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قرص isotretinoin 20mg
قرص isotretinoin 20mg


داروی ایزوترتینوئین یا آکوتان، برای درمان آکنه های شدید پوستی (جوش) به کار می رود. این دارو موجب کاهش فعالیت و کم شدن اندازه غدد سباسه (چربی) می شود.




قرص isotretinoin 20mg

داروی ایزوترتینوئین یا آکوتان (Accuntane)، یکی از مشتقات ویتامین A است که برای درمان آکنه های شدید پوستی (جوش) به کار می رود. این دارو موجب کاهش فعالیت و کم شدن اندازه غدد سباسه (چربی) می شود و ترشح سبوم را کم می کند.

 

جذب این دارو با غذا زیاد می شود و دفع آن از طریق ادرار و مدفوع است. این دارو به صورت کپسول های 10 و 20 میلی گرم و با نام های تجاری claravis، Amnesteen، Accutane و Sotret موجود است.

 

دکتر محمدعلی نیلفروش زاده، متخصص پوست مو به سئوالات زیر پاسخ می دهد.

 

1- آیا داروی ایزوترتینوئین برای درمان جوش های پوستی موثر است؟

ایزوترتینوئین پله آخر درمان جوش های صورت می باشد و بیشتر برای درمان جوش یا آکنه های شدید پوستی توسط پزشک متخصص تجویز می شود. ایزوترتینوئین تنها درمانی است که بر علل اصلی موثر در بروز آکنه اثر می کند.

 

2- آیا آکوتان عوارضی مثل نازایی، کاهش میل جنسی و … ندارد؟

ایزوترتینوئین عوارض متعددی دارد، بخصوص اینکه مصرف آن در دوران بارداری باعث آسیب های جدی جنین می گردد. مصرف این دارو در دوران بارداری تا 50 درصد منجر به سقط جنین می گردد و در نیمی از موارد باقیمانده هم، باعث تولد نوزاد با مشکلات قلبی-عروقی و یا اسکلتی می گردد.

تغییرات خلقی مثل افسردگی در شروع درمان با این دارو معمول است.

بیشتر عوارض جانبی این دارو در طی درمان، تداخلی با روند درمان بیمار ندارد و قابل تحمل است. از جمله آنها تشدید آکنه در شروع درمان است که در 6 درصد افراد دیده می شود که با مصرف پردنیزولون خوراکی به مدت تقریبا شش هفته، قابل بهبود است.


عوارض جلدی مخاطی نیز از عوارض شایع این دارو است که با خشکی لب و پوست و گاهی بروز درماتیت و حتی زخم همراه است که با استفاده از مرطوب کننده ها و نرم کننده های لب تا حدودی بهتر می شود. البته در صورت بروز زخم باید از کرم های حاوی آنتی بیوتیک استفاده کرد تا زخم عفونی نشود.


خشکی مخاط چشم و بینی نیز با استفاده از کرم های مخصوص قابل بهبودی است.

اثرات مضر این دارو بر احشاء داخلی غیر معمول است و بیشتر شامل سردرد است. سردرد عارضه افزایش فشار داخل مغزی است که البته خوش خیم بوده و غیر شایع است.

عارضه دیگر درد مفاصل و عضلات است که با استفاده از مسکن قابل بهبودی است.

با توجه به شواهدی که نشان می دهد این دارو بر فعالیت آنزیمی کبد و لیپیدها اثر دارد، اندازه گیری این فاکتورهای خونی لازم است و در افراد در معرض خطر مثل دیابتی ها و افراد با سابقه فامیلی افزایش چربی خون باید تکرار شود. ولی این دارو باعث نازایی و یا کاهش میل جنسی نمی شود.


 

3- آیا طول مدت درمان با داروی ایزوترتینوئین باید ممتد باشد و یا باید دوره ای مصرف کرد و دوره ای را استراحت نمود و دوباره شروع کرد؟

درمان به مدت 4 تا 6 ماه باید ادامه پیدا کند و نشان داده شود که 3 تا 5 سال پس از درمان، فرد بدون آکنه باقی می ماند، ولی معمولا یک بار درمان کافی نیست و عود نیز در بعضی موارد دیده می شود.

بهتر است دوز شروع و دوره مصرف آن با پاسخ به درمان تعیین شود. در بعضی مقالات مطرح شده که درمان با دوز کم به مدت 9 ماه و حتی تا یک سال ادامه پیدا کند.

 

 

4- داروی ایزوترتینوئین تداخلی با بارداری خانم ها ندارد؟ آیا اگر قصد بچه دار شدن نداریم می توانیم ایزوترتینوئین استفاده کنیم؟

همانطور که ذکر شد این دارو به شدت باعث بروز نواقص جنینی می شود. بنابراین قبل از شروع درمان با این دارو باید تست بارداری بدهیم و اگر جواب تست منفی بود، درمان معمولا در روز اول یا دوم پریود شروع می شود. خانم ها در سنین بارداری باید کاملا در این زمینه تحت مشاوره قرار بگیرند و از خطرات این دارو بر جنین کاملا آگاه باشند.


5- آیا درمان با داروی ایزوترتینوئین، یک درمان قطعی است و روی همه افراد جواب می دهد. اگر چنین نیست پس چرا از این روش برای همه یکسان استفاده می شود؟


این درمان در 70 درصد موارد، باعث بهبودی کامل می شود، ولی در بقیه موارد ممکن است درمان طولانی تری لازم باشد و یا اصلا پاسخ به درمان دیده نشود که علل متفاوتی از جمله اختلالات هورمونی و … می تواند داشته باشد و تا زمانی که مشکل اصلی وجود دارد، درمان ایزوترتینوئین کفایت نمی کند.

 

6- پس با توجه به عوارضی که ذکر شد به نظر می رسد باید از مصرف این دارو ترسید. آیا چنین است؟

قرص isotretinoin 20mg

واقعیت این است که باید عوارض جانبی را در نظر داشت، ولی اثرات سودمند این دارو نیز قابل چشم‌پوشی نیست و بهتر است این دارو طبق نظر پزشک مصرف گردد که با کنترل آزمایشات لازم و عوارض جانبی، بتوان اثرات سودمند این دارو را تجربه کرد.


