Isotretinoin and the controversy of psychiatric adverse effects

Isotretinoin-Induced Hypersomnia: A Cross-sectional Study and Literature Review

BACKGROUND

Isotretinoin is an oral retinoic drug for severe resistant acne cases that has controversially been associated with multiple psychiatric adverse effects. Research has primarily focused on depression and suicidality; however, a few case studies reported hypersomnia and sleep changes after isotretinoin initiation.

OBJECTIVE

To assess sleep quality and measure rates of hypersomnia, depression, and anxiety in patients undergoing isotretinoin therapy.

METHODS

This cross-sectional study was conducted at outpatient clinics of the university hospital. The rate of self-reported oversleeping was measured. In addition, researchers used the Pittsburgh Sleep Quality Index to assess sleep quality and conducted semistructured clinical interviews to detect depression and anxiety.

RESULTS

Of 123 patients with acne on isotretinoin, 77 (62.6%) reported oversleeping. Nearly half (60 patients, 48.8%) were categorized as poor sleepers according to the Pittsburgh Sleep Quality Index. The interviews revealed anxiety and depression percentages among 9.8% and 4.9% of participants, respectively.

CONCLUSIONS

Hypersomnia was noticeably high in this study sample; thus, it may cautiously suggest a possible link between isotretinoin and hypersomnia. However, more research is needed to investigate this potential relationship.

Cytotoxic Evaluation in HaCaT Cells of the Pa.7 Bacteriophage from Cutibacterium (Propionibacterium) acnes, Free and Encapsulated Within Liposomes

Introduction

Acne is a multifactorial disease involving the colonization of skin follicles by Cutibacterium (formerly Propionibacterium) acnes. A combination of different retinoid-derived products, antibiotics, and hormonal antiandrogens are used to treat the disease, but these treatments require extended periods, may have secondary effects, are expensive, and not always effective. Owing to antibiotic resistance, the use of bacteriophages has been proposed as an alternative treatment. However, if they are intended for a cosmetic or pharmaceutical use, it is necessary to evaluate the safety of the phages and the preparations containing them.

Materials and Methods

In this study, the cytotoxicity of Pa.7 bacteriophage was evaluated in HaCaT cells, along with a liposome suitable for their encapsulation, using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide and trypan blue assays.

Results

We found that Pa.7 was not cytotoxic for HaCaT cells. Also, 30 mM of liposomes, or below are considered noncytotoxic concentrations.

Conclusion

Phages encapsulated in the liposomes presented in this study can be used safely for skin treatments.

Isotretinoin and the risk of psychiatric disturbances: A global study shedding new light on a debatable story

INTRODUCTION

Isotretinoin-related risk of depression and suicidal behavior is a topic of inconclusiveness. A crucial knowledge gap exists in defining the association of isotretinoin with other psychiatric comorbidities.

OBJECTIVE

To evaluate the risk of psychiatric outcomes among patients with acne treated with isotretinoin versus oral antibiotics.

METHODS

A global population-based retrospective cohort study enrolled 2 groups of patients with acne managed by isotretinoin (n = 75,708) and oral antibiotics (n = 75,708). Patients were compared regarding the risk of 9 psychiatric outcomes.

RESULTS

Relative to those treated with oral antibiotics, patients prescribed isotretinoin experienced lower risk of depression (hazard ratio [HR], 0.90; 95% confidence interval [CI], 0.87-0.93; P < .001), but comparable risk of major depressive disorder (HR, 0.97; 95% CI, 0.92-1.03; P = .318). Risk of suicidal attempts was comparable between groups (HR, 0.97; 95% CI, 0.85-1.11; P = .663), despite the elevated risk of suicidal ideation in those under isotretinoin (HR, 1.41; 95% CI, 1.32-1.50; P < .001). Patients under isotretinoin had lower risk of post-traumatic stress disorder (HR, 0.75; 95% CI, 0.68-0.82; P < .001), anxiety (HR, 0.84; 95% CI, 0.82-0.87; P < .001), bipolar disorder (HR, 0.65; 95% CI, 0.59-0.72; P < .001), schizophrenia (HR, 0.60; 95% CI, 0.48-0.76; P < .001), and adjustment disorder (HR, 0.82; 95% CI, 0.77-0.87; P < .001).

LIMITATIONS

Retrospective data collection.

CONCLUSION

Isotretinoin confers lower risk of 6 psychiatric comorbidities and comparable risk of suicidal attempts.

Risk of psychiatric events in women treated with isotretinoin: a self-controlled study with SIDIAP database

BACKGROUND

Since isotretinoin marketing, reports of psychiatric events have been noted. Howeverto date, a relation between these events and acne or isotretinoin treatment has not been clearly established. Our objective was to analyze the incidence of psychiatric events in women receiving isotretinoin.

METHODS

Self-controlled study including women treated with isotretinoin from July 2014 to December 2018. Data source was SIDIAP, a primary health care-based database from Catalonia, Spain. Risk of psychiatric events was analyzed during the isotretinoin exposure and during the previous and posterior periods of non-exposure.

