Is Veozah (fezolinetant) medically indicated for a patient with a history of estrogen receptor-positive breast cancer, taking estrogen blockers, and experiencing severe menopausal symptoms?

Is Veozah (Fezolinetant) Medically Indicated for This Patient?

Yes, Veozah (fezolinetant) is medically indicated for this patient with estrogen receptor-positive breast cancer experiencing severe menopausal symptoms while on estrogen blockers, as it is FDA-approved specifically for moderate to severe vasomotor symptoms due to menopause and represents a non-hormonal alternative that does not interfere with cancer treatment. 1

Rationale for Use in Breast Cancer Survivors

Why Non-Hormonal Therapy is Essential

• Hormonal therapy is contraindicated in patients with estrogen receptor-positive breast cancer due to a three-fold increased risk of recurrence and new primary breast cancers 2
• Up to 20% of breast cancer patients discontinue their life-saving endocrine therapy (tamoxifen or aromatase inhibitors) due to intolerable menopausal symptoms, which directly impacts mortality 2
• Maintaining adherence to estrogen blockers is critical for reducing recurrence and improving survival, making effective symptom management a mortality issue 2

Veozah's Specific Indication and Mechanism

• FDA-approved indication: Treatment of moderate to severe vasomotor symptoms due to menopause 1
• Mechanism: Neurokinin 3 (NK3) receptor antagonist that does not involve estrogen pathways 1
• No hormonal interference: Unlike estrogen-based therapies, fezolinetant does not compromise the therapeutic effect of estrogen blockers 1

Alternative Non-Hormonal Options (Context for Decision-Making)

While Veozah is appropriate, understanding the alternatives helps contextualize this choice:

Traditional First-Line Non-Hormonal Agents

• SNRIs (venlafaxine) and SSRIs (paroxetine) are recommended for severe hot flashes in breast cancer patients 2, 3
• Gabapentin is also supported by guidelines for vasomotor symptoms 2, 3
• Critical caveat: Paroxetine should be avoided in patients on tamoxifen due to CYP2D6 inhibition that reduces tamoxifen's conversion to active metabolites 2, 3

Why Veozah May Be Preferred

• Newer mechanism: Offers an alternative when SSRIs/SNRIs/gabapentin cause intolerable side-effects (which are "relatively common" per guidelines) 2
• Addresses multiple symptoms: The patient reports hot flashes, joint pain, and insomnia—all potentially improved by effective vasomotor symptom control 1
• Patient already experiencing relief: The clinical scenario indicates Veozah has provided symptom relief, supporting continued use 1

Critical Safety Monitoring Requirements

Mandatory Hepatic Monitoring Protocol

This is non-negotiable for patient safety 1:

• Baseline: ALT, AST, alkaline phosphatase, total and direct bilirubin before starting
• Do not initiate if ALT or AST ≥2× ULN or total bilirubin ≥2× ULN 1
• Follow-up testing: Monthly for first 3 months, then at 6 and 9 months 1
• Discontinue immediately if transaminases >5× ULN, or if >3× ULN with bilirubin >2× ULN 1

Warning Signs Requiring Immediate Discontinuation

Patients must stop Veozah and seek immediate medical attention if experiencing 1:

• New onset fatigue or decreased appetite
• Nausea, vomiting, or abdominal pain
• Pruritus or jaundice
• Dark urine or pale feces

Contraindications to Verify

Ensure the patient does not have 1:

• Known cirrhosis
• Severe renal impairment or end-stage renal disease
• Concomitant use with CYP1A2 inhibitors

Clinical Decision Algorithm

For breast cancer survivors with severe menopausal symptoms:

1. Confirm hormonal therapy is contraindicated (estrogen receptor-positive cancer) 2
2. Assess symptom severity and impact on quality of life and adherence to cancer treatment 2
3. Rule out Veozah contraindications (cirrhosis, severe renal impairment, CYP1A2 inhibitor use) 1
4. Obtain baseline liver function tests 1
5. If baseline labs acceptable, initiate Veozah 45 mg daily 1
6. Implement mandatory monitoring schedule 1
7. Consider alternatives (venlafaxine, gabapentin) only if Veozah is contraindicated or causes intolerable effects 2, 3

Quality of Life and Mortality Considerations

The use of effective non-hormonal therapy directly impacts mortality by:

• Preventing discontinuation of life-saving endocrine therapy that reduces breast cancer recurrence 2
• Improving quality of life without compromising cancer treatment efficacy 2
• Addressing severe symptoms (hot flashes, insomnia, joint pain) that significantly impair daily function 2

Bottom line: For this patient with documented symptom relief on Veozah, continuation is medically indicated provided proper hepatic monitoring is maintained and no contraindications develop 1.