Adults including adolescents and the elderly:Isotretinoin therapy should be started at a dose of 0.5 mg/kg daily. The therapeutic response to isotretinoin and some of the adverse effects are dose-related and vary between patients. This necessitates individual dosage adjustment during therapy. For most patients, the dose ranges from 0.5-1.0 mg/kg per day.Long-term remission and relapse rates are more closely related to the total dose administered than to either duration of treatment or daily dose. It has been shown that no substantial additional benefit is to be expected beyond a cumulative treatment dose of 120-150 mg/kg. The duration of treatment will depend on the individual daily dose. A treatment course of 16-24 weeks is normally sufficient to achieve remission.In the majority of patients, complete clearing of the acne is obtained with a single treatment course. In the event of a definite relapse a further course of isotretinoin therapy may be considered using the same daily dose and cumulative treatment dose. As further improvement of the acne can be observed up to 8 weeks after discontinuation of treatment, a further course of treatment should not be considered until at least this period has elapsed.
Patients with severe renal insufficiencyIn patients with severe renal insufficiency treatment should be started at a lower dose (e.g. 10 mg/day). The dose should then be increased up to 1 mg/kg/day or until the patient is receiving the maximum tolerated dose (see section 4.4).
ChildrenRoaccutane is not indicated for the treatment of prepubertal acne and is not recommended in patients less than 12 years of age due to a lack of data on efficacy and safety.
Patients with intoleranceIn patients who show severe intolerance to the recommended dose, treatment may be continued at a lower dose with the consequences of a longer therapy duration and a higher risk of relapse. In order to achieve the maximum possible efficacy in these patients the dose should normally be continued at the highest tolerated dose.
Pregnancy Prevention Programme
This medicinal product is TERATOGENICIsotretinoin is contraindicated in women of childbearing potential unless all of the following conditions of the Pregnancy Prevention Programme are met:• She has severe acne (such as nodular or conglobate acne or acne at risk of permanent scarring) resistant to adequate courses of standard therapy with systemic anti-bacterials and topical therapy (see section 4.1).• She understands the teratogenic risk.• She understands the need for rigorous follow-up, on a monthly basis.• She understands and accepts the need for effective contraception, without interruption, 1 month before starting treatment, throughout the duration of treatment and 1 month after the end of treatment. At least one and preferably two complementary forms of contraception including a barrier method should be used.• Even if she has amenorrhea she must follow all of the advice on effective contraception.• She should be capable of complying with effective contraceptive measures.• She is informed and understands the potential consequences of pregnancy and the need to rapidly consult if there is a risk of pregnancy.• She understands the need and accepts to undergo pregnancy testing before, during and 5 weeks after the end of treatment.• She has acknowledged that she has understood the hazards and necessary precautions associated with the use of isotretinoin.These conditions also concern women who are not currently sexually active unless the prescriber considers that there are compelling reasons to indicate that there is no risk of pregnancy.The prescriber must ensure that:• The patient complies with the conditions for pregnancy prevention as listed above, including confirmation that she has an adequate level of understanding.• The patient has acknowledged the aforementioned conditions.• The patient has used at least one and preferably two methods of effective contraception including a barrier method for at least 1 month prior to starting treatment and is continuing to use effective contraception throughout the treatment period and for at least 1 month after cessation of treatment.• Negative pregnancy test results have been obtained before, during and 5 weeks after the end of treatment. The dates and results of pregnancy tests should be documented.
ContraceptionFemale patients must be provided with comprehensive information on pregnancy prevention and should be referred for contraceptive advice if they are not using effective contraception.As a minimum requirement, female patients at potential risk of pregnancy must use at least one effective method of contraception. Preferably the patient should use two complementary forms of contraception including a barrier method. Contraception should be continued for at least 1 month after stopping treatment with isotretinoin, even in patients with amenorrhea.
Pregnancy testingAccording to local practice, medically supervised pregnancy tests with a minimum sensitivity of 25mIU/mL are recommended to be performed in the first 3 days of the menstrual cycle, as follows.