مصرف ایزوترتینوئین در بارداری

خطراتی که به دنبال مصرف داروی ایزوترتینوئین می تواند در طول بارداری به وجود بیاید موضوعی است که ذهن بسیاری از محققین را به خود مشغول کرده است.

دکتر رضا ابراهیم زاده وصال، استاد دانشگاه و متخصص ژنتیک به سئوالات زیر پاسخ می دهد.

 

1- چه مدت زمانی داروی ایزوترتینوئین در بدن باقی می ماند و چد مدت زمانی پس از این که فردی مصرف داروی ایزوترتینوئین را قطع کرد، می تواند اقدام به بارداری کند؟

مدت زمانی دقیقی که این دارو پس از مصرف از جریان خون پاک می شود در افراد مختلف، متفاوت است و این زمان به نوع دوز مصرفی هم بستگی دارد، چون برخی خانم ها دوزهای بالای دارویی را استفاده می کنند. ولی بطور متوسط حدود چهار تا پنج روز طول می کشد تا دارو از بدن دفع شود.

پزشکان پیشنهاد می کنند در صورتی که خانمی بخواهد اقدام به بارداری کند، بهتر است مدت یک ماه از آخرین مصرف این دارو گذشته باشد.

 

2- آیا مصرف ایزوترتینوئین می تواند منجر به سقط جنین و یا مرده زایی شود؟

بله. در صورتی که خانمی در اوایل بارداری ایزوترتینوئین مصرف کند، احتمال خطر سقط جنین می تواند تا حدود 50 درصد برسد.


3- آیا مصرف ایزوترتینوئین در طول بارداری می تواند منجر به نقایص تولد شود؟


بله. ایزوترتینوئین می تواند منجر به نقایص هنگام تولد در بیش از 35 درصد نوزادانی شود که مادرانشان این دارو را در طول بارداری، خصوصا در طول سه ماهه اول بارداری مصرف کرده اند.

از جمله این نقایص می توان به اختلالات و مشکلات بینایی، شنوایی، کوچکی و یا حتی عدم وجود چشم، کوچکی فک، کوچکی سر، شکاف کام و در برخی موارد به اختلالات غده تیروئید اشاره کرد.

 

4- اگر خانمی در طول دوران بارداری این دارو را مصرف کند چه اقدامی را باید انجام دهد؟

اولین و مهم ترین اقدام، قطع سریع مصرف دارو است. باید به پزشک متخصص خود مراجعه کرده و با او مشورت کند. در سه ماهه دوم بارداری می تواند با انجام سونوگرافی از وضعیت جنین خود اطلاع پیدا کند.

سونوگرافی بسیاری از نقایص مادرزادی را مشخص می کند، ولی نوزاد می تواند پس از تولد با وجود سالم بودن از لحاظ ظاهری، مشکلات تکاملی و یادگیری داشته باشد.

مصرف این دارو باید تحت نظر پزشک متخصص باشد و حتی در دوران شیردهی هم توصیه نمی شود.

فرآوری: نیره ولدخانی

بخش سلامت تبیان


منابع:

روزنامه ایران – الهام تقی زاده

هفته نامه سلامت

 

مطالب مرتبط:

قرص آکوتان برای رفع جوش

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کورک چه نوع جوشی است؟

جوش های سر سیاه

روزاسه شبیه آکنه است

جوش‌ های دوران جوانی

Isotretinoin, also known as 13-cis-retinoic acid (and colloquially referred to by its former brand name Accutane or Roaccutane), is a medication primarily used to treat severe acne. Rarely, it is also used to prevent certain skin cancers (squamous-cell carcinoma), and in the treatment of other cancers. It is used to treat harlequin-type ichthyosis, a usually lethal skin disease, and lamellar ichthyosis. It is a retinoid, meaning it is related to vitamin A, and is found in small quantities naturally in the body. Its isomer, tretinoin, is also an acne drug.

Isotretinoin is primarily used as a treatment for severe acne. The most common adverse effects are a transient worsening of acne (lasting 1–4 months), dry lips (cheilitis), dry and fragile skin, and an increased susceptibility to sunburn. Uncommon and rare side effects include muscle aches and pains (myalgias), and headaches. Isotretinoin is known to cause birth defects due to in-utero exposure because of the molecule’s close resemblance to retinoic acid, a natural vitamin A derivative which controls normal embryonic development. It is also associated with psychiatric side effects, most commonly depression but also, more rarely, psychosis and unusual behaviours. Other rare side effects include hyperostosis, and premature epiphyseal closure, have been reported to be persistent.

In the United States, a special procedure is required to obtain the pharmaceutical. In most other countries, a consent form is required which explains these risks. Women taking isotretinoin must not get pregnant during and for 1 month after the discontinuation of isotretinoin therapy. Sexual abstinence or effective contraception is mandatory during this period. Barrier methods by themselves (e.g., condoms) are not considered adequate due to the unacceptable failure rates of approximately 3%. Women who become pregnant while taking isotretinoin therapy are generally counseled to have an abortion.

It was patented in 1969 and approved for medical use in 1982.[2] It sold well for many years, but in 2009, Roche decided to discontinue manufacturing due to diminishing market share due to the availability of the many generic versions of the drug and in the setting of multiple lawsuits over side effects. It continues to be manufactured worldwide in 2019 as Absorica, Amnesteem, Claravis, Myorisan, Sotret, and Zenatane.[3]

Isotretinoin is used primarily for severe cystic acne and acne that has not responded to other treatments.[4][5][6][7] Many dermatologists also support its use for treatment of lesser degrees of acne that prove resistant to other treatments, or that produce physical or psychological scarring.[8] Isotretinoin is not indicated for treatment of prepubertal acne and is not recommended in children less than 12 years of age.[9]

قرص isotretinoin 20mg

It is also somewhat effective for hidradenitis suppurativa and some cases of severe rosacea.[10] It can also be used to help treat harlequin ichthyosis, lamellar ichthyosis and is used in xeroderma pigmentosum cases to relieve keratoses. Isotretinoin has been used to treat the extremely rare condition fibrodysplasia ossificans progressiva. It is also used for treatment of neuroblastoma, a form of nerve cancer.

