Renal impairment induced by isotretinoin

Systemic isotretinoin has an impact on hemoglobin, ferritin, urea, ceruloplasmin, albumin, uric acid levels, and neutrophil to lymphocyte ratio in acne patients

BACKGROUND

Patients suffering from moderate-to-severe acne are commonly treated with systemin isotretinoin; however, a great controverse about its safety had been raised. The aim of the present study is to evaluate the effects of isotretinoin on hepatic, renal, and hematologic functions and to evaluate the potential oxidative stress in relation to isotretinoin therapy.

METHODS

Fifty-three female patients, treated from moderate-severe acne with isotretinoin (0.5 mg/kg/day), were included. Blood samples were taken for measuring low density lipoprotein (LDL), triglycerides, hemoglobin, erythrocyte sedimentation rate (ESR), bilirubin, total protein, albumin, globulin, blood urea nitrogen, ferritin, uric acid, creatinine, C-reactive protein (CRP), ceruloplasmin, alanine transaminase (ALT), aspartate transaminase (AST) levels, and red blood cells (RBC), white blood cells (WBCs), and platelet counts before starting isotretinoin treatment and 6 months later.

RESULTS

Isotretinoin was associated with increased levels of triglycerides, LDL, ESR, CRP, uric acid, and ferritin after 6 months of therapy (p < 0.0001), blood urea levels were significantly elevated from 3.681 ± 0.91 to 3.838 ± 0.877 (p = 0.014), ALT, AST, hemoglobin, globulin, and total proteins were significantly elevated after 6 months. Platelets, WBCs, albumin, albumin/globulin ratio, copper, ceruloplasmin, and neutrophil/lymphocyte ratio were significantly decreased after 6 months.

CONCLUSION

Isotretinoin therapy could be associated with oxidative stress and hepatic, lipid, and blood abnormalities in patients with acne. Serum ferritin was elevated while serum ceruloplasmin was decreased. Isotretinoin could also affect immune regulation (decreasing neutrophil to lymphocyte ratio), isotretinoin was associated with a possible positive nitrogen balance (increasing proteins) and with elevations of blood urea nitrogen and uric acid levels.

Isotretinoin and the Kidney: Opportunities and Threats

Retinoids are one of the most effective drugs in inducing complete or prolonged remission of severe acne vulgaris, but the adverse reactions associated with the use of them are raising a concern about the potential effect of these drugs on internal organs function such as the kidney. The aim of this review is to comprehensively gather data about isotretinoin, both potential adverse and beneficial effects on the kidney based on the current experimental and clinical findings. Very few studies, including five case reports, described that systemic oral isotretinoin within usual doses (40 mg/day or 0.5 mg/kg⁄day) within 1 to 4 months of treatment might be associated with different types of renal dysfunctions. These include acute interstitial nephritis, nephrotic syndrome, and hematuria with dysuria. The adverse reactions of systemic isotretinoin on the kidney and urinary system are unlikely and rare. In contrast, six experimental studies demonstrated the beneficial effects of either oral or parenteral low- (2 or 5 mg/kg/day) or high- (10, 20, 25, 40 mg/kg/day) dose isotretinoin on the kidney in the rat models of glomerulonephritis, obstructive nephropathy or allograft nephropathy. The nephroprotective functions of isotretinoin in these studies were attributed to its anti-proliferative, anti-fibrotic, and anti-inflammatory actions. However, clinical studies are warranted to elucidate the possible beneficial effects of isotretinoin in preventing or attenuating kidney injury in different settings.

The safety of isotretinoin in patients with lupus nephritis: a comprehensive review

Oral isotretinoin (13-cis-retinoinc acid) is a derivative of vitamin A and belongs to the first generation of retinoids, which act as synthetic isomers of retinoic acid (RA). It is a very effective agent in a treatment of acne vulgaris; however, multiple side effects related to therapy with retinoids preclude the use of isotretinoin in less severe acne vulgaris. A significant limitation for the administration of isotretinoin appears in case of concomitant kidney disease with a special attention regarding the safety of the agent in patients with lupus nephritis (LN). The aim of this review is an assessment of the safety of isotretinoin for the treatment of acne vulgaris in patients with LN. We searched both MEDLINE and SCOPUS databases, as well as several dermatological textbooks, to present all limitations and benefits of therapy with isotretinoin or its isomer (ATRA) for patients with kidney diseases. Several mouse models of SLE revealed a significant modulatory influence of retinoids on autoimmune injury of the glomerular unit. Retinoids were demonstrated to affect mononuclear cell infiltrations of renal tissue allowing for a reduction in the overall glomerular damage. Presumptively, they can affect a synthesis of autoantibodies significantly limiting their deposition in the glomerular unit. Moreover, retinoids were also shown to affect the synthesis of different cytokines specific both for lymphocytes Th1 (IL-2, IL-12, INFγ) ant Th2 (IL-4, IL-10). The influence of retinoids on the course of LN seems to be more multidimensional than only restricted to immune aspects and these synthetic RA isomers manifest also antiproteinuric activity in comparable extent to steroidal agents. The agents were demonstrated to counteract a loss of podocytes after the injury of the glomerular unit. They can promote a differentiation of renal progenitor cells (RPCs) within the Bowman capsule into mature podocytes leading to regeneration of podocyte number. Additionally, retinoids can probably protect podocytes from injury limiting their apoptosis, as well as reducing foot process effacement. Although, an endogenous production of RA isomers increases after the injury of the glomerular unit aiming to the restoration of podocyte number, it can be significantly impaired by a loss of albumins into urine. RA isomers are progressively sequestered by albumin within the Bowman's space and therefore, they are quickly eliminated with urine. It was demonstrated that the administration of exogenous RA isomers (retinoids) can bypass the activity of albumins enhancing the regeneration of podocytes. Finally, retinoids can regulate the production of vasoactive substances influencing on different vascular functions in the kidney. They can beneficially change a balance of angiotensin metabolites through by down-regulation of angiotensin-converting enzyme type 1 and the enhancement of an expression of angiotensin-converting enzyme type 2. Another studies revealed that retinoids could also alter the activity of renal endothelin pathway; however, the significance of this effect requires further elucidation. Taken all these presented effects of retinoids in the kidney into consideration, we can conclude that isotretinoin can be the safe treatment option of acne vulgaris in patients with LN.

