Evaluation of compliance with isotretinoin PPP recommendations and exploration of reasons for non-compliance: Survey among French-speaking health care professionals and patients in Belgium

Compliance with the pregnancy prevention program among women initiating isotretinoin treatment between 2014 and 2021: A nationwide cohort study on the French Health Data System (SNDS)

BACKGROUND

Despite the French pregnancy prevention program (PPP), a considerable number of pregnancies are potentially exposed to oral isotretinoin. New measures were taken by the French Medicines Agency, including the restriction of initial isotretinoin prescriptions to dermatology specialists in May 2015 and a new information campaign on teratogenicity in January 2019.

OBJECTIVES

The aims were to: describe, between 2014 and 2021, compliance with PPP recommendations: isotretinoin use as a second-line treatment, first prescription by a dermatology specialist, monthly prescription renewal and pregnancy testing (PT); assess the effect of the 2015 and 2019 measures on PT compliance; and identify the determinants of PT noncompliance.

METHODS

A retrospective cohort study was conducted among women aged 11-50 years initiating isotretinoin between 2014 and 2021 using the French Health Data System. PT compliance corresponded to pregnancy test completion and specific delays between prescription and dispensation. Time series analyses were performed to evaluate the effect of the 2015 and 2019 measures on PT compliance, and log-binomial and Poisson multivariate regression models were used to identify the determinants of PT noncompliance.

RESULTS

Isotretinoin was prescribed as a second-line treatment in 64% of initiations, mainly by dermatology specialists (92%). A new monthly prescription was observed in 98% of dispensations. PT compliance reached 61%, 72% and 25% at initiation, renewals and end of treatment, respectively. The 2015 measure was associated with better PT compliance at initiation and renewals. The 2019 measure had no significant effect on PT compliance at the initiation or end of treatment but was associated with a decrease in PT compliance at renewals. Age, low socioeconomic level, initiation by a nondermatology specialist and during summer were associated with PT noncompliance.

CONCLUSIONS

Understanding factors associated with PT noncompliance could help to target specific subpopulations of women treated with isotretinoin.

Compliance with Pregnancy Prevention Recommendations for Isotretinoin Following the Amendment of the European Union Pregnancy Prevention Program: A Repeat Study in Estonia

BACKGROUND

Isotretinoin, indicated for severe acne, is a potent teratogen and therefore contraindicated in pregnancy. Thus, the pregnancy prevention program (PPP) for isotretinoin has been introduced.

OBJECTIVES

The aim of this study was to assess the concomitant use of isotretinoin and effective contraception and the rate of potential isotretinoin-exposed pregnancies in females of childbearing age in 2017-2020 in Estonia. In addition, we aimed to evaluate whether compliance with the PPP has improved compared with the previous study conducted in Estonia covering the period of 2012-2016.

METHODS

This retrospective, nationwide study using prescription and healthcare claims data included 2575 females aged 15-45 years who started using isotretinoin between 2017 and 2020.

RESULTS

For 64.7% of females of childbearing age, no concurrent use of an effective contraceptive was detected while using isotretinoin. A moderately higher contraceptive coverage (35.3%) was observed compared with the previous study (29.7%) (p < 0.001). Complete contraception coverage was highest in females aged 30-39 years with an adjusted OR of 12.8 (p < 0.001) compared with the age group 15-19 years and 2.47 (p < 0.001) compared with the age group 20-29 years. 17 pregnancies coincided with the isotretinoin treatment-related period. The risk for potential isotretinoin-exposed pregnancy was 6.6 (95% CI 3.9-10.5) per 1000 treated females of childbearing age over the 4-year observation period. The risk for potential isotretinoin-exposed pregnancies per 1000 treated females was 1.0 in females aged 15-19 years, 11.6 in females aged 20-29 years, 8.8 in females aged 30-39 years, and 7.4 in females aged 40-45 years (p = 0.009).