Isotretinoin therapy has furthermore proven effective against genital warts in experimental use, but is rarely used for this indication as there are more effective treatments. Isotretinoin may represent an efficacious and safe alternative systemic form of therapy for recalcitrant condylomata acuminata (RCA) of the cervix. In most countries this therapy is currently unapproved and only used if other therapies failed.[11][12]

Isotretinoin is a teratogen; there is about a 20–35% risk for congenital defects in infants exposed to the drug in utero, and about 30–60% of children exposed to isotretinoin prenatally have been reported to show neurocognitive impairment.[13] Because of this, there are strict controls on prescribing isotretinoin to women who may become pregnant and women who become pregnant while taking isotretinoin are strongly advised to terminate their pregnancies.[13]

In most countries, isotretinoin can only be prescribed by dermatologists or specialist physicians; some countries also allow limited prescription by general practitioners and family doctors. In the United Kingdom[14] and Australia,[15][16] isotretinoin may be prescribed only by or under the supervision of a consultant dermatologist. Because severe cystic acne has the potential to cause permanent scarring over a short period, restrictions on its more immediate availability have proved contentious.[17] In New Zealand, isotretinoin can be prescribed by any doctor but subsidised only when prescribed by a vocationally-registered general practitioner, dermatologist or nurse practitioner.[18]

In the United States, since March 2006 the dispensing of isotretinoin is run through a website called iPLEDGE. The FDA required the companies marketing the drug in the US, which at the time that iPLEDGE was launched were Roche, Mylan, Barr, and Ranbaxy, to put this website in place as a risk evaluation and mitigation strategy. These companies formed a group called the Isotretinoin Products Manufacturing Group, and it hired Covance to run the website.[19][20] Prescribers, pharmacists, and all people to whom the drug is prescribed need to register on the site and log information into it. Women with child-bearing potential must commit to using two forms of effective contraception simultaneously for the duration of isotretinoin therapy and for a month immediately preceding and a month immediately following therapy. Additionally they must have two negative pregnancy tests 30 days apart and have negative pregnancy tests before each prescription is written.[21][22]

Increasingly higher dosages will result in higher toxicity, resembling vitamin A toxicity. Adverse effects include:[23]

Type of disorders

Very common (≥ 1/10)

Common (≥ 1/100, < 1/10)

Rare (≥ 1/10 000,< 1/1000)

Very rare (≤ 1/10 000)

bacterial infection

and mediastinal

subcutaneous tissues

connective tissue

and tendons)

Isotretinoin may stop long bone growth in young people who are still growing.[7] Premature epiphyseal closure can occur in people with acne receiving recommended doses[24] of Accutane.[25][26][27]

Generally though, premature epiphyseal closure seems to be primarily related to:

Isotretinoin is known to cause meibomian gland dysfunction which causes persistent keratoconjunctivitis sicca (dry eye).[29] Problems with the meibomian and salivary glands are likely due to the non-selective apoptosis of the cells of the exocrine glands.[30] Decreased night vision has been reported to persist in some people after discontinuation of isotretinoin therapy.[31]

The most common side effects are mucocutaneous: dry lips, skin and nose. Other common mucocutaneous side effects are inflammation and chapping of the lips (cheilitis), redness of the skin (erythema), rashes, peeling, eczema (dermatitis), itching (pruritus) and nose bleeds (epistaxis).[32] Absence of dryness of the lips is considered an indication of non-compliance with treatment (not taking the drug as advised), as it occurs in almost all people who take it.[32]

Regular use of lip balm and moisturizer is recommended throughout a course of treatment to reduce these problems. The dose may need to be decreased to reduce the severity of these side effects.[33] The skin becomes more fragile—especially to frictional forces—and may not heal as quickly as normal. Wound healing is delayed. For this reason elective surgery, waxing of hair, tattooing, tattoo removal, piercings, dermabrasion, exfoliation, etc., are not recommended. Treatment of acne scars is generally deferred until 12 months after completion of a course of isotretinoin.

Acne usually flares up 2–3 weeks into the treatment and is usually mild and tolerable. Occasionally this flare-up is severe, necessitating oral antiobiotics such as erythromycin. A short course of oral prednisolone may be required. Some dermatologists favour a few weeks of pre-treatment with oral antibiotics before commencing isotretinoin to reduce the chance of a severe flare. A “stepped” course may also be used to reduce the chance of this initial flare, by which the initial dose is low (e.g. 0.5 mg/kg) and subsequently increased throughout the course.

Isotretinoin use can rarely lead to a more severe form of acne, acne fulminans.

Isotretinoin is a teratogen highly likely to cause birth defects if taken by women during pregnancy or even a short time before conception. A few of the more common birth defects this drug can cause are hearing and visual impairment, missing or malformed earlobes, facial dysmorphism, and abnormalities in brain function. Isotretinoin is classified as FDA Pregnancy Category X and ADEC Category X, and use is contraindicated in pregnancy.[10]

The manufacturer recommends pregnancy be ruled out two weeks prior to commencement of isotretinoin, and women should use two simultaneous forms of effective contraception at least one month prior to commencement, during, and for at least one month following isotretinoin therapy.[34]

In the U.S., around 2000 women became pregnant while taking the drug between 1982 and 2000, with most pregnancies ending in abortion or miscarriage. About 160 babies with birth defects were born. After the FDA put the more strict iPLEDGE program in place for the companies marketing the drug in the US, in 2011, 155 pregnancies occurred among 129,544 women of childbearing potential taking isotrentinoin (0.12%).[35]

People taking isotretinoin are not permitted to donate blood during and for at least one month after discontinuation of therapy due to its teratogenicity.[36]

Rare psychological side effects may include depression, worsening of pre-existing depression, aggressive tendencies, irritable mood and anxiety. Very rare effects include abnormal behaviour, psychosis, suicidal ideation, suicide attempts and suicide.[6][37][38][39] In a total of 5577 adverse reactions reported to the UK’s MHRA up to 31 March 2017, the plurality (1207, or 22%) concerned psychiatric effects.[40] There were 85 reports of suicidal ideation, 56 of completed suicide and 43 of suicide attempts.[40]