Safety Considerations and Monitoring in Patients Treated with Systemic Medications for Acne

Acne vulgaris, a disorder of the pilosebaceous unit, is one of the most commonly encountered conditions in dermatology practice. Effective treatment of acne vulgaris is important in that it can prevent psychosocial distress and physical scarring. Systemic therapeutic options are available for moderate to severe acne. It is imperative that the safe and effective treatment revolves around the health care provider's familiarity of side effects of various treatments. In this article, the side effects and monitoring guide for the most commonly prescribed systemic agents for acne vulgaris are reviewed.

A hidradenitis suppurativa related SAPHO case associated with features resembling spondylarthropathy and proteinuria

We present a 53-year-old man with synovitis-acne-palmoplantar pustulosis-hyperosteosis-osteitis (SAPHO) syndrome who is HLA-B27 positive with a history of uveitis and complicated by proteinuria and osteoporosis. Interesting, yet unreported features of SAPHO syndrome and the etiology of proteinuria are further discussed.

Four weeks of oral isotretinoin treatment causes few signs of general toxicity in male and female Sprague–Dawley rats

Despite widespread use of isotretinoin for its anti-acne effects and its current evaluation in clinical trials as a cancer treatment, little is known about its general toxicity in adult nonpregnant animals, particularly after oral administration which mimics the human route. Here, adult male and female Sprague-Dawley rats were gavaged daily with 0 (soy oil), 7.5, or 15 mg/kg isotretinoin for 28 days during which time body weight, food/water intake, and estrous phase were measured. At sacrifice, organ weights were collected and concentrations of dopamine (DA), serotonin and metabolites were measured in frontal cortex, striatum, hippocampus, and diencephalon. Food intake was mildly decreased in both treated groups (approximately 15% in males and 7% in females); however, body weight and water consumption were unaffected. The estrous cycle appeared slightly affected (i.e., lengthened by 15 mg/kg, and both treated groups appeared to have less time in diestrus and more time in estrus). Kidney/body weight ratio was decreased by 7.5 and 15 mg/kg isotretinoin and spleen/body weight ratio was increased in the 7.5 mg/kg group. Males of the 7.5 mg/kg group exhibited significantly higher gonad/body weight ratios than did same-sex controls. Concentrations of monoamine and metabolites in the frontal cortex and diencephalon were unaffected. Nor were striatal DA and DOPAC concentrations affected; however, there were isolated effects on striatal HVA and 5-HIAA. Hippocampal DA concentrations were marginally increased. These data indicate mild effects resulting from oral isotretinoin treatment at doses which likely produce serum levels within the range of humans.

The life-threatening complications of dermatologic therapies

Dermatologists use a variety of systemic drugs, some of which can cause severe adverse reactions and even fatalities. Ivermectin, a well-tolerated drug, can cause severe neurological side effects, whereas metronidazole, in high cumulative doses, has been associated with convulsions and rarely with hepatotoxicity. Dapsone is associated with frequent hematologic side effects, such as methemoglobinemia, hemolysis, and anemia. Although hepatotoxicity is rare and usually mild and reversible with the new antifungal agents, severe cutaneous reactions (such as toxic epidermal necrolysis, Stevens-Johnson syndrome, and anaphylaxis) have been reported. Even a relatively safe drug such as acyclovir has been reported to be the cause of renal failure and neurotoxicity. Retinoids can cause not so benign "benign" intracranial hypertension. Methotrexate can cause not only liver toxicity, but also myelosuppression and pancytopenia, which may be acute and life threatening. Nephrotoxicity is a well-recognized side effect of cyclosporine, whereas thrombotic thrombocytopenic purpura, which is associated with high morbidity and mortality, is less well known. Dermatologists should be familiar with these and other severe adverse reactions of the most popular and most used systemic medications of our trade.

Safety issues in isotretinoin therapy

Isotretinoin (Accutane, Roche Laboratories Inc, Nutley, NJ) is an important drug, not only for the treatment of severe acne, but also for other diagnoses and in chemoprevention settings. Because the use of isotretinoin is increasing, it is important for physicians to be aware of the adverse events, toxicities, and management issues related to its use. The most important issue is that of congenital defects, which has resulted in new pregnancy prevention policies and programs implemented by the manufacturer. A relatively new concern is that of depression associated with isotretinoin use, also resulting in new policies placed by the manufacturer and the FDA. The most common adverse effects observed during treatment are mucocutaneous and ocular in nature, but laboratory abnormalities and effects in the nervous, musculoskeletal, gastrointestinal, pulmonary, hematologic, and other systems are also described. Additionally, potential drug interactions, follow-up, and toxicity prevention measures are discussed.