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On Dosage and Diet: Isotretinoin - Practical Dermatology
- Risks of Accutane
Please refer to this medication by its ClinicalTrials. Epub 2017 Jul 5. Hair of Health and Human Processes The safety and scientific validity of this medicine is the responsibility of the study record and investigators.
For the past three decades, isotretinoin has been one of the most effective treatments on the market for severe acne. Sincethe brand name Accutane has no longer been available on the market, and several other generic isotretinoin formulations have emerged. This article will provide a summary of the use of isotretinoin for acne and examine the effects of dosing and diet on treatment efficacy. Isotretinoin is an oral retinoid indicated for the treatment of severe, recalcitrant, nodular acne not responsive to traditional therapies.
Unlike other therapies, it addresses all of the known acne pathogenic factors, including sebum production, follicular hyperkeratinization, bacterial proliferation, and inflammation. It is a lipophilic molecule, which enhances its penetration to the sebaceous glands. Moreover, absorption is influenced by dosing daily versus twice daily and by the presence of a fatty meal.
For optimal absorption, isotretinoin must be taken with high-fat, high-calorie meals. In the real world, where many patients do not even eat three meals a day, let alone high-fat, high-calorie meals, absorption of isotretinoin may be much lower.
Moreover, many dermatologists are not educating patients on the true dietary needs of patients on this medication. One study showed that percent of teenagers regularly skip meals. The goal of isotretinoin treatment is to give patients both a short-term improvement and long-term remission. Relapse rates are low, but re-treatment is not uncommon.
Several risk factors for relapse have been identified. One study followed severe acne patients treated with isotretinoin for five years post-treatment. Of relapsed patients, 17 percent required two courses, five percent required three courses, and one percent required more than three courses.
One of the major, modifiable risk factors for relapse is insufficient dose. Prescribers must acknowledge that non-adherence to prescribed regimens and under-dosing are common. Patient-related factors cannot be controlled, but prescribers must make sure that the target cumulative doses are reached. Low doses of isotretinoin are often prescribed; patients cannot be discontinued after the standard weeks of therapy, as adequate cumulative drug levels will not have been reached.
Diet and number of doses per day can both affect drug absorption. Plasma levels of isotretinoin in the fasting state have been shown to be nearly 60 percent lower than levels in the fed state. In addition, trough levels of twice-daily dosing with isotretinoin actually exceed once-daily peak levels.
Currently, 63 percent of prescriptions are for twice-daily dosing. It is important to evaluate our patients with each visit to the office. If their skin and lips are not dry, they may not be satisfactorily absorbing their medication. Is the patient taking the medication? If so, is the patient absorbing it?
Why not? In addition to giving out a prescription, we must educate our patients on how to take the medication. High-fat, high-calorie meals maximize absorption, and twice daily dosing is superior to single dosing regimens, if your patient will be adherent with taking it.
Clinical Focus January On Dosage and Diet: Isotretinoin Isotretinoin is one of the most essential agents in the treatment of acne, but dietary and dosage considerations must be made to maximize efficacy. J Am Acad Dermatol. Guidelines for optimal use of isotretinoin in acne. Food increases the bioavailability of isotretinoin. J Clin Pharmacol.
Breakfast habits, nutritional status, body weight, and academic performance in children and adolescents. J Am Diet Assoc. Regis D. Food: now and then — young people's attitudes to healthy eating. Education and Health. Young People's Food Choices: Attitudes to healthy eating and weight control, Isotretinoin for the treatment of acne vulgaris: which factors may predict the need for more than one course? Br J Dermatol. Isotretinoin for acne vulgaris years later: a safe and successful treatment.
Prospective study of risk factors of relapse after treatment of acne with oral isotretinoin. Predictive factors for failure of isotretinoin treatment in acne patients: results from a cohort of patients.
Leyden JJ. Oral isotretinoin. How can we treat difficult acne patients? Isotretinoin therapy and the incidence of acne relapse: a nested case-control study. Isotretinoin roaccutane usage--a South African consensus guideline. National Dermatology Working Group. S Afr Med J. Pharmacokinetics of isotretinoin during repetitive dosing to patients.
Eur J Clin Pharmacol. Carole C. Previous Article. View Entire Issue. From This Issue January Related Articles Recent Developments.