Prior to starting therapy:In order to exclude the possibility of pregnancy prior to starting contraception, it is recommended that an initial medically supervised pregnancy test should be performed and its date and result recorded. In patients without regular menses, the timing of this pregnancy test should reflect the sexual activity of the patient and should be undertaken approximately 3 weeks after the patient last had unprotected sexual intercourse. The prescriber should educate the patient about contraception.A medically supervised pregnancy test should also be performed during the consultation when isotretinoin is prescribed or in the 3 days prior to the visit to the prescriber, and should have been delayed until the patient had been using effective contraception for at least 1 month. This test should ensure the patient is not pregnant when she starts treatment with isotretinoin.
Follow-up visitsFollow-up visits should be arranged at 28 day intervals. The need for repeated medically supervised pregnancy tests every month should be determined according to local practice including consideration of the patient's sexual activity and recent menstrual history (abnormal menses, missed periods or amenorrhea). Where indicated, follow-up pregnancy tests should be performed on the day of the prescribing visit or in the 3 days prior to the visit to the prescriber.
End of treatmentFive weeks after stopping treatment, women should undergo a final pregnancy test to exclude pregnancy.
Prescribing and dispensing restrictionsPrescriptions of isotretinoin for women of childbearing potential should be limited to 30 days of treatment and continuation of treatment requires a new prescription. Ideally, pregnancy testing, issuing a prescription and dispensing of isotretinoin should occur on the same day. Dispensing of isotretinoin should occur within a maximum of 7 days of the prescription.
Male patients:The available data suggest that the level of maternal exposure from the semen of the patients receiving isotretinoin, is not of a sufficient magnitude to be associated with the teratogenic effects of isotretinoin.Male patients should be reminded that they must not share their medication with anyone, particularly not females.
Additional precautionsPatients should be instructed never to give this medicinal product to another person, and to return any unused capsules to their pharmacist at the end of treatment.Patients should not donate blood during therapy and for 1 month following discontinuation of isotretinoin because of the potential risk to the foetus of a pregnant transfusion recipient.
Educational materialIn order to assist prescribers, pharmacists and patients in avoiding foetal exposure to isotretinoin the Marketing Authorisation Holder will provide educational material to reinforce the warnings about the teratogenicity of isotretinoin, to provide advice on contraception before therapy is started and to provide guidance on the need for pregnancy testing.Full patient information about the teratogenic risk and the strict pregnancy prevention measures as specified in the Pregnancy Prevention Programme should be given by the physician to all patients, both male and female.
Psychiatric disordersDepression, depression aggravated, anxiety, aggressive tendencies, mood alterations, psychotic symptoms, and very rarely, suicidal ideation, suicide attempts and suicide have been reported in patients treated with isotretinoin (see section 4.8). Particular care needs to be taken in patients with a history of depression and all patients should be monitored for signs of depression and referred for appropriate treatment if necessary. However, discontinuation of isotretinoin may be insufficient to alleviate symptoms and therefore further psychiatric or psychological evaluation may be necessary.
Skin and subcutaneous tissues disordersAcute exacerbation of acne is occasionally seen during the initial period but this subsides with continued treatment, usually within 7 - 10 days, and usually does not require dose adjustment.Exposure to intense sunlight or to UV rays should be avoided. Where necessary a sun-protection product with a high protection factor of at least SPF 15 should be used.Aggressive chemical dermabrasion and cutaneous laser treatment should be avoided in patients on isotretinoin for a period of 5-6 months after the end of the treatment because of the risk of hypertrophic scarring in atypical areas and more rarely post inflammatory hyper or hypopigmentation in treated areas. Wax depilation should be avoided in patients on isotretinoin for at least a period of 6 months after treatment because of the risk of epidermal stripping.Concurrent administration of isotretinoin with topical keratolytic or exfoliative anti-acne agents should be avoided as local irritation may increase (see section 4.5).Patients should be advised to use a skin moisturising ointment or cream and a lip balm from the start of treatment as isotretinoin is likely to cause dryness of the skin and lips.There have been post-marketing reports of severe skin reactions (e.g. erythema multiforme (EM), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN)) associated with isotretinoin use. As these events may be difficult to distinguish from other skin reactions that may occur (see section 4.8), patients should be advised of the signs and symptoms and monitored closely for severe skin reactions. If a severe reaction is suspected, isotretinoin treatment should be discontinued.
Allergic reactionsAnaphylactic reactions have been rarely reported, in some cases after previous topical exposure to retinoids. Allergic cutaneous reactions are reported infrequently. Serious cases of allergic vasculitis, often with purpura (bruises and red patches) of the extremities and extracutaneous involvement have been reported. Severe allergic reactions necessitate interruption of therapy and careful monitoring.