RESULTS

We included 4,738 women in the study, 25.3% of them had history psychiatric disorders prior to receiving isotretinoin. During the follow-up, 782 (16.5%) patients were diagnosed with new mental disorders and 925 (19.5%) received new psychotropic drug prescriptions. We found a trend to an increase of new events when the previous non-exposure and the isotretinoin exposure periods were compared, with no significant differences. Incident psychiatric events during isotretinoin exposure was significantly higher in those patients with previous psychiatric history.

CONCLUSIONS

We cannot conclude any causality between acne and isotretinoin and the appearance of new psychiatric events. However, we contribute to the evidence with a more robust methodological approach, which minimizes the effect of confounding variables.

Risk of psychiatric disorders in patients taking isotretinoin: A nationwide, population-based, cohort study in Taiwan

BACKGROUND

After isotretinoin's approval to treat patients with recalcitrant acne, there have been continued debates around its psychiatric safety profile. This study aimed to assess the risk of psychiatric disorders in patients with acne who are taking isotretinoin.

METHODS

We used de-identified information from Taiwan's National Health Insurance Research Database from 2000 to 2015 to examine the risk for psychiatric disorders among patients with acne who were taking isotretinoin. We performed subgroup analyses based on the dosage and duration of isotretinoin administration.

RESULTS

This study included 29,943 participants during a 16-year follow-up period. We found no significantly increased risk for psychiatric disorders among patients taking isotretinoin compared with patients who did not receive isotretinoin treatment (adjusted hazard ratio [aHR]: 1.009, 95% confidence interval [CI]: 0.422-1.696). Subgroup analyses showed no significantly increased risk for psychiatric disorders in patients taking different doses of isotretinoin (≤ 20 mg per day, aHR: 0.892, 95% CI: 0.371-1.501; > 20 mg per day, aHR: 1.068, 95% CI: 0.446-1.798). There was also no significant increase in risk for patients undergoing isotretinoin treatment over different periods (≤ 6 months, aHR: 0.924, 95% CI: 0.392-1.612; > 6 months, aHR: 1.196, 95% CI: 0.488-2.004).

LIMITATIONS

We did not analyze the risk of suicidal ideation, and it could be underestimated in medical claims databases.

CONCLUSIONS

We found no increased risk of psychiatric disorders among Taiwanese patients with acne who were taking isotretinoin. Higher dosage or longer duration of isotretinoin treatment did not increase the risk for developing a psychiatric disorder.

Isotretinoin and neuropsychiatric side effects: Continued vigilance is needed

Background

Isotretinoin (13-cis-retinoic acid, marketed under the names Accutane, Roaccutane, and others) is an effective treatment for acne that has been on the market for over 30 years, although reports of neuropsychiatric side effects continue to be reported. Isotretinoin is an isomer of the active form of Vitamin A, 13-trans-retinoic acid, which has known psychiatric side effects when given in excessive doses, and is part of the family of compounds called retinoids, which have multiple functions in the central nervous system.

Methods

The literature was reviewed in pubmed and psychinfo for research related to isotretinoin and neuropsychiatric side effects including depression, suicidal thoughts, suicide, mania, anxiety, impulsivity, emotional lability, violence, aggression, and psychosis.

Results

Multiple case series have shown that successful treatment of acne with isotretinoin results in improvements in measures of quality of life and self esteem However, studies show individual cases of clinically significant depression and other neuropsychiatric events that, although not common, are persistent in the literature. Since the original cases of depression were reported to the United States Food and Drug Administration, numerous cases have been reported to regulatory agencies in the United Kingdom, France, Ireland, Denmark, Australia, Canada, and other countries, making isotretinoin one of the top five medications in the world associated with depression and other neuropsychiatric side effects. Clinicians are advised to warn patients of the risks of neuropsychiatric side effects with isotretinoin which may arise from the medication itself, and not just as a side effect of acne or youth.

Chronic retinoic acid treatment induces affective disorders by impairing the synaptic plasticity of the hippocampus

BACKGROUND

More and more people are suffering from depression in modern society. It is believed that the development of depression results from alterations in synaptic transmission, especially in the hippocampus. Animal experiments and clinical studies have demonstrated that retinoids are essential components in hippocampal synaptic plasticity, and they have a close relationship with depression. However, it is still unclear how excessive retinoic acid (RA) causes depression and what synaptic and molecular mechanisms underlie it.

METHODS

Behavioral, electrophysiological, and molecular approaches were employed to characterize the effects of RA on depression and synaptic plasticity. RA was continuously administered intracerebroventricularly through an osmotic pump.

RESULTS

RA treatment induced depression-like behaviors, as evidenced by decreased sucrose preference and increased immobile duration in both the forced swim test and the tail suspension test. RA administration also induced anxiety-like behaviors, indicated by decreased duration in the open arms of the elevated plus maze and the central of the open field. RA treatment decreased the neuronal excitability of the hippocampus either by changing the excitatory/inhibitory receptor balance or by promoting the synthesis of inhibitory neurotransmitters. Moreover, long-term potentiation was decreased in both the excitatory postsynaptic potential and the population spike in RA-treated rats, presumably a consequence of the reduced glur1 transcript level.

LIMITATIONS

The mechanism of how excess RA affects the hippocampal gene expression and synaptic plasticity requires further study.

