Would you use fezolinetant for hot flashes for men on ADT?

I might consider it after trying the usual agents that will at least partially relieve symptoms in the majority of patients, such as low-dose megestrol or venlafaxine (there are others, but these are the ones with which I have had the most experience and success).

Fezolinetant is expensive and requires monitoring liver function tests. It is not approved for this use, only for moderate-severe hot flashes caused by menopause, so you may have trouble getting it covered by insurance.

That said, it would seem like a very good question for a clinical trial.

Start with medroxyprogesterone 20 mg daily.

“Medroxyprogesterone could be considered to be the standard treatment for hot flushes in men undergoing androgen suppression for prostate cancer.”

Reference: Irani et al., PMID 19963436

Presently, I would not use Fezolinetant. First I try Effexor. It can be helpful. But in my experience, this works in a minority of men's bothersome hot flashes.

The next step, which is much more effective is low-dose estrogen patches. This has been studied in randomized clinical trials - Russell et al., PMID 29549104. The VA studied the use of DES (pre-LHRH agonist). This was used to lower testosterone to castrate levels. There was a significant rate of thromboembolic events. This is not observed with low-dose transdermal estrogens (no first pass liver metabolism effect).

These are generic and low-cost. The only downside I have experienced is calls from pharmacies asking if this was prescribed in error.