Eye disordersDry eyes, corneal opacities, decreased night vision and keratitis usually resolve after discontinuation of therapy. Dry eyes can be helped by the application of a lubricating eye ointment or by the application of tear replacement therapy. Intolerance to contact lenses may occur which may necessitate the patient to wear glasses during treatment.Decreased night vision has also been reported and the onset in some patients was sudden (see section 4.7). Patients experiencing visual difficulties should be referred for an expert ophthalmological opinion. Withdrawal of isotretinoin may be necessary.
Musculo-skeletal and connective tissue disordersMyalgia, arthralgia and increased serum creatine phosphokinase values have been reported in patients receiving isotretinoin, particularly in those undertaking vigorous physical activity (see section 4.8).Bone changes including premature epiphyseal closure, hyperostosis, and calcification of tendons and ligaments have occurred after several years of administration at very high doses for treating disorders of keratinisation. The dose levels, duration of treatment and total cumulative dose in these patients generally far exceeded those recommended for the treatment of acne.
Benign intracranial hypertensionCases of benign intracranial hypertension have been reported, some of which involved concomitant use of tetracyclines (see section 4.3 and section 4.5). Signs and symptoms of benign intracranial hypertension include headache, nausea and vomiting, visual disturbances and papilloedema. Patients who develop benign intracranial hypertension should discontinue isotretinoin immediately.
Hepatobiliary disordersLiver enzymes should be checked before treatment, 1 month after the start of treatment, and subsequently at 3 monthly intervals unless more frequent monitoring is clinically indicated. Transient and reversible increases in liver transaminases have been reported. In many cases these changes have been within the normal range and values have returned to baseline levels during treatment. However, in the event of persistent clinically relevant elevation of transaminase levels, reduction of the dose or discontinuation of treatment should be considered.
Renal insufficiencyRenal insufficiency and renal failure do not affect the pharmacokinetics of isotretinoin. Therefore, isotretinoin can be given to patients with renal insufficiency. However, it is recommended that patients are started on a low dose and titrated up to the maximum tolerated dose (see section 4.2).
Lipid MetabolismSerum lipids (fasting values) should be checked before treatment, 1 month after the start of treatment, and subsequently at 3 monthly intervals unless more frequent monitoring is clinically indicated. Elevated serum lipid values usually return to normal on reduction of the dose or discontinuation of treatment and may also respond to dietary measures.Isotretinoin has been associated with an increase in plasma triglyceride levels. Isotretinoin should be discontinued if hypertriglyceridaemia cannot be controlled at an acceptable level or if symptoms of pancreatitis occur (see section 4.8). Levels in excess of 800mg/dL or 9mmol/L are sometimes associated with acute pancreatitis, which may be fatal.
Gastrointestinal disordersIsotretinoin has been associated with inflammatory bowel disease (including regional ileitis) in patients without a prior history of intestinal disorders. Patients experiencing severe (hemorrhagic) diarrhoea should discontinue isotretinoin immediately.
Fructose intoleranceRoaccutane contains sorbitol. Patients with rare hereditary problems of fructose intolerance should not take this medicine.
High Risk PatientsIn patients with diabetes, obesity, alcoholism or a lipid metabolism disorder undergoing treatment with isotretinoin, more frequent checks of serum values for lipids and/or blood glucose may be necessary. Elevated fasting blood sugars have been reported, and new cases of diabetes have been diagnosed during isotretinoin therapy.