CONCLUSIONS

RA treatment can induce depression-like behavior in rats and impair hippocampal plasticity. Thus, improving synaptic plasticity in the hippocampus may ameliorate the affective disorders caused by excessive RA.

Challenges and Solutions in Oral Isotretinoin in Acne: Reflections on 35 Years of Experience

Acne vulgaris affects more than 80% of adolescents and young adults and forms a substantial proportion of the dermatologist's and general practitioner's caseload. Severity of symptoms varies but may result in facial scarring and psychological repercussions. Oral isotretinoin is highly effective but can only be prescribed by specialists. Side effects are recognized and mostly predictable, ranging from cosmetic effects to teratogenicity. These can affect patients' quality of life and treatment adherence. This article provides a commentary on 4 key areas: the use of oral isotretinoin vs oral antibiotics, including the importance of early recognition of nonresponse to treatment, the psychological effects of acne and isotretinoin treatment, the side effects of isotretinoin therapy, and cosmetic treatment options that can help alleviate predictable side effects. The authors, who have all participated in various international expert groups, draw on relevant literature and their extensive professional experience with oral isotretinoin in the treatment of acne. The aim of this article is to provide an informative and practical approach to managing oral isotretinoin treatment in patients with acne, to help optimize treatment of this skin disease.

Psychiatric Adverse Events in Patients Taking Isotretinoin as Reported in a Food and Drug Administration Database From 1997 to 2017

Importance

Isotretinoin is a highly effective medication for severe acne. Although no causal link between isotretinoin and psychiatric adverse effects has been established, widespread media reporting of depression and suicidality with use of isotretinoin have raised concerns in both patients and clinicians and generated numerous cases of costly litigation.

Objective

To evaluate reports of psychiatric adverse events associated with isotretinoin use submitted to the US Food and Drug Administration from January 1, 1997, through December 31, 2017.

Design, Setting, and Participants

This retrospective study evaluated reports of psychiatric adverse events with isotretinoin as the primary suspect drug in the US Food and Drug Administration's Adverse Event Reporting System from 1997 through 2017. Publicly available data on number of patients enrolled in the iPLEDGE program were used to calculate rates of completed suicide per 100 000 patients enrolled in iPLEDGE in 2009 and 2010. All data were analyzed between July 1, 2018, and January 31, 2019.

Main Outcomes and Measures

The main outcomes were frequency and type of psychiatric adverse events in patients taking isotretinoin. Secondary analyses were stratification by age and sex and evaluation of completed suicide rates.

Results

Between 1997 and 2017, 17 829 psychiatric adverse events with isotretinoin use were reported to the US Food and Drug Administration, with depressive disorders, emotional lability, and anxiety disorders reported most frequently. Of these events, 8936 (50.1%) were reported among men and 8362 (46.9%) among women; the sex of the individual was not reported for 531 events (3.0%). Of the 13 553 reports that included patient age, the mean (SD) age was 22.1 (8.6) years. More than half (52.5%) of all events occurred in 10- to 19-year-old individuals. Whereas depression and anxiety were reported equally between sexes, eating disorders were more common in females (58 of 85 [68.2%]), while attention-deficit/hyperactivity disorder (55 of 83 events [66.3%]) and completed suicides (290 of 368 [78.8%]) were more common in males. The rates of completed suicide were 8.4 and 5.6 suicides per 100 000 patients enrolled in iPLEDGE in 2009 and 2010, respectively.

Conclusions and Relevance

Although depressive disorders and suicidality were frequently reported with isotretinoin use, these reports must be considered in the context of elevated rates of depression and suicide among patients with acne at large. These data suggest that the rate of completed suicide in patients taking isotretinoin may be lower than that of the general US population. Many psychiatric adverse events unrelated to depression and suicidality were also reported, but it is unclear if they were a result of isotretinoin therapy. Although no causal link between isotretinoin and psychiatric risk has been established, patients taking the drug appear vulnerable to psychiatric concerns. Mandated monthly iPLEDGE visits may provide an opportunity to screen patients for psychiatric conditions and improve outcomes.

Psychiatric and Developmental Effects of Isotretinoin (Retinoid) Treatment for Acne Vulgaris

BACKGROUND

An association between isotretinoin (13-cis-retinoic acid, sold under trade names including Accutane [Hoffmann-La Roche Inc, Basel, Switzerland]) and birth defects, depression, and suicide is well documented but controversial. A link to psychosis and exacerbation of bipolar symptoms is less extensively addressed in the literature.

OBJECTIVE

Given recent conceptualization of psychotic disorders as neurodevelopmental, and current interest in possible shared etiology of different neurodevelopmental disorders such as psychosis, autism, and intellectual disability, this review concurrently examines the literature on developmental (primarily teratogenic) and psychiatric side effects of isotretinoin exposure. The goal of concurrent review is to identify shared mechanisms in the literature that may inform future efforts to clarify the neurocognitive and psychiatric effects of isotretinoin exposure at different developmental stages or given different genetic backgrounds.