The association between isotretinoin use and psychopathology has been controversial. Beginning in 1983, isolated case reports emerged suggesting mood change, particularly depression, occurring during or soon after isotretinoin use.[41] A number of studies have been conducted since then of the drug’s effect on depression, psychosis, suicidal thoughts and other psychological effects.[41]

Isotretinoin is the only non-psychiatric drug on the FDA’s top 10 list of drugs associated with depression[38][42] and is also within the top 10 for suicide attempts.[43] A black box warning for suicide, depression and psychosis has been present on isotretinoin’s packaging in the United States since 2005.[42]

In 2012, a systematic review covering all articles in the literature related to isotretinoin, depression and suicide, as well as articles related to class effect, dose response, and biologic plausibility found that the literature reviewed was consistent with an association of isotretinoin administration and depression and with suicide in a subgroup of vulnerable individuals.[37] Following this systematic review, in a 2014 review a group of Australian dermatologists and psychiatrists collaborated on a set of recommendations for safe prescribing of isotretinoin.[44] However, whether isotretinoin use is causally associated with mental illness remains controversial.[44]

Evidence for depression being causally associated with isotretinoin use includes 41 reports of positive challenge/dechallenge/rechallenge with isotretinoin, involving administering isotretinoin, withdrawing the drug and then re-administering it.[37] The majority of these cases had no psychiatric history.[37] There is also a temporal relationship between development of depression and initiation of isotretinoin treatment, with most cases developing after 1–2 months of treatment.[37] Further, higher doses of isotretinoin increases the risk of developing depression, with 25% of people showing depression on a dose of 3 mg/kg/day as compared with 3–4% at normal doses.[37] Studies have uncovered several biological processes which may credibly explain the affective changes induced by isotretinoin.

Isotretinoin has also been linked to psychosis.[23] Many of the side effects of isotretinoin mimic hypervitaminosis A, which has been associated with psychotic symptoms.[37] The dopamine hypothesis of schizophrenia and psychosis suggests that an increase in dopaminergic stimulation or sensitivity in the limbic system causes psychotic symptoms.[45]

It has been suggested that dysregulation of retinoid receptors by retinoids such as isotretinoin may cause schizophrenia.[46][47] The evidence for this is threefold – Transcriptional activation of the dopamine D2 receptor, in addition to serotonin and glutamate receptors, is regulated by retinoic acid,[46] schizophrenia and the retinoid cascade have been linked to the same gene loci[46] and retinoid dysfunction causes congenital anomalies identical to those observed in people with schizophrenia.[46] Further, the expression of dopamine receptors has indeed been shown to be regulated by retinoic acid.[48][49]

Isotretinoin has a number of muscoloskeletal effects. Myalgia (muscular pain) and arthralgia (joint pain) are rare side effects.[32] Retinoids, such as high dose etretinate, are well known to cause bone changes, the most common type of which is hyperostotic changes (excessive bone growth), especially in growing children and adolescents.[32] Other problems include premature epiphyseal closure and calcification of tendons and ligaments.[32] The bones of the spine and feet are most commonly affected. Risk factors for skeletal effects include older age, greater dosage and longer course of treatment. Most bone changes cause no symptoms and may only be noticed using X-ray imaging.[32]

قرص isotretinoin 20mg

Isotretinoin may cause non-specific gastrointestinal symptoms including nausea, diarrhea and abdominal pain.[32] The drug is associated with inflammatory bowel disease (IBD)—ulcerative colitis, but not Crohn’s disease.[50] There are also reports of people developing irritable bowel syndrome (IBS) and worsening of existing IBS.[51]

Isotretinoin and other retinoids are well known to affect the eyes. Dry eyes are very common during treatment and is caused by isotretinoin’s apoptotic effect on the meibomian glands. Some people develop contact lens intolerance as a result.[32] In some people, these changes are long-lasting or irreversible and represent Meibomian Gland Dysfunction (MGD).[29] Other common effects on the eyes include inflammation of the eyelid (blepharitis), red eye caused by conjunctivitis and irritation of the eye. More rare ocular side effects include blurred vision, decreased night vision (which may be permanent), colour blindness, development of corneal opacities, inflammation of the cornea (keratitis), swelling of the optic disk (papilloedema, associated with IIH), photophobia and other visual disturbances.[6]

Isotretinoin is also associated with sexual side effects, namely erectile dysfunction and reduced libido.[23] In October 2017, the UK MHRA issued a Drug Safety Update to physicians in response to reports of these problems.[52] This was in response to an EU review, published in August 2017, which states that a plausible physiological explanation of these side effects “may be a reduction in plasma testosterone”.[9] The review also stated that “the product information should be updated to include ‘sexual dysfunction including erectile dysfunction and decreased libido’ as an undesirable effect with an unknown frequency”.[53] There have also been reports of spermatogenesis disorders, such as oligospermia. 27 cases of sexual dysfunction report either negative dechallenge or positive dechallenge.[clarification needed][9]

Isotretinoin’s exact mechanism of action is unknown, but several studies have shown that isotretinoin induces apoptosis (programmatic cell death) in various cells in the body. Cell death may be instigated in the meibomian glands,[30][54] hypothalamic cells,[55] hippocampus cells[56][57] and—important for treatment of acne—in sebaceous gland cells.[58][59] Isotretinoin has a low affinity for retinoic acid receptors (RAR) and retinoid X receptors (RXR), but may be converted intracellularly to metabolites that act as agonists of RAR and RXR nuclear receptors.[5]

One study suggests the drug amplifies production of neutrophil gelatinase-associated lipocalin (NGAL) in the skin, which has been shown to reduce sebum production by inducing apoptosis in sebaceous gland cells, while exhibiting an antimicrobial effect on Cutibacterium acnes.[60][61][62] The drug decreases the size and sebum output of the sebaceous glands.[63] Isotretinoin is the only available acne drug that affects all four major pathogenic processes in acne, which distinguishes it from alternative treatments (such as antibiotics) and accounts for its efficacy in severe, nodulocystic cases.[64] The effect of Isotretinoin on sebum production can be temporary,[7] or remission of the disease can be “complete and prolonged.”[63][65][66]

