- Dry Lips and Skin
- Dry Eyes and Vision
- Nasal Dryness
- Thinning Hair:
- Fatigue (15-20%)
- Headaches (5-16%)
Organs That May Be Affected
Dry Itchy Eyes
- Common problem (blepharoconjunctivitis)
- Loss of visual acuity uncommon.
- Rare night blindness which may be permanent
- Stop wearing lenses
- Frequent use of artificial tears
- If possible loss of visual acuity or night vision changes
- Opthalmological opinion should be sought
Dry Skin and Lips
- Dry lips:
- Almost all patients have very dry lips. The lack of dryness raises the possibility of the patient either not taking the medication or not ingesting the drug with food.
- Secondary bacterial infection is common
- Dry Skin:
- The face and backs of the hands and forearms are usually the driest. 87% of patients
- There is often a low grade dermatitis present.
- Look out for secondary staph infection.
- Dry Lips:
- Frequent use of vaseline and lip balm containing sunscreen.
- Antibiotic ointments if inflammation or crusting
- Dry Skin:
- Avoid drying cleansers
- Regular moisturizing
Uncommon Eye Side Effects
- Corneal opacities which do not impair vision and have been show o disappear after discontinuation of drug
- Cataracts have been reported in adults
- Retinal changes leading to night blindness. Rarely these changes can be permanent
- Tetracyclines – may increase risk of pseudotumour cerebri – avoid concomitant use
- Pancreatitis – rare
- in patients with normal or elevated triglycerides
- d/c drug
- also d/c if triglycerides cannot be controlled due to increase risk of pancreatitis
- Hepatoxicity – increased lfts, usually resolve if continue with therapy
- Inflammatory bowel disease -d/c drug
- may or may not result in resolution of sx
- Rhabdomyolysis – rare
- CVS: palipitations, tachycardia, stroke
- Endocrine: altered blood sugars
- Heme: anemia, thrombocytopenia rare
- Cuts that take longer to heal
- Facial redness, flushing – more common .in fair haired people
- This drug is teratogenic and causes fetal abnormalities.
- Hyperostosis, osteophytes (bony spurs) may develop, but are usually of little consequence.
- There is a possible risk of osteoporosis, osteopena, bone #, increased risks with high does, long-term, multiple courses.
- A pseudotumor in the cerebrum can occur, which can cause increased brain fluid pressure, headaches, vomiting, and visual disturbances.
- Depression and suicidal thoughts have been reported in some patients.
- Cholesterol/ triglyceride levels may increase, a short-term increase in cholesterol, though this is not thought to be very significant. The increase is dose related.
- Usually reversible with D/C therapy. Full impact on lipids seen in about 4 weeks following therapy
- Incidence of hypertriglyceridemia is 1 in 4
- Pancreatitis is a risk if your triglycerides rise quickly.
- This may be a marker for familial hyperlipidaemia. And may be an indication to check lipid levels in 1st degree relatives
- A pseudotumor in the cerebrum can occur, which can cause increased brain fluid pressure, headaches, and vomiting.
- Tinnitus, hearing impairment has been reported
- Visual disturbances, corneal opacities usually resolve on stopping the drug
- Decreased night vision may or may not resolve with cessation of therapy
- Dizzy spells, drowsy, seizure, lethargy, malaise, nervousness may occur
- Headaches persist with benign intracranial hypertension and are present on waking. May lift as the day progresses, nausea, vomiting and visual changes are warning signs.
- Opthalmologic exam is required. Refer to Neurologist if in doubt.
Depression caused by Isotretinoin?
- Anxiety and depression and decrease quality of life is associated with acne.
- Depression and suicide is relatively common in the teenage population.
- Accutane packet insert warns of possible psychiatric side effects including aggressive and violent behaviour.
- Mood swings, depressive symptoms and suicidal thoughts may be a very uncommon idoisyncratic reaction for those on Isotretinoin.
- A causal relationship has not been firmly established.
- Awareness of mood changes in all teenagers with acne is important.
- Close monitoring of mood in all patients on Isotretinoin is prudent.
- Clinical experience shows that depressive symptoms, if they occur, disappear quickly in the vast majority on discontinuation of the drug.
Publications About Psyche and Isotretinoin
- Arch Dermatol 2000 oct;136(10):1231-6 – “No evidence.”
- Clin Exp Dermatol 1991 may;16(30:210-1 – Psych benefit of Isotretinoin use.
- J Am Acad Dermatol 2001 nov;45(5):s168-75 – be aware of risk factors for suicide and monitor for depressive symptoms.
- J Am Acad Dermatol 1987 jul;17(10:25-32 – Reduced anxiety and depression from Isotretinoin use.
- Australasian J Dermatol.2002 nov;43(4):262-8 – No link with Isotretinoin and depression apart from being a rare, unpredictable idiosyncratic side-effect.
- Austral N Z J Psychiatry 2003 feb;37(1):78-84 – Causal relationship for depression not clearly established. A positive psychological effect in the majority.Depression may occur as an idiosyncratic side-effect and requires detection and treatment.
- CBC, Cholesterol, Trigycerides
- ALT, AST
- LFTS During Use:
- Repeat in 4 weeks. If ALT is 2-3 times baseline repeat testing in 3 weeks and reduce the dose.
- If the levels climb higher d/c the drug and retest in 3 weeks
- Pregnancy Testing:
- Two negative urine tests prior to initiating therapy.
- Repeat monthly prior to renewal of prescription.
- Fasting Lipids at baseline then every 1-2 weeks until response is established.
- Monitoring of Lipids next slide
- Triglyceride elevation during Isotretinoin use may be a marker of familial combined hyperlipidemia
- See Ann Inter Med 2002:136:582-589
- Trigycerides and cholesterol elevation of the triglycerides above 7 may be associated with pancreatitis.
- Cholesterol elevation during therapy may not pose a short term threat.
- Familial combined hyperlipidemia is associated with a risk of hyperlipidemia, diabetes, hypertension and obesity in later life
- Check lipids of first degree relatives of Isotretinoin patients who have elevated triglycerides