, implement close monitoring for neurological symptoms.
Until specific safety data becomes available regarding the use of Veozah in patients with a history of stroke, a cautious approach is warranted, with preference given to alternative treatments with established safety profiles in this vulnerable population.