Isotretinoin has been speculated to down-regulate the enzyme telomerase and hTERT, inhibiting “cellular immortalization and tumorigenesis.”[67] In a 2007 study, Isotretinoin was proven to inhibit the action of the metalloprotease MMP-9 (gelatinase) in sebum without any influence in the action of TIMP1 and TIMP2 (the tissue inhibitors of metalloproteases).[68] It is already known that metalloproteases play an important role in the pathogenesis of acne.[69]

A possible biological basis for the case reports of depression involves decreased metabolism in the orbitofrontal cortex (OFC) of the frontal lobe.[37] It has also been found that decreased OFC metabolism was correlated with headaches.[37] People reporting headache as a side effect often report comorbid neuropsychiatric symptoms, especially depression; a statistically significant relationship between headache and depression has been established.[70] It is suggested that people sensitive to isotretinoin-induced CNS effects may also be susceptible to other psychiatric side effects such as depression.[37]

Studies in mice and rats have found that retinoids, including isotretinoin, bind to dopaminergic receptors in the central nervous system.[38][71][72] Isotretinoin may affect dopaminergic neurotransmission by disrupting the structure of dopamine receptors and decreasing dopaminergic activity.[39] The dopaminergic system is implicated in numerous psychological disorders, including depression. Isotretinoin is also thought to affect the serotonergic system – it increases expression of 5-HT1A receptors in the pre-synaptic neuron, which inhibit serotonin secretion.[39] Isotretinoin also directly and indirectly increases the translation of the serotonin transporter protein (SERT), leading to increased reuptake and consequently reduced synaptic availability of serotonin.[39]

Inhibition of hippocampal neurogenesis may also play a role in the development of isotretinoin-induced depression.[37] A further effect of isotretinoin on the brain involves retinoic acid function in the hypothalamus, the hormone regulatory centre of the brain and part of the hypothalamus-pituitary-adrenal axis, a key part of the body’s stress response.[37] Other brain regions regulated by retinoic acid and potentially disrupted by isotretinoin include the frontal cortex and the striatum.[37]

Oral Isotretinoin is best absorbed when taken with a high-fat meal, because it has a high level of lipophilicity.[73] The efficacy of isotretinoin doubles when taken after a high-fat meal compared to when taken without food.[74] Due to Isotretinoin’s molecular relationship to Vitamin A, it should not be taken with Vitamin A supplements due to the danger of toxicity through cumulative overdosing.[75] Accutane also negatively interacts with tetracycline, another class of acne drug, and with micro-dosed (‘mini-pill’) progesterone preparations, norethisterone/ethinylestradiol (‘OrthoNovum 7/7/7’), St. John’s Wort, phenytoin, and systemic corticosteroids.

Isotretinoin is primarily (99.9%) bound to plasma proteins, mostly albumin. Three metabolites of Isotretinoin are detectable in human plasma after oral administration: 4-oxo-isotretinoin, retinoid acid (tretinoin), and 4-oxo-retinoic acid (4-oxo-tretinoin). Isotretinoin also oxidizes, irreversibly, to 4-oxo-isotretinoin—which forms its geometric isomer 4-oxo-tretinoin. After an orally-administered, 80 mg dose of liquid suspension 14C-isotretinoin, 14C-activity in blood declines with a half-life of 90 hours.[73] The metabolites of isotretinoin and its conjugates are then excreted in the subject’s urine and faeces in relatively equal amounts.[73] After a single, 80 mg oral dose of Isotretinoin to 74 healthy adult subjects under fed conditions, the mean ±SD elimination half-life (t1/2) of isotretinoin and 4-oxo-isotretinoin were 21.0 ± 8.2 hours and 24.0 ± 5.3 hours, respectively.[73] After both single and multiple doses, the observed accumulation ratios of isotretinoin ranged from 0.90 to 5.43 in people with cystic acne.[73]

The compound 13-cis retinoic acid was first studied in the 1960s at Roche Laboratories in Switzerland by Werner Bollag as a treatment for skin cancer. Experiments completed in 1971 showed that the compound was likely to be ineffective for cancer and, surprisingly, that it could be useful to treat acne. However, they also showed that the compound was likely to cause birth defects, so in light of the events around thalidomide, Roche abandoned the product. In 1975, Gary Peck and Frank Yoder independently rediscovered the drug’s use as a treatment of cystic acne while studying it as a treatment for lamellar ichthyosis, and published that work. Roche resumed work on the drug. In clinical trials, subjects were carefully screened to avoid including women who were or might become pregnant. Roche’s New Drug Application for isotretinoin for the treatment of acne included data showing that the drug caused birth defects in rabbits. The FDA approved the application in 1982.

Scientists involved in the clinical trials published articles warning of birth defects at the same time the drug was launched in the US, but nonetheless isotretinoin was taken up quickly and widely, both among dermatologists and general practitioners. Cases of birth defects showed up in the first year, leading the FDA to begin publishing case reports and to Roche sending warning letters to doctors and placing warning stickers on drug bottles, and including stronger warnings on the label. Lawsuits against Roche started to be filed. In 1983 the FDA’s advisory committee was convened and recommended stronger measures, which the FDA took and were that time unprecedented: warning blood banks not to accept blood from people taking the drug, and adding a warning to the label advising women to start taking contraceptives a month before starting the drug. However use of the drug continued to grow, as did the number of babies born with birth defects. In 1985 the label was updated to include a boxed warning. In early 1988 the FDA called for another advisory committee, and FDA employees prepared an internal memo estimating that around 1,000 babies had been born with birth defects due to isotretinoin, that up to around 1,000 miscarriages had been caused, and that between 5,000 and 7,000 women had had abortions due to isotretinoin. The memo was leaked to the New York Times[76] a few days before the meeting, leading to a storm of media attention. In the committee meeting, dermatologists and Roche each argued to keep the drug on the market but to increase education efforts; pediatricians and the CDC argued to withdraw the drug from the market. The committee recommended to restrict physicians who could prescribe the drug and to require a second opinion before it could be prescribed. The FDA, believing it did not have authority under the law to restrict who had the right to prescribe the drug, kept the drug on the market but took further unprecedented measures: it required to Roche to make warnings yet more visible and graphic, provide doctors with informed consent forms to be used when prescribing the drug, and to conduct follow up studies to test whether the measures were reducing exposure of pregnant women to the drug. Roche implemented those measures, and offered to pay for contraception counseling and pregnancy testing for women prescribed the drug – the program was called the “Pregnancy Prevention Program”.