METHODS

Literature was obtained by PubMed search for the term isotretinoin in combination with each of the terms psychosis, psychiatric, and teratogenic. Resulting articles met inclusion criteria for review if they addressed psychiatric side effects of isotretinoin treatment or the neurobehavioral teratology of isotretinoin.

RESULTS

The association of isotretinoin exposure with prenatal developmental toxicity is well established. Although numerous reports also link isotretinoin treatment with psychiatric side effects, this association remains controversial.

CONCLUSIONS

The extent to which isotretinoin influences pediatric and adult development and cognition, and whether and why certain individuals may be susceptible to psychiatric side effects, remains to be clarified. Curr Ther Res Clin Exp. 2019; 80:XXX-XXX).

Use of oral isotretinoin to treat acne in the public system: a hospital-based retrospective cohort

BACKGROUND

Acne needs to be treated early to prevent negative psychosocial impacts. In severe or moderate forms, which tend to leave scars, oral isotretinoin is the first-line therapy. However, concern about its adverse events, especially in developed countries, delays effective treatment. In contrast, isotretinoin is widely prescribed in Brazilian private clinics.

OBJECTIVES

To describe the use of isotretinoin for treating acne in a Brazilian public hospital, and to analyze whether its prescription is effective or belated.

DESIGN AND SETTING

Retrospective cohort study in a public hospital.

METHODS

Clinical and therapeutic data were obtained from the medical records of patients who were undergoing or had undergone acne treatment with isotretinoin in this hospital's general dermatology outpatient clinic over the last seven years, up to April 2018.

RESULTS

1526 medical records from patients with acne were analyzed. Isotretinoin was prescribed for 279 patients (18.28%) with mild (1.19%), moderate (57.37%), severe (35.85%) or conglobata (5.57%) forms of acne vulgaris. Sequelae of acne were present at the start of most of these patients' treatment. An initial daily dose of 20 mg was usually prescribed. The average initial dose/weight ratio was 0.33 mg/kg/day. The average total dose/weight ratio was 127.61 mg/kg. There were only a few cases of laboratory abnormalities.

CONCLUSION

Sequelae of acne at the onset of treatment reveal delayed indication of isotretinoin, which can have negative psychosocial impacts on quality of life. Isotretinoin should be indicated early to prevent this. Its use is supported by its lack of laboratory alterations and controllable adverse events.

Transcriptional regulation of corticotropin-releasing hormone gene in stress response

As a central player of the hypothalamic-pituitary-adrenal (HPA) axis, the corticotropin -releasing hormone (CRH) neurons in the hypothalamic paraventricular nucleus (PVN) determine the state of HPA axis and play a key role in stress response. Evidence supports that during stress response the transcription and expression of CRH was finely tuned, which involved cis-element-transcriptional factor (TF) interactions and epigenetic mechanisms. Here we reviewed recent progress in CRH transcription regulation from DNA methylation to classic TFs regulation, in which a number of paired receptors were involved. The imbalance of multiple paired receptors in regulating the activity of CRH neurons indicates a possible molecular network mechanisms underlying depression etiology and directs novel therapeutic strategies of depression in the future.

Drug-induced panic attacks: Analysis of cases registered in the French pharmacovigilance database

BACKGROUND

The potential role of drugs in the onset of panic attacks (PAs) is poorly understood.

AIM

The objective of our study was to characterize drug-induced PAs.

METHOD

We performed an analysis of PAs registered in the French pharmacovigilance database between 01/01/1985 and 05/11/2014.

RESULTS

Among the 163 recorded cases, 136 (83.4%) were directly related to drugs, mainly antidepressants (11.3%, mainly serotonin reuptake inhibitors), mefloquine (7.2%), isotretinoin (5.2%), rimonabant (3.6%) and corticosteroids (4.7%). PAs are labelled in the Summary of Product Characteristics (SmPC) for a minority (8.6%) of these drugs. In 31.4% of these cases, withdrawal of the suspected drug was performed more than a week after the onset of PAs. PAs could also be secondary to another adverse drug reaction (ADR; n = 14, 8.6%), mainly an allergy to antineoplastic or immunomodulating agents. In 13 cases (8.0%), PAs occurred during a drug-withdrawal syndrome, mainly after benzodiazepines or opioids. Most cases (73%) involved patients without any previous psychiatric disorder.

CONCLUSION

This is the first pharmacoepidemiological study about iatrogenic PAs. Beside antidepressants, the most often encountered drugs are not indicated for psychiatric diseases. This study also reveals that iatrogenic PAs mostly occur in patients without any psychiatric medical history and that PAs can be triggered by another ADR. Lastly, the many cases with delayed management underline the need to raise awareness of this relatively unknown ADR among physicians, especially since PAs are generally not labelled in SmPCs of the suspected drugs.

Does isotretinoin therapy of acne cure or cause depression?