|Pregnancy is an absolute contraindication to treatment with isotretinoin (see section 4.3). If pregnancy does occur in spite of these precautions during treatment with isotretinoin or in the month following, there is a great risk of very severe and serious malformation of the foetus.|
|Very Rare (≤ 1/10 000)||Gram positive (mucocutaneous) bacterial infection|
|Blood and lymphatic system disorders:|
|Very common (≥ 1/10)||Anaemia, red blood cell sedimentation rate increased, thrombocytopenia, thrombocytosis|
|Common (≥ 1/100, < 1/10)||Neutropenia|
|Very Rare (≤ 1/10 000)||Lymphadenopathy|
|Immune system disorders:|
|Rare (≥ 1/10 000,< 1/1000)||Allergic skin reaction, anaphylactic reactions, hypersensitivity|
|Metabolism and nutrition disorders:|
|Very Rare (≤ 1/10 000)||Diabetes mellitus, hyperuricaemia|
|Rare (≥ 1/10 000,< 1/1000)||Depression, depression aggravated, aggressive tendencies, anxiety, mood alterations.|
|Very Rare (≤ 1/10 000)||Abnormal behaviour, psychotic disorder, suicidal ideation suicide attempt, suicide|
|Nervous system disorders:|
|Common (≥ 1/100, < 1/10)||Headache|
|Very Rare (≤ 1/10 000)||Benign intracranial hypertension, convulsions, drowsiness, dizziness|
|Very common (≥ 1/10)||Blepharitis, conjunctivitis, dry eye, eye irritation|
|Very Rare (≤ 1/10 000)||Blurred vision, cataract, colour blindness (colour vision deficiencies), contact lens intolerance, corneal opacity, decreased night vision, keratitis, papilloedema (as sign of benign intracranial hypertension), photophobia, visual disturbances.|
|Ear and labyrinth disorders:|
|Very Rare (≤ 1/10 000)||Hearing impaired|
|Very Rare (≤ 1/10 000)||Vasculitis (for example Wegener's granulomatosis, allergic vasculitis)|
|Respiratory, thoracic and mediastinal disorders:|
|Common (≥ 1/100, < 1/10)||Epistaxis, nasal dryness, nasopharyngitis|
|Very Rare (≤ 1/10 000)||Bronchospasm (particularly in patients with asthma), hoarseness|
|Very Rare (≤ 1/10 000)||Colitis, ileitis, dry throat, gastrointestinal haemorrhage, haemorrhagic diarrhoea and inflammatory bowel disease, nausea, pancreatitis (see section 4.4)|
|Very common (≥ 1/10)||Transaminase increased (see section 4.4)|
|Very Rare (≤ 1/10 000)||Hepatitis|
|Skin and subcutaneous tissues disorders:|
|Very common (≥ 1/10)||Cheilitis, dermatitis, dry skin, localised exfoliation, pruritus, rash erythematous, skin fragility (risk of frictional trauma)|
|Rare (≥ 1/10 000,< 1/1000)||Alopecia|
|Very Rare (≤ 1/10 000)||Acne fulminans, acne aggravated (acne flare), erythema (facial), exanthema, hair disorders, hirsutism, nail dystrophy, paronychia, photosensitivity reaction, pyogenic granuloma, skin hyperpigmentation, sweating increased|
|Frequency unknown*||Erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis|
|Musculo-skeletal and connective tissue disorders:|
|Very common (≥ 1/10)||Arthralgia, myalgia, back pain (particularly in children and adolescent patients)|
|Very Rare (≤ 1/10 000)||Arthritis, calcinosis (calcification of ligaments and tendons), epiphyses premature fusion, exostosis, (hyperostosis), reduced bone density, tendonitis|
|Renal and urinary disorders:|
|Very Rare (≤ 1/10 000)||Glomerulonephritis|
|General disorders and administration site conditions:|
|Very Rare (≤ 1/10 000)||Granulation tissue (increased formation of), malaise|
|Very common (≥ 1/10)||Blood triglycerides increased, high density lipoprotein decreased|
|Common (≥ 1/100, < 1/10)||Blood cholesterol increased, blood glucose increased, haematuria, proteinuria|
|Very Rare (≤ 1/10 000)||Blood creatine phosphokinase increased|
The incidence of the adverse events was calculated from pooled clinical trial data involving 824 patients and from post-marketing data.
Mechanism of actionIsotretinoin is a stereoisomer of all-trans retinoic acid (tretinoin). The exact mechanism of action of isotretinoin has not yet been elucidated in detail, but it has been established that the improvement observed in the clinical picture of severe acne is associated with suppression of sebaceous gland activity and a histologically demonstrated reduction in the size of the sebaceous glands. Furthermore, a dermal anti-inflammatory effect of isotretinoin has been established.
EfficacyHypercornification of the epithelial lining of the pilosebaceous unit leads to shedding of corneocytes into the duct and blockage by keratin and excess sebum. This is followed by formation of a comedone and, eventually, inflammatory lesions. Isotretinoin inhibits proliferation of sebocytes and appears to act in acne by re-setting the orderly program of differentiation. Sebum is a major substrate for the growth of Propionibacterium acnes so that reduced sebum production inhibits bacterial colonisation of the duct.