A CDC report published in 2000[77] showed problems with the Pregnancy Prevention Program and showed that the increase in prescriptions was from off-label use, and prompted Roche to revamp its program, renaming it the “Targeted Pregnancy Prevention Program” and adding label changes like requirements for two pregnancy tests, two kinds of contraception, and for doctors to provide pharmacists with prescriptions directly; providing additional educational materials, and providing free pregnancy tests. The FDA had another advisory meeting in late 2000 that again debated how to prevent pregnant women from being exposed to the drug; dermatologists testified about the remarkable efficacy of the drug, the psychological impact of acne, and demanded autonomy to prescribe the drug; others argued that the drug be withdrawn or much stricter measures be taken. In 2001 the FDA announced a new regulatory scheme called SMART (the System to Manage Accutane Related Teratogenicity) that required Roche to provide defined training materials to doctors, and for doctors to sign and return a letter to Roche acknowledging that they had reviewed the training materials, for Roche to then send stickers to doctors, which doctors would have to place on prescriptions they give people after they have confirmed a negative pregnancy test; prescriptions could only be written for 30 days and could not be renewed, thus requiring a new pregnancy test for each prescription.[citation needed]

In February 2002, Roche’s patents for isotretinoin expired, and there are now many other companies selling cheaper generic versions of the drug. On June 29, 2009, Roche Pharmaceuticals, the original creator and distributor of isotretinoin, officially discontinued both the manufacture and distribution of their Accutane brand in the United States due to what the company described as business reasons related to low market share (below 5%), coupled with the high cost of defending personal-injury lawsuits brought by some people who took the drug.[78] Generic isotretinoin will remain available in the United States through various manufacturers. Roche USA continues to defend Accutane and claims to have treated over 13 million people since its introduction in 1982. F. Hoffmann-La Roche Ltd. apparently will continue to manufacture and distribute Roaccutane outside of the United States.[79]

Among others, actor James Marshall sued Roche over allegedly Accutane-related disease that resulted in removal of his colon.[80] The jury, however, decided that James Marshall had a pre-existing bowel disease.[81]

Several trials over inflammatory bowel disease claims have been held in the United States thus far, with many of them resulting in multimillion-dollar judgments against the makers of isotretinoin.[82]

As of 2017 isotretinoin was marketed under many brand names worldwide: A-Cnotren, Absorica, Accuran, Accutane, Accutin, Acne Free, Acnecutan, Acnegen, Acnemin, Acneone, Acneral, Acnestar, Acnetane, Acnetin A, Acnetrait, Acnetrex, Acnogen, Acnotin, Acnotren, Acretin, Actaven, Acugen, Acutret, Acutrex, Ai Si Jie, Aisoskin, Aknal, Aknefug Iso, Aknenormin, Aknesil, Aknetrent, Amnesteem, Atlacne, Atretin, Axotret, Casius, Ciscutan, Claravis, Contracné, Curacne, Curacné, Curakne, Curatane, Cuticilin, Decutan, Dercutane, Effederm, Epuris, Eudyna, Farmacne, Flexresan, Flitrion, I-Ret, Inerta, Inflader, Inotrin, Isac, Isdiben, Isoacne, Isobest, Isocural, Isoderm, Isoface, IsoGalen, Isogeril, Isolve, Isoprotil, Isoriac, Isosupra, Isosupra Lidose, Isotane, Isotina, Isotinon, Isotren, Isotret, Isotretinoin, Isotretinoina, Isotretinoína, Isotretinoine, Isotretinoïne, Isotrétinoïne, Isotretinoinum, Isotrex, Isotrin, Isotroin, Izotek, Izotziaja, Lisacne, Locatret, Mayesta, Myorisan, Neotrex, Netlook, Nimegen, Noitron, Noroseptan, Novacne, Oralne, Oraret, Oratane, Piplex, Policano, Procuta, Reducar, Retin A, Roaccutan, Roaccutane, Roacnetan, Roacta, Roacutan, Rocne, Rocta, Sotret, Stiefotrex, Tai Er Si, Teweisi, Tretin, Tretinac, Tretinex, Tretiva, Tufacne, Zenatane, Zerocutan, Zonatian ME, and Zoretanin.[1]

As of 2017 it was marketed as a topical combination drug with erythromycin under the brand names Isotrex Eritromicina, Isotrexin, and Munderm.[1]

While excessive bone growth has been raised a possible side effect, a 2006 review found little evidence for this.[83]


مجری طرح پایلوت : انجمن داروسازان اصفهان

تحت نظارت معاونت غذا و دارو

مسئولیت صحت اطلاعات بر عهده داروخانه می باشد

*دریافت دارو فقط بصورت حضوری در محل داروخانه و با نسخه کامل امکان پذیر است*

چنانچه در خصوص “ایزوترتینوئین” سوالی دارید، عارضه خاصی مشاهده نموده اید و یا مطلب ویژه ای به نظرتان می رسد با دیگران به اشتراک بگذارید

Isotretinoin is the active ingredient in a prescription drug available under the brand names Sortret, Zenatane, Myorisane, Claravis, Amnesteem, and Absorica.

Doctors prescribe isotretinoin to treat a severe form of acne called recalcitrant nodular or cystic acne.

The Food and Drug Administration (FDA) originally approved isotretinoin as the brand name Accutane in 1982. Hoffmann La Roche manufactured it.

Hoffmann La Roche stopped making Accutane in 2009, partly due to numerous class action lawsuits filed against the company for birth defects caused by the drug.

قرص isotretinoin 20mg

In addition, plaintiffs’ complaints included Crohn’s disease, depression, suicide, and disabilities that caused them to miss work and lose wages.

Today, women and men must agree to follow guidelines in iPLEDGE program before taking isotretinoin.

iPLEDGE requires that you and your doctor and pharmacist follow certain detailed steps to ensure your safety and prevent pregnancy while you are being treated with the drug.