Cosmetic defects in acne may provoke a wide range of mental disorders (depressive, social-phobic, etc.). Isotretinoin is a very effective acne treatment; hence, it usually resolves the associated mental disorders. However, more available data show the possible association of taking isotretinoin and the onset of a depressive syndrome that includes frank depression and even suicidal ideation. The frequency of depressive disorders during isotretinoin treatment varies from 1% to 11% in different studies, and it is unclear whether this is a consequence of isotretinoin therapy. Since it crosses the blood-brain barrier, isotretinoin affects the expression of a broad spectrum of genes in the limbic structures, thus affecting the function of the dopaminergic, serotonergic, and noradrenergic neurons involved in the regulation of mood and emotion. It was suggested that isotretinoin in high concentrations inhibits hippocampal neurogenesis and induces apoptosis of hippocampal cells. However, some studies do not confirm this pathogenic role, and isotretinoin was even reported to have a therapeutic effect in acne-associated depression. In this review, we highlight epidemiological data, the underlying molecular pathogenesis, and the aspects of prevention concerning retinoid-induced depression in acne from the practical point of view of a dermatologist.

Mood changes, depression and suicide risk during isotretinoin treatment: a prospective study

BACKGROUND

Depression and mood changes appear as potentional side effects of isotretinoin in the Summary of Product Characteristics. There have been many studies treating this topic but in most cases not identifying any significant depression or suicide risk. To further investigate this issue, we conducted a prospective, uncontrolled study to evaluate mood changes and suicidal ideations in patients receiving isotretinoin therapy.

METHODS

One-hundred patients were included in our single center, no-blind, and no controlled prospective study. All patients completed the Beck's Depression Inventory, Version II (BDI-II) before the treatment, following the first month of the treatment and then every third month until finishing the isotretinoin therapy. All questionnaires were checked by a psychiatrist. Suicidal ideations were monitored. Statistical analysis of BDI-II scores was performed.

RESULTS

All patients completed the study. Before the treatment, six percent of the patients had suffered from depressive symptoms. During the isotretinoin treatment, we did not find any deterioration of depression problems in any of these patients. On the contrary, in most patients the depressive symptoms disappeared. Symptoms of depression occurred in two patients, in which case coexisting situational factors were found to be the cause. No occurrence of suicidal ideations was found.

CONCLUSIONS

We did not find any depressive symptoms or suicide risk caused by isotretinoin. On the contrary, a statistically significant improvement of BDI-II scores was found. In our opinion, patients have to be informed about the risk of depression but emphasizing the fact that it is very rare.

Suicide risk in skin disorders

Suicide accounts for about 1,000,000 deaths worldwide every year and is among the leading causes of death in young adults. Reports of high prevalence of suicidal ideation and increased suicide risk in several skin diseases raised concerns about deliberate self-harm in dermatological patients. The literature consistently points to an increased suicide risk in patients with psoriasis, atopic dermatitis, and acne, with higher risk in patients in whom the skin condition is associated with clinically significant emotional distress, changes in body image, difficulties in close relationships, and impaired daily activities. Other risk factors for suicide include a history of suicide attempts, severe mental or physical disorders, alcoholism, unemployment, bereavement or divorce, and access to firearms or other lethal means. Dermatologists may play an important role in recognizing suicidal ideation and preventing fatal self-harm in their patients. Increasing dermatologists' awareness of the issue of suicide and developing mental health consultation-liaison services within dermatology settings would be instrumental in contributing to suicide prevention in this population.

Retinoic acid and affective disorders: the evidence for an association

OBJECTIVE

Isotretinoin (13-cis-retinoic acid), approved by the US Food and Drug Administration for the treatment of acne, carries a black box warning related to the risk of depression, suicide, and psychosis. Retinoic acid, the active form of vitamin A, regulates gene expression in the brain, and isotretinoin is its 13-cis isomer. Retinoids represent a group of compounds derived from vitamin A that perform a large variety of functions in many systems, in particular the central nervous system, and abnormal retinoid levels can have neurologic effects. Although infrequent, proper recognition and treatment of psychiatric side effects in acne patients is critical given the risk of death and disability. This article reviews the evidence for isotretinoin's relationships with depression and suicidality.

DATA SOURCES

The PsycINFO, MEDLINE, and PubMed searchable database indexes were searched for articles published in the English language from 1960 to June 2010 using the key words isotretinoin, retinoids, retinoic acid, depression, depressive disorders, and vitamin A. Evidence examined includes (1) case reports; (2) temporal association between onset of depression and exposure to the drug; (3) challenge-rechallenge cases; (4) class effect (other compounds in the same class, like vitamin A, having similar neuropsychiatric effects); (5) dose response; and (6) biologically plausible mechanisms.

STUDY SELECTION

All articles in the literature related to isotretinoin, depression, and suicide were reviewed, as well as articles related to class effect, dose response, and biologic plausibility.

DATA EXTRACTION

Information from individual articles in the literature was extracted, including number of episodes of depression, suicidality, suicide, psychosis, violence and aggression, past psychiatric history, time of onset in relation to isotretinoin usage, medication dosage, duration of treatment, and dechallenge and challenge history.

RESULTS

The literature reviewed is consistent with associations of isotretinoin administration with depression and with suicide in a subgroup of vulnerable individuals.

CONCLUSIONS

The relationship between isotretinoin and depression may have implications for a greater understanding of the neurobiology of affective disorders.

Prescribed drugs and violence: a case/noncase study in the French PharmacoVigilance Database

AIM

Our aim was to identify prescribed drugs associated with violent behaviours using the French PharmacoVigilance Database (FPVD).

