What medication is recommended for managing hot flashes?

Medications for Hot Flashes Management

For moderate to severe hot flashes, SSRI/SNRIs (particularly venlafaxine 75 mg daily) or gabapentin are recommended as first-line non-hormonal treatments, with venlafaxine being preferred by most patients despite similar efficacy. 1

First-Line Treatment Options

SSRI/SNRIs

• Venlafaxine (SNRI)

  • Start at 37.5 mg daily for 1 week, then increase to 75 mg daily
  • Reduces hot flashes by 61% (compared to 27% with placebo) 2
  • Optimal dose is 75 mg daily (higher doses don't provide additional benefit but increase side effects) 1
  • Rapid onset of action (within 1 week)
  • Common side effects: dry mouth, decreased appetite, nausea, constipation 2
  • Preferred by 68% of breast cancer survivors when compared to gabapentin 3

• Paroxetine (SSRI)

  • Start at 10 mg daily (or 12.5 mg controlled release)
  • Can increase to 20 mg daily if needed after 1 week
  • Reduces hot flash composite score by 62-65% 1
  • CAUTION: Avoid in women taking tamoxifen due to CYP2D6 inhibition which may reduce tamoxifen's efficacy 1, 4

Gabapentin

• Dosing: Start at 300 mg once daily for 3 days, then 300 mg twice daily for 3 days, then 300 mg three times daily
• Reduces hot flashes by approximately 51% (compared to 26% with placebo) 1
• Rapid onset of action (within 1 week)
• Common side effects: dizziness, somnolence, unsteadiness 1
• May be particularly useful for women with concurrent neuropathic pain 1

Second-Line Options

Other SSRIs

• Citalopram: May be effective for those who don't respond to venlafaxine 1
• Fluoxetine: Decreases hot flash composite score by 50% versus 36% for placebo 1
• Sertraline: Mixed results, but may benefit some women 1
• Desvenlafaxine: 100 mg daily reduces hot flashes by 64% at 12 weeks 1

Clonidine

• Centrally acting α-adrenergic agonist
• Modest efficacy (reduces hot flashes by up to 46%)
• Dose: 0.1 mg daily (oral or transdermal)
• Side effects: dry mouth, insomnia or drowsiness 1
• Consider for mild to moderate hot flashes when other options aren't suitable 1

Treatment Algorithm

1. Assess severity and impact on quality of life:

   • For mild symptoms that don't interfere with sleep or daily function: behavioral changes and vitamin E (800 IU/day) 5
   • For moderate to severe symptoms: proceed to pharmacologic therapy

2. Determine if estrogen therapy is contraindicated:

   • If no contraindications and patient is willing: estrogen therapy (reduces symptoms by 80-90%) 5
   • If contraindicated (e.g., breast cancer history) or patient unwilling: proceed to non-hormonal options

3. Non-hormonal pharmacologic therapy:

   • First choice: Venlafaxine 37.5 mg daily for 1 week, then 75 mg daily 1, 2, 3
   • Alternative first choice: Gabapentin (titrate to 300 mg three times daily) 1
   • For tamoxifen users: Avoid paroxetine and fluoxetine; use venlafaxine, citalopram, or gabapentin 1

Important Clinical Considerations

• Efficacy monitoring: At least 50% reduction in physiological hot flashes may be needed for improvements in fatigue, sleep quality, and overall quality of life 6

• Duration of therapy: Optimal duration is unknown; gradual tapering is recommended when discontinuing, especially for short-acting agents like paroxetine and venlafaxine 1

• Response variability: Marked variability in individual response exists; if one agent fails, trying another is reasonable 1, 7

• Long-term adherence: Despite initial efficacy, some patients may discontinue venlafaxine long-term due to side effects 6

• Breast cancer considerations: In tamoxifen users, avoid strong CYP2D6 inhibitors (paroxetine, fluoxetine); prefer citalopram, venlafaxine, or gabapentin 1