Monitoring

Serum lipid and liver function tests (LFTs) should be monitored. LFTs should be measured as a baseline prior to the commencement of treatment and then checked at 4 and 8 weeks (although exact timings will vary depending on local clinical practice). If blood levels are normal at 8 weeks, further monitoring is probably not necessary as long as the dose remains the same.

Because isotretinoin is teratogenic (it can seriously adversely affect the unborn child), women of child-bearing age must have a negative blood pregnancy test before commencement of therapy. Once a negative pregnancy test has been received, therapy should be started after the 2nd or 3rd day of the first menstrual period after the test. Current practice requires women to undergo monthly urine pregnancy tests prior to a further prescription of isotretinoin being given. It should be noted in the patient record that contraception and pregnancy avoidance advice have been discussed and understood by the patient. Different countries have different policies on the issue of pregnancy avoidance. Grewal-Fry outlines the policy in the USA (Grewal-Fry, 2007).

Patients may well already be aware of the potential psychological impacts of taking isotretinoin as these have been extensively covered in the popular press. Whilst severe psychiatric changes are unlikely, patients should be counselled about the possibility of mood swings. Acne itself can lead to high levels of anxiety (Aktan et al., 2000) and it is not always possible to categorically identify mental health changes being as a result of isotretinoin. Very occasionally severe psychiatric changes may occur with some reports of depression and suicidal ideation (Gollnick et al., 2003). A more recent study suggested that there is a link between isotretinoin use and depression in those with acne vulgaris (Azoulay et al., 2008). In a commentary on this article, however, the categoric results were debated with the author questioning whether the research methods allowed the conclusions to be drawn (Bigby, 2008). This author states that ‘Firm conclusions regarding the risk of depression associated with isotretinoin cannot be drawn, although he confirms that discussions about the possibility of depression should be had with the patient. It is important, therefore that patients are asked about their mood and warned of depression as a potential side effect.