METHODS

All reports of adverse drug reactions (ADR) recorded in the FPVD between 1 January 1985 and 31 July 2008 and including the terms aggressiveness or violence were selected. We compared proportion of exposure to different drugs between cases (reports with violence) and noncases (other reports in the database).

RESULTS

Among 537 cases, 56 were included (48 men, mean age 46 years). Misuse was observed in ten cases (18%). In 25 cases (44.6%), a previous psychiatric history was documented. Main drugs involved were nervous system (63.6%) followed by respiratory (7.8%), alimentary tract and metabolism (7.8%), dermatological (5.2%) and anti-infective (5.2%) agents. Case/noncase analysis found an association with dopaminergic agonists (pergolide, pramipexole, bromocriptine, piribedil), benzodiazepines (alprazolam, bromazepam) and serotoninergic antidepressants (taken as a whole), but not antipsychotics or antiepileptics. Association was also found with varenicline, isotretinoin, interferon alpha-2b, rimonabant, benfluorex, topiramate and antiviral drugs (ribavirin, efavirenz).

CONCLUSION

Dopaminergic agonists, benzodiazepines and serotoninergic antidepressants are the main pharmacological classes able to induce aggressive behaviour. This study also emphasises the putative role of other drugs less known to be involved in such ADR.

Effective monitoring of isotretinoin safety in a pediatric dermatology population: a novel "patient symptom survey" approach

BACKGROUND

Assessment of adverse effects in pediatric patients on oral isotretinoin has not been standardized and the exact incidence is unknown.

OBJECTIVE

Our goal was to determine the usefulness of an isotretinoin symptom survey as a screening tool for assessment and quantification of adverse effects, including psychiatric symptoms, during isotretinoin treatment in a pediatric population of different age groups.

METHODS

We performed a retrospective chart review on a random sample of patients treated with isotretinoin at a tertiary pediatric dermatology clinic where patients completed an isotretinoin symptom survey at each visit. Responses were stratified by age group and psychiatric history.

RESULTS

The charts of 102 patients, representing 123 courses of isotretinoin and 760 treatment-months, were reviewed. A total of 722 (95.0%) symptom surveys were complete and 38 (5.0%) were incomplete/missing. Recorded side effects were similar to published adult data; dry lips/dry skin were reported in 94.25% and 72.13% of treatment-months of isotretinoin, respectively. Psychiatric symptoms were reported in 1.65%, with no statistical difference between patients with or without a mental health history. Patients aged 11 to 15 years had similar side-effect profiles to those aged 16 to 21 years. Impaired night vision, nosebleeds, and dry/bloodshot eyes were more common in the older age group.

LIMITATIONS

This was a retrospective chart review, with known limitations. The study was performed at a tertiary referral center for pediatric dermatology, possibly allowing patient selection bias.

CONCLUSIONS

The isotretinoin symptom survey appears to be an effective screening tool to standardize monitoring of isotretinoin side effects in the pediatric population.

Distribution of retinoic acid receptor-α immunoreactivity in the human hypothalamus

Retinoids, a family of molecules that is derived from vitamin A, are involved in a complex signaling pathway that regulates gene expression and controls neuronal differentiation in the central nervous system. The physiological actions of retinoids are mainly mediated by retinoic acid receptors. Here we describe the distribution of retinoic acid receptor α (RARα) in the human hypothalamus by immunohistochemistry. RARα immunoreactivity showed a widespread pattern throughout the hypothalamus, with high density in the suprachiasmatic nucleus (SCN), paraventricular nucleus (PVN), supraoptic nucleus (SON), infundibular nucleus and medial mamillary nucleus. No staining was observed in the sexually dimorphic nucleus of preoptic area, tuberomamillary nucleus and lateral hypothalamic area. RARα was co-localized with vasopressin (AVP) neurons in the SCN, PVN and SON, and co-localized with corticotropin releasing hormone (CRH) neurons in the PVN. These findings provide a neurobiological basis for the participation of retinoids in the regulation of various hypothalamic functions. As shown earlier, the co-localization of RARα in CRH neurons suggests that retinoids might directly modulate the hypothalamus-pituitary-adrenal axis in the PVN, which may have implications for the stress response and its involvement in mood disorders. Functional studies in the other sites of RARα localization have to follow in the future.

Obsessive-compulsive disorder with bipolar diathesis following isotretinoin therapy remitting upon treatment with olanzapine and fluvoxamine

Isotretinoin, a drug used for moderate to severe acne, has been repeatedly associated with various psychiatric complications, although a definitive causal relationship has not been established to date. This case report describes a 25-year-old male who developed obsessive-compulsive disorder at the age of 23 years following isotretinoin treatment for acne (10-20 mg/day) since the age of 16 years. Although standard treatment for obsessive-compulsive disorder caused mood swings, the combination of fluvoxamine 300 mg/day and olanzapine 15 mg/day significantly improves the clinical picture. Although rare, severe adulthood psychiatric complications may occur following isotretinoin treatment, requiring management which is individually tailored to the patient.