CONCLUSION

A slight improvement in complete contraceptive coverage during isotretinoin use has not resulted in a decrease in the risk of isotretinoin-exposed pregnancies. The contraceptive usage and risk for pregnancy vary greatly across age groups, suggesting the need for a more targeted approach to improve the effectiveness of the PPP.

Practices, Efficacy, and Reported Side Effects Associated with Isotretinoin Treatment in Palestine

Background

Isotretinoin is a commonly prescribed medication for the treatment of acne. It is associated with serious side effects that require monitoring and adherence by patients and healthcare providers. No studies have been conducted in Palestine to explore isotretinoin prescribing and utilization.

Objective

This study aims to evaluate the current clinical practices, adherence to clinical guidelines, efficacy, and reported side effects associated with Isotretinoin treatment in Palestine.

Methods

A descriptive cross-sectional online questionnaire-based study using social media platforms (eg, Facebook and Telegram) was conducted among Birzeit University students in April 2023. This study included participants aged ≥ 18 years with a history of isotretinoin treatment; subjects with incomplete data were excluded. Statistical significance was set at P < 0.05. SPSS version 27 was used for data analysis.

Results

A total of 548 participants were included in the study, the majority of most of whom were female (96%). The most predominant side effects were cracked, dry lips and xeroderma (96.2%). Moreover, 12% of participants had depression. Most respondents were educated about medication side effects and only 39.1% were counseled about blood donation. Of the 59 sexually active women, only 4 (6.8%) were asked for a recent pregnancy test. A total of 60.2% of dermatologists adhered to the American Academy of Dermatology (AAD) guidelines, and 48.7% ordered the required laboratory tests before initiating isotretinoin treatment. Only 1.7% of pharmacists followed the FDA-suggested protocols for dispensing isotretinoin to childbearing females.

Conclusion

Adherence to isotretinoin safety prescribing protocols to provide patient education, monitoring, and ordering of laboratories to ensure patient safety can be improved by adapting policies and protocols in pharmacy and medical practice in Palestine to monitor and enforce adherence when prescribing, dispensing, or taking high-risk medications.

Community pharmacists' knowledge and awareness about isotretinoin therapy and its dispensing practice in Jordan

A validated self-reported questionnaire was used to evaluate pharmacists' knowledge about isotretinoin and their awareness of isotretinoin dispensing practice. The majority were not able to recognize the initial dose of isotretinoin, the potential side effects such as dyslipidemia and liver toxicity, the potential interaction with tetracycline and Vitamin A and the contraindications of isotretinoin. Around 41.3 % of the pharmacists dispensed isotretinoin without a prescription, and the majority did not recognize that isotretinoin should be dispensed for only 30 days, should not be dispensed without an emphasis on the appropriate indication, and did not know the appropriate duration of isotretinoin therapy. Male gender and postgraduate degree were associated with better awareness, while increased work experience and postgraduate degree were associated with better knowledge about isotretinoin therapy. Nevertheless, both male and female pharmacists demonstrated equivalent knowledge levels. The current study demonstrates the need to implement educational programs to improve pharmacists' knowledge and awareness about isotretinoin and its dispensing practice.

Clinical pharmacist role in improving the knowledge and outcomes in patients using isotretinoin: A randomized, controlled study

Objective

To evaluate the role of a clinical pharmacist in improving knowledge and outcomes among isotretinoin users.

Methods

Patients were randomly assigned to an intervention group (received education about isotretinoin by a clinical pharmacist in addition to the physician) and a control group (received routine education by the physician), then followed for three months. Patients' knowledge about isotretinoin optimal use, and side effects and their management and other outcomes were measured in both groups at baseline and at follow up after three months using a validated questionnaire.

Results

Two-hundred and three patients completed the study; 103 were in the intervention group and 100 in the control group. The knowledge improvement between baseline score and follow-up score was greater in the intervention group (mean = 2.835 ± 1.329) compared to the control group (mean = 0.530 ± 0.784) with mean differences = -2.30495, P < 0.001.