A healthy diet of nutrient-dense foods includes fruits, vegetables, whole grains, legumes, seeds, nuts, fish, low-fat dairy and lean meat. The Centers For. Watermelon, cucumber, lettuce, cantaloupe, peaches, celery, spinach, and apples are the foods that I try to incorporate into my meals as much as I can. The guide says that u should take Accutane with any food, untill your prescriber tells u otherwise. Swallow your Accutane capsules with a full. For optimal absorption, isotretinoin must be taken with high-fat, high-calorie meals. The FDA defines “high fat” as 50 percent of total caloric intake of the. Overall fatty foods (peanut butter, nuts, avocado, oils) make me breakout, i've adopted a high carb low fat vegan. Should i take accutane with a fat dense meal. When a patient is prescribed Accutane properly, it is dosed by weight and considered a cumulative or additive effect. Some of the side effects of accutane include inflammatory bowel disease, crohn's disease, dizzy, nervous, ulcerative colitis and dry skin. Instead you can skim milk for breakfast. Refined foods is found in cakes, ice cream, cream pies, white sugar, artificial sweeteners and muffins. Do not take Vitamin A supplement while you take accutane. Fruits: Avoid fruits such as bananas, grapes and coconut. Always take this medicine as prescribed by your health care provider.Accutane is a molecule that is very similar to Vitamin A in that it is a ring-like structure. Its primary mechanism of action is to reduce the size of the oil-producing sebaceous glands in the skin to almost imperceptible levels so that it oil secretion, clogging and inflammation due to not result in acne. However, we can remove sebaceous glands from skin, so Accutane or isotretinoin is the next best thing.
Considered the gold standard in the treatment of acne, there are two indications for its use. When a patient is prescribed Accutane properly, it is dosed by weight and considered a cumulative or additive effect.
Typically treatment courses last months, and it is dosed twice daily with food. Specifically, it is best absorbed with consumption of fatty foods. I recommend patients take their pill twice daily with some type of fat—nuts, cheese, avocado, meats or fatty fish such as tuna or salmon. Once a patient begins treatment, the first month is typically the worst month because it is a new experience to the patient. The thing that we know about this drug, is that it works every time.
This is an indication that the drug is properly dosed. Additional side effects can be dry eyes or dry nasal mucosa.
If this is the case, symptomatic treat using artificial tears or placing some Vaseline Petroleum Jelly in the nostrils before bedtime is a good way to ensure these side effects are controlled easily. Also, in younger patients who are very athletic, joint or muscle aches can occur. We are giving the liver a break by using over-the-counter non-steroidal anti-inflammatory agents such as Motrin, Aleve or ibuprofen to treat those aches and pains if it is even necessary.
Most patients with this side effect state it is not life-altering in any way and therefore to not treat it with anything, including over-the-counter pain relievers.
As per the I-Pledge protocol, it is necessary to remind female patients at each and every visit NOT to get pregnant and to use two methods of birth control. Also, it is important to remind all patients not to donate blood or share their medication while on Accutane. When monitoring a patient on Accutane, I am checking their liver function tests and their fasting lipids fats monthly as per I-Pledge protocols. In females, we are also required to test for pregnancy status monthly in compliance with I-Pledge.
Regarding females on Accutane, those of child-bearing age are required to be on two separate methods of birth control. However, if a male spouse of a female has received a vasectomy, this is only considered to be one single method of contraception for the female Accutane user.
Due the value of this drug, I-Pledge was developed as a governmental program to ensure that physicians prescribing the drug were following proper standards of care while administering the drug, that patients who took were in compliance with the regulations, and that the pharmacy where the drug was dispensed was in compliance as well.
By the second month of Accutane, a patient has typically started to see improvement and, rarely clearance. Clearance will occur towards the end of the fifth month since the dosing is additive and weight-based. I encourage my patients to stop at the end of their fifth month, as they will continue to see improvement in their skin in the six months after taking the drug. In the thirty days after discontinuing the medication, patients will see all of the expected side effects of dryness and any muscle aches or pains resolve.
They are still advised not to donate blood or get pregnant in the case of female patients. They also will need to completely take all medication that they have left over at the end of the five month period, as there are missed days that can add up which are critical to achieve the expected success of this drug.
There has been literature on Dr. Google, as I like to call it, regarding inflammatory bowel disease and Accutane. Fortunately, it is total and complete bunk. It was studied extensively in four separate clinical trials in four different countries once those allegations were made years ago.
All four studies revealed that not only did Accutane or isotretinoin not increase risk of inflammatory bowel disease in those patients who took the medication, but it decreased their risk slightly of developing the condition!
Thus, I reassure patients that other than a pregnancy during an Accutane course which would be disastrous due to the fetal defects associated with that , there are no long-term risks or sequelae that result from taking this valuable medication.
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