Suicidal ideation, mental health problems, and social impairment are increased in adolescents with acne: a population-based study

We performed a cross-sectional, questionnaire-based study to explore the relationship of suicidal ideation, mental health problems, and social functioning to acne severity among adolescents aged 18-19 years. A total of 4,744 youth were invited and 3,775 (80%) participated. In all, 14% reported having substantial acne (a lot and very much). Among those with very much acne, as compared those with no/little acne, suicidal ideation was twice as frequently reported among girls (25.5 vs. 11.9%) and three times more frequently reported among boys (22.6 vs. 6.3%). Suicidal ideation remained significantly associated with substantial acne (odds ratio 1.80, 95% confidence interval 1.30-2.50) in a multivariate model including adjustments of symptoms of depression, ethnicity, and family income. Mental health problems, as assessed by the Strengths and Difficulties Questionnaire (2.25, 1.69-3.00), low attachment to friends (1.52, 1.21-1.91), not thriving at school (1.41, 1.12-1.78), never having had a romantic relationship (1.35, 1.05-1.70), and never having had sexual intercourse (1.51, 1.21-1.89) were all associated with substantial acne in a multivariate model. Acne is frequently found in late adolescence and is associated with social and psychological problems. Adverse events including suicidal ideation and depression that have been associated with therapies for acne may reflect the burden of substantial acne rather than the effects of medication.

Psychiatric reactions to isotretinoin in patients with bipolar disorder

BACKGROUND

Isotretinoin (Accutane(R)) has been available for the treatment of severe cystic acne for about twenty-five years. There have been several reports of adverse psychiatric reactions to isotretinoin, including depressive symptoms and suicide. However, there have been only three case reports of patients with bipolar disorder (BD) who experienced an untoward psychiatric side effect while receiving isotretinoin treatment. In this study, the psychiatric side effects from isotretinoin were assessed in a larger group of BD patients than has previously been reported.

METHODS

A retrospective chart review of 300 BD outpatients identified ten patients treated with isotretinoin.

RESULTS

Nine of these ten patients experienced a significant worsening of mood symptoms, and three developed suicidal ideation. Eight experienced a reversal of the relapsed mood symptoms when the isotretinoin was discontinued, whether prematurely or after a full course.

LIMITATIONS

The limitations of this study include small sample size, retrospective data collection, absence of double-blind controlled design, and inability to control for spontaneous mood episodes in patients with BD.

CONCLUSIONS

These results indicate that BD patients treated with isotretinoin for acne are at risk for clinically significant exacerbation of mood symptoms, including suicidal ideation, even with concurrent use of psychiatric medicines for BD. The clinical implications of this study are especially relevant to the treatment of patients with BD because acne usually occurs during adolescence, which is often the age of onset of BD and because a common side effect of lithium (a standard treatment for BD) is acne.

Acitretin-associated erectile dysfunction: a case report

Introduction

Two cases of impotence following a treatment with etretinate have been reported in the literature. Acitretin is the principal active metabolite of etretinate. We report a case of erectile dysfunction associated with the use of acitretin.

Case presentation

A 39-year-old Caucasian man referred his incapacity to reach and maintain a penile erection during a course of acitretin for the treatment of a severe form of psoriasis. Physical examination, laboratory findings and psychological analysis did not reveal any abnormalities. Two weeks after the withdrawal of acitretin, the patient reported a normalization of his sexual activity.

Conclusion

Retinoids have been associated with male reproductive system dysfunctions in human and animal studies. Clinicians should be aware of the possibility of acitretin-induced erectile dysfunction.

Isotretinoin is not associated with inflammatory bowel disease: a population-based case-control study

OBJECTIVES

There is anecdotal evidence that isotretinoin use is associated with development of colitis. We aimed at determining whether there is an association between isotretinoin use and development of inflammatory bowel disease (IBD).

METHODS

The population-based University of Manitoba IBD Epidemiology Database and a control group matched by age, sex, and geographical residence were linked to the provincial prescription drug registry, a registry that was initiated in 1995. The number of users and duration of isotretinoin use were identified in both IBD cases and controls.

RESULTS

We found that 1.2% of IBD cases used isotretinoin before IBD diagnosis, which was statistically similar to controls (1.1% users). This was also similar to the number of IBD patients who used isotretinoin after a diagnosis of IBD (1.1%). There was no difference between isotretinoin use before Crohn's disease compared with its use before ulcerative colitis.

CONCLUSIONS

Patients with IBD were no more likely to have used isotretinoin before diagnosis than were sex-, age-, and geography-matched controls. Although there may be anecdotes of isotretinoin causing acute colitis, our data suggest that isotretinoin is not likely to cause chronic IBD.

The involvement of retinoic acid receptor-alpha in corticotropin-releasing hormone gene expression and affective disorders

BACKGROUND

Corticotropin-releasing hormone (CRH) is considered the central driving force in the stress response and plays a key role in the pathogenesis of depression. Retinoic acid (RA) has been suggested by clinical studies to be associated with affective disorders.

METHODS

First, hypothalamic tissues of 12 patients with affective disorders and 12 matched control subjects were studied by double-label immunofluorescence to analyze the expression of CRH and retinoic acid receptor-alpha (RAR-alpha). Second, critical genes involved in the RA signaling pathways were analyzed in a rat model of depression. Finally, the regulatory effect of RAR-alpha on CRH gene expression was studied in vitro.