Conclusion

Implementing clinical pharmacy services in dermatology clinics can positively increase patients' level of knowledge about isotretinoin, which could reduce the severity of its side effects. Therefore, improving patients' quality of life, and improvement in acne.

Practice implications

Implementing clinical pharmacist services to patients using isotretinoin is feasible in an outpatient setting. Clinical pharmacist counseling and education improve the medication knowledge among patients who use isotretinoin.

Impact of the 2018 revised Pregnancy Prevention Programme by the European Medicines Agency on the use of oral retinoids in females of childbearing age in Denmark, Italy, Netherlands, and Spain: an interrupted time series analysis

Background: In March 2018, the European pregnancy prevention programme for oral retinoids was updated as part of risk minimisation measures (RMM), emphasising their contraindication in pregnant women. Objective: To measure the impact of the 2018 revision of the RMMs in Europe by assessing the utilisation patterns of isotretinoin, alitretinoin and acitretin, contraceptive measures, pregnancy testing, discontinuation, and pregnancy occurrence concomitantly with a retinoid prescription. Methods: An interrupted time series (ITS) analysis to compare level and trend changes after the risk minimisation measures implementation was conducted on a cohort of females of childbearing age (12-55 years of age) from January 2010 to December 2020, derived from six electronic health data sources in four countries: Denmark, Netherlands, Spain, and Italy. Monthly utilisation figures (incidence rates [IR], prevalence rates [PR] and proportions) of oral retinoids were calculated, as well as discontinuation rates, contraception coverage, pregnancy testing, and rates of exposed pregnancies to oral retinoids, before and after the 2018 RMMs. Results: From 10,714,182 females of child-bearing age, 88,992 used an oral retinoid at any point during the study period (mean age 18.9-22.2 years old). We found non-significant level and trend changes in incidence or prevalence of retinoid use in females of child-bearing age after the 2018 RMMs. The reason of discontinuation was unknown in >95% of cases. Contraception use showed a significant increase trend in Spain; for other databases this information was limited. Pregnancy testing was hardly recorded thus was not possible to model ITS analyses. After the 2018 RMM, rates of pregnancy occurrence during retinoid use, and start of a retinoid during a pregnancy varied from 0.0 to 0.4, and from 0.2 to 0.8, respectively. Conclusion: This study shows a limited impact of the 2018 RMMs on oral retinoids utilisation patterns among females of child-bearing age in four European countries. Pregnancies still occur during retinoid use, and oral retinoids are still prescribed to pregnant women. Contraception and pregnancy testing information was limited in most databases. Regulators, policymakers, prescribers, and researchers must rethink implementation strategies to avoid any pregnancy becoming temporarily related to retinoid use.

An Assessment of the Knowledge of Oral Isotretinoin (Roaccutane) Treatment Among Pharmacy Students in Saudi Arabia

BACKGROUND

Oral isotretinoin (Roaccutane) is one of the most effective treatments for severe acne. However, it displays significant side effects such as teratogenicity and psychological adverse events. Previous studies have reported inadequate awareness of community pharmacists and the general population regarding the medication's potential risks and adverse effects. The aim of this study is to assess pharmacy students' awareness and knowledge about the appropriate use of oral isotretinoin (known as Roaccutane) and its associated side effects in Saudi Arabia.

METHODS

 This is a cross-sectional study that uses a validated online questionnaire adopted from the literature distributed among pharmacy students between September 2021 and November 2021.

RESULTS

This study includes 1044 pharmacy students from multiple regions of Saudi Arabia. Among the total number of students included, 47.5% of the participants had used oral isotretinoin before or had a close family member who had used it previously. The most well-known side effect reported is skin dryness (87.7%), followed by teratogenicity (45.2%) and depression (37.9%). Most of the students (90.6%) know that isotretinoin's use is contraindicated in pregnancy. Despite this, only 39.6% of the participants state that married women of childbearing age using isotretinoin must utilize two types of contraception. There was a significant difference between genders in their knowledge about the side effects of the medication (P=0.01), as well as the safety precautions that women of childbearing age should take while taking the medication, as females had better knowledge and understanding of the required measures.

