What alternative medication can be ordered for a patient with hot flashes when Voezah (generic name not specified, possibly referring to a brand name) is denied by insurance?

Alternative Medications for Hot Flashes When Veozah is Denied

Start with gabapentin 900 mg/day as your first-line alternative, as it reduces hot flash severity by 46% and has no drug interactions, no sexual dysfunction, and no withdrawal syndrome. 1

Primary Pharmacologic Options

Gabapentin (First Choice)

• Dosing: Start at 300 mg/day and titrate up to 900 mg/day over 1-2 weeks 1
• Efficacy: Reduces hot flash severity by 46-49% at 900 mg/day compared to 15-21% with placebo 1
• Advantages over other options:
  • No drug interactions (critical advantage over SSRIs/SNRIs) 1
  • No sexual dysfunction 1
  • No withdrawal syndrome unlike venlafaxine or paroxetine 1
  • Particularly useful when given at bedtime for patients with sleep disturbance from hot flashes 1
• Side effects: Dizziness, unsteadiness, and drowsiness affect up to 20% but markedly improve after the first week and largely resolve by week 4 1

Venlafaxine (Second Choice)

• Dosing: Start at 37.5 mg daily, increase to 75 mg daily after 1 week 1
• Efficacy: Reduces hot flashes by 61% at 75 mg/day compared to 27% with placebo 1, 2
• Key consideration: If patient is on tamoxifen, venlafaxine is preferred over paroxetine because it has minimal effects on CYP2D6 and doesn't interfere with tamoxifen metabolism 1, 2
• Side effects: Dry mouth, reduced appetite, nausea, constipation, and possible sexual dysfunction 1
• Important: Must be gradually tapered on discontinuation to minimize withdrawal symptoms 1

SSRIs (Third Choice)

• Paroxetine: 10-20 mg daily (start at 10 mg, increase after 1 week if needed) reduces hot flashes by 50-65% 1, 2
• Citalopram: Also effective with 50-65% reduction 2
• Critical warning: Avoid paroxetine and fluoxetine in patients taking tamoxifen - they are potent CYP2D6 inhibitors that interfere with conversion of tamoxifen to its active metabolite endoxifen 1, 2
• Preferred SSRI if on tamoxifen: Citalopram has minimal impact on tamoxifen metabolism 1, 2

Clonidine (Fourth Choice)

• Reduces hot flashes by up to 46% 2
• Less effective and slower onset than venlafaxine, though may be better tolerated 1
• Side effects: Sleep difficulties, dry mouth, fatigue, dizziness, nausea 1

Clinical Decision Algorithm

Step 1: Assess if patient is on tamoxifen or other medications

• If on tamoxifen: Choose gabapentin first, or venlafaxine/citalopram as alternatives. Never use paroxetine or fluoxetine 1, 2
• If not on tamoxifen: Gabapentin remains first choice, but paroxetine becomes a reasonable alternative 1

Step 2: Consider patient-specific factors

• If sleep disturbance is prominent: Gabapentin at bedtime is ideal due to somnolence side effect 1
• If patient has bipolar disorder/manic depression: Avoid SSRIs/SNRIs due to risk of inducing mania 1
• If patient is on MAO inhibitors: SSRIs and SNRIs are contraindicated 1

Step 3: Reassess at 4 weeks

• If no response by 4 weeks, switch to a different class rather than continuing 1, 3
• If venlafaxine fails, try paroxetine (if not on tamoxifen) or gabapentin 1

Common Pitfalls to Avoid

• Don't use paroxetine or fluoxetine with tamoxifen - this is the most critical drug interaction that reduces tamoxifen efficacy 1, 2
• Don't forget to taper SSRIs/SNRIs when discontinuing to avoid withdrawal syndrome 1
• Don't continue ineffective treatment beyond 4 weeks - if no improvement by then, switch agents 1, 3
• Don't add estrogen/progestin therapy in patients taking SERMs as they have potential interactions 1

Adjunctive Non-Pharmacologic Options

While pharmacologic therapy should be initiated, consider adding:

• Weight loss if overweight/obese 1, 3
• Cognitive behavioral therapy 1, 3
• Acupuncture - shown equivalent to or better than venlafaxine or gabapentin in some studies 1