RESULTS

We found that the expression of RAR-alpha was colocalized with CRH neurons in human hypothalamic paraventricular nucleus (PVN). The density of RAR-alpha-immunoreactive neurons and CRH-RAR-alpha double-staining neurons was significantly increased in the PVN of patients with affective disorders. The ratio of the CRH-RAR-alpha double-staining neurons to the CRH-immunoreactive neurons in affective disorder patients was also increased. Recruitment of RAR-alpha by the CRH promoter was observed in the rat hypothalamus. A dysregulated RA metabolism and signaling was also found in the hypothalamus of a rat model for depression. Finally, in vitro studies demonstrated that RAR-alpha mediated an upregulation of CRH gene expression.

CONCLUSIONS

These results suggest that RAR-alpha might contribute to regulating the activity of CRH neurons in vivo, and the vulnerable character of the critical proteins in RA signaling pathways might provide novel targets for therapeutic strategies for depression.

Comparison of depression, anxiety and life quality in acne vulgaris patients who were treated with either isotretinoin or topical agents

BACKGROUND

Since the introduction of isotretinoin to the market, many adverse psychiatric effects, including depression, anxiety and suicide attempts were reported. The aim of this study was to determine whether patients with acne who were treated with isotretinoin experienced significant increases in psychiatric symptoms over a 4-month period compared with patients who received topical acne therapy.

METHODS

Seventy-eight acne patients were allocated either to isotretinoin treatment (study group) (n = 37) or to topical treatment (control group) (n = 41). Their psychological status was evaluated at the baseline, second and fourth months of the treatment. All patients were required to complete the dermatology life quality index (DLQI), the Hospital anxiety and depression (HAD) scale, and the beck depression inventory (BDI).

RESULTS

The two groups were not different from each other in terms of DLQI, BDI, HAD-A, HAD-D and total HAD scores at baseline. However, at the end of the second month quality of life was more impaired in the topical treatment group compared to the isotretinoin group (P < 0.05), and there were no difference between two groups in terms of BDI, HAD-A, HAD-D, and total HAD scores (P > 0.05). At the end of fourth month quality of life and all psychological test scores had improved more in the isotretinoin group compared to topical treatment group (P < 0.05).

CONCLUSION

Results of the present study indicate that there is no increase in depressive and anxiety symptoms in the isotretinoin treatment group compared to that in the topical group. Instead, successful treatment of acne seems to improve both depressive and anxiety symptoms and improve quality of life.

Darier's disease: a calcium-signaling perspective

Ca(2+) influx evoked across the plasma membrane upon internal store depletion is essential for a myriad of cellular functions including gene expression, cell proliferation, differentiation and even apoptosis. Darier's disease (DD), an autosomal dominant inherited disorder of the skin, arising due to mutations in the isoform 2 of the sarco (endo) plasmic reticulum Ca(2+) ATPase (SERCA2), exemplifies an anomaly of Ca(2+) signaling disturbances. Owing to loss of function mutations in SERCA2, keratinocytes in DD patients have a reduced pool of endoplasmic reticulum (ER) Ca(2+). Importantly, the status of ER Ca(2+) is critical for the activation of a class of plasma membrane Ca(2+) channels referred to as store operated Ca(2+) channels (SOCs). The widely expressed transient receptor potential (TRP) family of channels is proposed to be SOCs. In this review we discuss DD from the viewpoint of Ca(2+) signaling and present a potential role for TRPC1 in the disease pathogenesis.

Retinoic acids acting through retinoid receptors protect hippocampal neurons from oxygen-glucose deprivation-mediated cell death by inhibition of c-jun-N-terminal kinase and p38 mitogen-activated protein kinase

Retinoic acids (RAs), including all-trans retinoic acid (ATRA) and 9-cis retinoic acid (9-cis RA), play fundamental roles in a variety of physiological events in vertebrates, through their specific nuclear receptors: retinoic acid receptor (RAR) and retinoid X receptor (RXR). Despite the physiological importance of RA, their functional significance under pathological conditions is not well understood. We examined the effect of ATRA on oxygen/glucose-deprivation/reperfusion (OGD/Rep)-induced neuronal damage in cultured rat hippocampal slices, and found that ATRA significantly reduced neuronal death. The cytoprotective effect of ATRA was observed not only in cornu ammonis (CA) 1 but also in CA2 and dentate gyrus (DG), and was attenuated by selective antagonists for RAR or RXR. By contrast, in the CA3 region, no protective effects of ATRA were observed. The OGD/Rep also increased phosphorylated forms of c-jun-N-terminal kinase (P-JNK) and p38 (P-p38) in hippocampus, and specific inhibitors for these kinases protected neurons. ATRA prevented the increases in P-JNK and P-p38 after OGD/Rep, as well as the decrease in NeuN and its shrinkage, all of which were inhibited by antagonists for RAR or RXR. These findings suggest that the ATRA signaling via retinoid receptors results in the inhibition of JNK and p38 activation, leading to the protection of neurons against OGD/Rep-induced damage in the rat hippocampus.