CONCLUSION

The total awareness level of pharmacy students about the most common side effects of isotretinoin is generally high. However, the students' knowledge about teratogenicity and depression is inadequate. We recommend paying attention to providing better education on the potential risks and precautionary measures related to the use of this medication, especially for women of childbearing age.

Evaluating awareness, knowledge and practice of healthcare professionals following implementation of a revised pregnancy prevention programme for isotretinoin in Ireland: A multi-stakeholder cross-sectional study

PURPOSE

In 2018, following an EU-wide safety review, a revised pregnancy prevention programme (PPP) was introduced for isotretinoin (Roaccutane®). This study aimed to examine awareness, knowledge, and experience implementing the revised isotretinoin PPP in clinical practice across three healthcare professional (HCP) groups in Ireland.

METHODS

A cross-sectional study using anonymous online surveys among general practitioners (GPs), community pharmacists, and specialist consultants was undertaken. Descriptive analyses are presented.

RESULTS

Across all HCP groups there was high (≥87%) awareness that oral isotretinoin is contraindicated in women of childbearing potential (WCBP) unless the conditions of the PPP are fulfilled, but varying awareness among GPs (54.9%) and community pharmacists (45.9%) that exposure during pregnancy can cause both severe fetal malformations and spontaneous abortions. Implementation of the PPP in clinical practice varied across HCP groups. When initiating isotretinoin in WCBP, 66.7% of specialists and 40.8% of GPs indicated they had considered alternative treatment options, and 71.4% of specialists and 31.6% of GPs reported they first requested a pregnancy test. There was limited provision of the patient reminder card to WCBP, where 26.1% of community pharmacists provide this at each dispensing, while 47.6% of specialists and 11.8% of GPs ensured WCBP had a copy of the card when initiating treatment. Across all HCP groups, there was high (≥81.6%) awareness of the need for urgent consultation and immediate cessation of isotretinoin in the event of an unplanned or suspected pregnancy.

CONCLUSIONS

Reinforcement of the provision and utilisation of the isotretinoin patient reminder card may be required, and further targeted education on specific elements of the PPP should be considered for GPs and community pharmacists.

Patients' Knowledge and Information Needs about Isotretinoin Therapy Use in Jordan

BACKGROUND

Despite being the first-line treatment for severe or moderate acne, isotretinoin has several serious side effects that necessitate the evaluation of patients' knowledge about isotretinoin side effects and its proper use.

OBJECTIVE

The current study aim was to explore information needs about isotretinoin by evaluating patients' knowledge about the appropriate use of isotretinoin and its associated side effects.

METHODS

In addition to the sociodemographic variables, a validated online questionnaire was adopted from the literature to evaluate patients' knowledge about isotretinoin use and its potential side effects. Independent t-test and one-way analysis of variance (ANOVA) test were implemented to find the correlation between the study variables and the knowledge score.

RESULTS

The most recognized side effect of isotretinoin therapy was dryness (98.1%). The study patients showed good knowledge about isotretinoin use with a mean knowledge score of 8.1 (SD = 0.7). However, more than half of them (61.0%) mistakenly thought that isotretinoin therapy should be taken continuously for more than 6 months without stop, and some of them did not know that isotretinoin is recommended to be taken with fatty meal (24%) and sunblock (24.6%). Female gender (8.2 (SD = 0.8)) and using isotretinoin for more than 6 months (8.3 (SD = 1.2)) were significantly associated with a higher knowledge score of isotretinoin use (p=0.01), when compared with male patients (7.8 (SD = 0.7)) and less than 6-month use of isotretinoin (7.7 (SD = 0.7)).