AbsorptionThe absorption of isotretinoin from the gastro-intestinal tract is variable and dose-linear over the therapeutic range. The absolute bioavailability of isotretinoin has not been determined, since the compound is not available as an intravenous preparation for human use, but extrapolation from dog studies would suggest a fairly low and variable systemic bioavailability. When isotretinoin is taken with food, the bioavailability is doubled relative to fasting conditions.
DistributionIsotretinoin is extensively bound to plasma proteins, mainly albumin (99.9 %). The volume of distribution of isotretinoin in man has not been determined since isotretinoin is not available as an intravenous preparation for human use. In humans little information is available on the distribution of isotretinoin into tissue. Concentrations of isotretinoin in the epidermis are only half of those in serum. Plasma concentrations of isotretinoin are about 1.7 times those of whole blood due to poor penetration of isotretinoin into red blood cells.
MetabolismAfter oral administration of isotretinoin, three major metabolites have been identified in plasma: 4-oxo-isotretinoin, tretinoin, (all-trans retinoic acid), and 4-oxo-tretinoin. These metabolites have shown biological activity in several in vitro tests. 4-oxo-isotretinoin has been shown in a clinical study to be a significant contributor to the activity of isotretinoin (reduction in sebum excretion rate despite no effect on plasma levels of isotretinoin and tretinoin). Other minor metabolites includes glucuronide conjugates. The major metabolite is 4-oxo-isotretinoin with plasma concentrations at steady state, that are 2.5 times higher than those of the parent compound. Isotretinoin and tretinoin (all-trans retinoic acid) are reversibly metabolised (interconverted), and the metabolism of tretinoin is therefore linked with that of isotretinoin. It has been estimated that 20-30 % of an isotretinoin dose is metabolised by isomerisation.Enterohepatic circulation may play a significant role in the pharmacokinetics of isotretinoin in man. In vitro metabolism studies have demonstrated that several CYP enzymes are involved in the metabolism of isotretinoin to 4-oxo-isotretinoin and tretinoin. No single isoform appears to have a predominant role. Isotretinoin and its metabolites do not significantly affect CYP activity.
EliminationAfter oral administration of radiolabelled isotretinoin approximately equal fractions of the dose were recovered in urine and faeces. Following oral administration of isotretinoin, the terminal elimination half-life of unchanged drug in patients with acne has a mean value of 19 hours. The terminal elimination half-life of 4-oxo-isotretinoin is longer, with a mean value of 29 hours.Isotretinoin is a physiological retinoid and endogenous retinoid concentrations are reached within approximately two weeks following the end of isotretinoin therapy.
Pharmacokinetics in special populationsSince isotretinoin is contraindicated in patients with hepatic impairment, limited information on the kinetics of isotretinoin is available in this patient population. Renal failure does not significantly reduce the plasma clearance of isotretinoin or 4-oxo-isotretinoin.
Acute toxicityThe acute oral toxicity of isotretinoin was determined in various animal species. LD50 is approximately 2000 mg/kg in rabbits, approximately 3000 mg/kg in mice, and over 4000 mg/kg in rats.
Chronic toxicityA long-term study in rats over 2 years (isotretinoin dosage 2, 8 and 32 mg/kg/d) produced evidence of partial hair loss and elevated plasma triglycerides in the higher dose groups. The side effect spectrum of isotretinoin in the rodent thus closely resembles that of vitamin A, but does not include the massive tissue and organ calcifications observed with vitamin A in the rat. The liver cell changes observed with vitamin A did not occur with isotretinoin.All observed side effects of hypervitaminosis A syndrome were spontaneously reversible after withdrawal of isotretinoin. Even experimental animals in a poor general state had largely recovered within 12 weeks.
TeratogenicityLike other vitamin A derivatives, isotretinoin has been shown in animal experiments to be teratogenic and embryotoxic.Due to the teratogenic potential of isotretinoin there are therapeutic consequences for the administration to women of a childbearing age (see section 4.3, section 4.4, and section 4.6).
FertilityIsotretinoin, in therapeutic dosages, does not affect the number, motility and morphology of sperm and does not jeopardise the formation and development of the embryo on the part of the men taking isotretinoin.
MutagenicityIsotretinoin has not been shown to be mutagenic in in vitro or in vivo animal tests.
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