Although requirements vary according to your gender and stage of life, iPLEDGE requires that people who are able to reproduce use two forms of birth control while taking isotretinoin.

Your doctor will enroll you in the iPLEDGE program. Then, before filling your prescription, your pharmacist will verify your enrollment and make sure you meet the program’s requirements.

One major side effect of isotretinoin is that it dries tissues, causing dry skin, cracked lips, dry mucous membranes, and dry scalp.

It may thin hair or cause it to become dry, brittle, and fragile.

This happens because isotretinoin slows down or blocks the production and secretion of the body’s on own natural oils.

According to anecdotal reports, isotretinoin may not only thin hair on the head but also on the face, causing a loss of eyelashes and eyebrows.

Some people may become bald.

Although hair may regrow a few months after stopping isotretinoin, some people report that it took several years.

Others say isotretinoin caused permanent hair loss.

The FDA has issued two black-box warnings for isotretinoin.

One requires anyone taking it comply with the iPLEDGE program.

The second bans isotretinoin from being prescribed to women who are either pregnant or are able to become pregnant.

The FDA also cautions people who use isotretinoin that it can cause serious skin reactions, some of which can be life threatening.

You should not take isotretinoin if you are:

Talk to your doctor before taking isotretinoin if you have:

Isotretinoin can cause severe birth defects and miscarriages. It should never be taken during pregnancy.

Isotretinoin passes into breast milk, so it also isn’t safe to take while breastfeeding.

Tell your doctor all the medications you’re taking.

This also includes prescription and over-the-counter medications, vitamins and other dietary supplements (nutritional shakes, protein powders, etc.), herbal remedies and any illegal and recreational drugs.

Do not take isotretinoin if you are taking tetracycline antibiotics, such as doxycycline (Vibramycin) or demeclocycline (Declomycin, Declostatin, Ledermycin) or vitamin A.

Avoid taking isotretinoin if you’re taking:

Talk to your doctor about the risks and benefits of taking isotretinoin if you’re using:

You should avoid or limit drinking while taking isotretinoin.

The liver breaks down isotretinoin several different ways, one of them being the same as grapefruit juice.

Avoid grapefruit and the juice while you’re taking isotretinoin.

Your doctor prescribes your dose and course of treatment based on your body weight.

Take isotretinoin quickly with a full glass of water, which prevents it from lodging in your esophagus and irritating it.

Some brands should be taken with food or milk.

If you suspect an overdose, you should contact a poison control center or emergency room immediately.

You can get in touch with a poison control center at (800) 222-1222.

If you miss a dose of Isotretinoin, try to take it as soon as you remember.

If it’s almost time for the next dose, just skip the missed dose and take your next dose as you normally would.

قرص isotretinoin 20mg

Don’t take two doses of isotretinoin at the same time.

By Frieda Wiley, PharmD, CGP, RPh | Medically Reviewed by Robert Jasmer, MD

Latest Update: 2015-05-18 Copyright © 2014 Everyday Health Media, LLC

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Review question

How effective and safe is isotretinoin, taken in a tablet for people with acne? We reviewed the evidence about the effect of isotretinoin when compared either to itself at a different dose, to placebo (an identical but inactive treatment), or to other systemic (oral or injected medicines that work throughout the entire body) or topical (applied to the outside of the body) therapies. Eligible participants had to have been diagnosed with acne by a doctor.

Background

Acne is a persistent inflammatory disease that can affect more than 80% of teenagers. Acne (including blackheads, whiteheads, and pimples) mostly appears on the face, but can also appear on the back and chest. Mental health problems, depression, and suicidal thoughts have been associated with acne. Isotretinoin, a currently widely used therapy derived from vitamin A, transformed acne treatment. However, it may cause adverse effects and has been associated with still uncertain psychiatric events and inflammatory bowel disease.

قرص isotretinoin 20mg

Study characteristics

We searched the medical literature up to July 2017 and included 31 studies, involving 3836 dermatology outpatients worldwide. There were twice as many males than females; their ages ranged from 12 to 55 years old. Acne severity ranged from mild to severe, although most participants had severe acne.

The pharmaceutical industry funded 12 included studies.

We found studies that compared oral isotretinoin versus placebo or other treatments such as antibiotics. In addition, different doses, regimens (course of medical treatment), or formulations of oral isotretinoin were assessed, as well as oral isotretinoin with the addition of topical agents.

Key results

Three studies compared oral isotretinoin versus any oral antibiotic plus any topical agent given to participants with moderate or severe acne for between 20 to 24 weeks. Their outcomes were measured straight after treatment stopped.

There was no difference between therapies in decreasing the number of inflamed lesions (an area of an organ or tissue that has been damaged by disease or trauma). In one participant, isotretinoin led to the development of Stevens-Johnson syndrome (a serious disease where skin reacts severely, often in response to medication); there were no serious side effects in the other group. However, we are uncertain of these results because they were based on very low-quality evidence.

When assessed by a doctor, the severity of acne may be slightly improved by isotretinoin, but it may cause more side effects such as inflamed lips, dry skin, or nausea (low-quality evidence).

Fourteen studies compared different doses/courses of oral isotretinoin between 12 to 32 weeks. Participants had mainly severe or moderate acne.

Two studies, each comparing three different doses of isotretinoin at 20 weeks, found a greater improvement (measured by inflammatory lesion counts) with the higher dose (low-quality evidence). A third study showed that continuous (daily) low dose and continuous (daily) conventional dose may improve acne more than intermittent therapy, measured at 24 weeks (low-quality evidence). Conventional dose isotretinoin reduced inflammatory lesion counts more than low dose, but this was based on very low-quality evidence, indicating uncertainty.

During treatment (from 12 to 32 weeks) or follow-up after end of treatment (up to 48 weeks), no serious side effects occurred in 14 studies analysing different doses of isotretinoin (low-quality evidence). Doctor-measured severity of acne was not assessed in this comparison. Less serious side effects, including skin dryness, hair loss, and itching, were assessed in 13 studies, but we are uncertain if there were any differences between groups (low- to very low-quality evidence, where assessed).

No study reported birth defects.