CONCLUSIONS

The lack of patients' information about the potential side effects, duration of therapy, and some instructions on isotretinoin use, such as taking the medication with fatty meal and sunblock, shed the light on the necessity to prepare leaflets, educational brochures, and educational posts via social media in order to improve patients' knowledge about isotretinoin therapy and its optimal use.

Awareness on Teratogenic Effects of Isotretinoin and Compliance with Precautionary Measures among Women of Childbearing Age in Makkah Province, Saudi Arabia

Acne vulgaris ranks among the most common dermatologic conditions encountered during adolescence up to adulthood. For moderate to severe cases of acne, isotretinoin is indicated as it is considered the most efficacious medication against acne. However, isotretinoin use is known to have its side effects and most importantly is the drug's teratogenic potential. As a response, programs such as the Retinoid Pregnancy Prevention Program (PPP), System to Manage Accutane-Related Teratogenicity (SMART), and iPLEDGE were put into action as attempts to promote awareness on isotretinoin's teratogenicity and reduce the incidence of exposed pregnancies. Such programs are lacking in Saudi Arabia. This study aimed, therefore, to evaluate the awareness of women of childbearing age in Makkah Province, Saudi Arabia, with regards to the side effects of the medication, specifically its teratogenicity. This study also intended to assess the compliance of both doctors and patients with the recommendations and precautions associated with isotretinoin. A cross-sectional study was conducted on 766 women participants using a previously validated questionnaire. Results showed that majority of the respondents (91%) are generally aware of the side effects of isotretinoin use, particularly its teratogenicity. However, lapses have been identified with regards to the compliance of both the treating physician and the patient. Three-fourths of sexually active women did not use any form of contraception while being on isotretinoin treatment. Two-thirds of the study participants responded that they were not issued approval forms indicating their understanding of the side effects of isotretinoin and the importance of compliance to the treating physician's instructions; 11.5% claimed that their doctors did not perform any blood tests; and 67.7% claimed that no pregnancy test was performed at any time during the treatment. These findings strongly suggest a need for improvement when it comes to compliance of both doctors and patients. It is recommended that doctor-patient communication be more comprehensive and more efforts should be made to follow international guidelines in that regard.

Proper Counseling and Dispensing of Isotretinoin Capsule Products by Community Pharmacists in UAE: A Simulated Patient Study

PURPOSE

To evaluate the pharmacist's assessment of patient eligibility for safe use of isotretinoin and the quality of pharmacist's counseling.

PATIENTS AND METHODS

A covert simulated patient (SP) methodology was used in which a trained female researcher, who was 25 years old, played the patient's role through this cross-sectional study by visiting community pharmacies and requesting isotretinoin capsules through a controlled prescription. A data form was used to collect the information following each pharmacy visit by asking about medical/family history and providing comprehensive counseling about the most common adverse effects, proper use instructions, and the importance of adherence to medication. The pharmacists, who did not initiate counseling, were prompted by the SP.

RESULTS

The pharmacists in 400 pharmacies who agreed to participate were visited by the SP. Only 7 (2%) pharmacists provided a complete assessment of patient eligibility for using isotretinoin with comprehensive counseling. Most of the pharmacists (84%) provided incomplete assessment as indicated by the overall score. Only 11 (3%) pharmacists asked the six crucial questions for the assessment of patient eligibility. On prompting, only 6 (2%) pharmacists provided complete counseling about the expected adverse effects. The most frequently provided adverse effect was dry skin, specifically dry lips (71.8%). A minority of 108 (27%) pharmacists provided education about the importance of using contraception during isotretinoin therapy. A complete level of counseling was provided by 125 (31.3%) pharmacists regarding the lab tests that the SP needs to undergo during therapy. Female pharmacists were more likely to provide counseling about the pregnancy test (mean=134, p=0.001).

CONCLUSION

Suboptimal level of the patient's assessment was revealed with poor educational counseling by the community pharmacists. New strategies are needed to improve pharmaceutical care services in the UAE.