Cardiac remodeling induced by 13-cis retinoic acid treatment in acne patients

A Young Patient Presenting with Dilated Cardiomyopathy and Renal Infarction during Treatment with Isotretinoin: Mere Coincidence or Serious Side Effect of a Drug Commonly Used in Adolescence?

Isotretinoin or 13-cis-retinoic acid (RA) is one of the most effective and widely used drugs for the treatment of severe acne vulgaris. Despite being deemed safe, no definite consensus has been reached on the cardiovascular risk of RA derivatives. We report a case of heart failure due to dilated cardiomyopathy (DCM) and concomitant renal infarction occurring after 5 months of isotretinoin use in a previously healthy 18-year-old male. The patient, with a history of acne vulgaris, presented to our emergency department with left iliac fossa pain and effort dyspnea. A trans-thoracic echocardiogram showed DCM and severely reduced left ventricle ejection fraction (LVEF: 29%). During hospitalization, a total body computed tomography (CT) showed an ischemic lesion in the left kidney. Ischemic, autoimmune, infective, and heritable causes of DCM were ruled out. Cardiac magnetic resonance (CMR) evidenced LV circumferential mid-wall late gadolinium enhancement. Heart failure therapy was promptly started and up-titrated, but only poor LVEF improvement was detected overtime. Our case aims to raise awareness on rare life-threatening cardiovascular events possibly associated with isotretinoin use. To the best of our knowledge, this is the first described case of renal thromboembolism and severe DCM leading to implantable cardioverter-defibrillator (ICD) implantation occurring during isotretinoin treatment.

Tocotrienols-enriched Self-nanoemulsifying Drug Delivery System Enhances the Antileukemic Activity of All-trans Retinoic Acid but not Electrocardiogram Alterations Evoked by Its Combination with Arsenic Trioxide

All-trans retinoic acid and arsenic trioxide are the leading choices for the treatment of acute promyelocytic leukemia. Notwithstanding the impressive differentiative properties of all-trans retinoic acid and the apoptotic properties of arsenic trioxide, some problems still occur in acute promyelocytic leukemia treatment. These problems are due to patients' relapses, mainly related to changes in the ligand-binding domain of RARα (retinoic acid receptor α) and the cardiotoxic effects caused by arsenic trioxide. We previously developed a self-nanoemulsifying drug delivery system enriched with tocotrienols to deliver all-trans retinoic acid (SNEDDS-TRF-ATRA). Herein, we have evaluated if tocotrienols can help revert ATRA resistance in an APL cell line (NB4-R2 compared to sensitive NB4 cells) and mitigate the cardiotoxic effects of arsenic trioxide in a murine model. SNEDDS-TRF-ATRA enhanced all-trans retinoic acid cytotoxicity in NB4-R2 (resistant) cells but not in NB4 (sensitive) cells. Moreover, SNEDDS-TRF-ATRA did not significantly change the differentiative properties of all-trans retinoic acid in both NB4 and NB4-R2 cells. Combined administration of SNEDDS-TRF-ATRA and arsenic trioxide could revert QTc interval prolongation caused by ATO but evoked other electrocardiogram alterations in mice, such as T wave flattening. Therefore, SNEDDS-TRF-ATRA may enhance the antileukemic properties of all-trans retinoic acid but may influence ECG changes caused by arsenic trioxide administration. SNEDDS-TRF-ATRA presents cytotoxicity in resistant APL cells (NB4-R2). Combined administration of ATO and SNEDDS-TRF-ATRA in mice prevented the prolongation of the QTc interval caused by ATO but evoked ECG abnormalities such as T wave flattening.

Isotretinoin and Risk of Cardiovascular Events in Adults with Acne: A Population-based Retrospective Cohort Study

BACKGROUND

Case reports have suggested isotretinoin exposure may be associated with adverse cardiac events. There are limited data where the cardiovascular safety of isotretinoin is systematically evaluated.

OBJECTIVE

The aim of this study was to determine the strength of association between isotretinoin exposure and adverse cardiovascular events.

METHODS

This was a population-based retrospective cohort study within an integrated healthcare delivery system. Adults ≥ 18 years of age with acne between 2009 and 2018 were included. Exposure to isotretinoin was identified using pharmacy records, and propensity score 1:1 matching was performed. The primary outcome was a composite of cardiovascular outcomes, including acute myocardial infarction, heart failure, and all-cause death.

RESULTS

The cohort consisted of 12,140 adults (10.5%) exposed to isotretinoin and 103,126 adults who were never exposed. Mean follow-up was 7.1 ± 2.9 years. After propensity score 1:1 matching, 23,844 patients were included. The rates of the composite cardiovascular outcomes were 0.47 versus 0.48 per 1000 person-years in the isotretinoin and non-exposed groups, respectively. No significant association was observed between isotretinoin treatment and the composite cardiovascular outcomes (adjusted hazard ratio [HR] 0.99, 95% confidence interval [CI] 0.62-1.58), all-cause mortality (adjusted HR 1.10, 95% CI 0.62-1.95), acute myocardial infarction (adjusted HR 1.00, 95% CI 0.33-3.09), congestive heart failure (adjusted HR 0.45, 95% CI 0.14-1.40), or atrial fibrillation (adjusted HR 0.44, 95% CI 0.12-1.65).

CONCLUSIONS

Among adult patients with acne, no association was found between exposure to isotretinoin and an increased risk of cardiovascular events. Physicians should not be discouraged from prescribing isotretinoin out of concern for cardiovascular effects.