Quality of the evidence

The overall quality of evidence for all of our key outcomes was low, due to serious limitations of study design and the limited amount of data. Thus, the identified clinical trials neither support nor challenge the established place of oral isotretinoin in acne treatment.

Evidence was low-quality for most assessed outcomes.

We did not find any clear evidence from RCTs that isotretinoin improves acne severity compared with standard oral antibiotic and topical treatment when assessed by a decrease in total inflammatory lesion count, but it may slightly improve physician-assessed acne severity. Only one serious adverse event was reported in the isotretinoin group, which means we are uncertain of the risk of serious adverse effects; however, isotretinoin may result in increased minor adverse effects.

Heterogeneity in the studies comparing different regimens, doses, or formulations of oral isotretinoin meant we were unable to undertake meta-analysis. Daily treatment may be more effective than treatment for one week each month. None of the randomised studies in this comparison reported serious adverse effects, or measured improvement in acne severity assessed by physician’s global evaluation. We are uncertain if there is a difference in number of minor adverse effects, such as skin dryness, between doses/regimens.

Evidence quality was lessened due to imprecision and attrition bias. Further studies should ensure clearly reported long- and short-term standardised assessment of improvement in total inflammatory lesion counts, participant-reported outcomes, and safety. Oral isotretinoin is a well-established treatment for severe acne, and for acne that has not responded to oral antibiotics plus topical agents. The clinical trial evidence for oral isotretinoin conducted around 30 years ago was low quality. Further trials are needed to evaluate different dose/regimens of oral isotretinoin in acne of all severities.

Acne vulgaris, a chronic inflammatory disease of the pilosebaceous unit associated with socialisation and mental health problems, may affect more than 80% of teenagers. Isotretinoin is widely recognised as a very effective treatment for severe acne; however, it may cause adverse effects.

To assess efficacy and safety of oral isotretinoin for acne vulgaris.

We searched the following databases up to July 2017: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO and LILACS. We updated this search in March 2018, but these results have not yet been incorporated in the review. We also searched five trial registries, checked the reference lists of retrieved studies for further references to relevant trials, and handsearched dermatology conference proceedings. A separate search for adverse effects of oral isotretinoin was undertaken in MEDLINE and Embase up to September 2013.

Randomised clinical trials (RCTs) of oral isotretinoin in participants with clinically diagnosed acne compared against placebo, any other systemic or topical active therapy, and itself in different formulation, doses, regimens, or course duration.

We used standard methodological procedures expected by Cochrane.

We included 31 RCTs, involving 3836 participants (12 to 55 years) with mild to severe acne. There were twice as many male participants as females.

Most studies were undertaken in Asia, Europe, and North America. Outcomes were generally measured between eight to 32 weeks (mean 19.7) of therapy.

Assessed comparisons included oral isotretinoin versus placebo or other treatments such as antibiotics. In addition, different doses, regimens, or formulations of oral isotretinoin were assessed, as well as oral isotretinoin with the addition of topical agents.

Pharmaceutical companies funded 12 included trials. All, except three studies, had high risk of bias in at least one domain. Attrition bias was high in 20 trials, selective reporting bias was high in 12 trials, and performance bias was high in 11 trials.

Oral isotretinoin compared with oral antibiotics plus topical agents

These studies included participants with moderate or severe acne and assessed outcomes immediately after 20 to 24 weeks of treatment (short-term). Three studies (400 participants) showed no evidence that isotretinoin decreases trial investigator-assessed inflammatory lesion count more than antibiotics (RR 1.01 95% CI 0.96 to 1.06), with only one serious adverse effect found, which was Stevens-Johnson syndrome in the isotretinoin group (RR 3.00, 95% CI 0.12 to 72.98). However, we are uncertain about these results as they were based on very low-quality evidence.

Isotretinoin may slightly improve (by 15%) acne severity, assessed by physician’s global evaluation (RR 1.15, 95% CI 1.00 to 1.32; 351 participants; 2 studies), but resulted in more less serious adverse effects (67% higher risk) (RR 1.67, 95% CI 1.42 to 1.98; 351 participants; 2 studies), such as dry lips/skin, cheilitis, vomiting, nausea (both outcomes, low-quality evidence).

Different doses/therapeutic regimens of oral isotretinoin

For our primary efficacy outcome, we found three RCTs, but heterogeneity precluded meta-analysis. One study (154 participants) reported 79%, 80% and 84% decrease in total inflammatory lesion count after 20 weeks of 0.05, 0.1, or 0.2 mg/kg/d of oral isotretinoin for severe acne (low-quality evidence). Another trial (150 participants, severe acne) compared 0.1, 0.5, and 1 mg/kg/d oral isotretinoin for 20 weeks and, respectively, 58%, 80% and 90% of participants achieved 95% decrease in total inflammatory lesion count. One 24-week RCT of participants with moderate acne compared isotretinoin at (a) continuous low dose (0.25 to 0.4 mg/kg/day), (b) continuous conventional dose (0.5 to 0.7 mg/kg/day), and (c) intermittent regimen (0.5 to 0.7 mg/kg/day, for one week in a month). Continuous low dose (MD 3.72 lesions; 95% CI 2.13 to 5.31; 40 participants; one study) and conventional dose (MD 3.87 lesions; 95% CI 2.31 to 5.43; 40 participants; one study) had a greater decrease in inflammatory lesion counts compared to intermittent treatment (all outcomes, low-quality evidence).

Fourteen RCTs (906 participants, severe and moderate acne) reported that no serious adverse events were observed when comparing different doses/therapeutic regimens of oral isotretinoin during treatment (from 12 to 32 weeks) or follow-up after end of treatment (up to 48 weeks). Thirteen RCTs (858 participants) analysed frequency of less serious adverse effects, which included skin dryness, hair loss, and itching, but heterogeneity regarding the assessment of the outcome precluded data pooling; hence, there is uncertainty about the results (low- to very low-quality evidence, where assessed).

Improvement in acne severity, assessed by physician’s global evaluation, was not measured for this comparison.

None of the included RCTs reported birth defects, but oral isotretinoin is contraindicated during pregnancy due to known teratogenic effects.

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قرص isotretinoin 20mg
قرص isotretinoin 20mg
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