Can Roaccutan (isotretinoin) be prescribed to a patient who has reacted with increased levels of AL

Fråga: Can Roaccutan (isotretinoin) be prescribed to a patient who has reacted with increased levels of ALP (6.1, normal <4.6 ukat/l) and ALAT (1.0 normal <0.7 ukat/l) probably due to treatment with Heracillin (flucloxacillin)?

Heracillin was given at a standard dosage for 10 days because of acne. Increased levels of ALP and ALAT (normal levels of ASAT, bilirubin, gamma-GT) were noted two weeks after initiation of treatment, and are now, two weeks later, almost normalized.

Sammanfattning: Mild and reversible liver enzyme elevation has been reported in 7-13 per cent of patients treated with isotretinoin. There is no data to indicate that the risk would be increased in patients who have previously reacted with increased liver enzymes during treatment with isoxazolylpenicillins.

Svar: Hepatic reactions of cholestatic type are well-known side effects of flucloxacillin and other isoxazolylpenicillin (1-2). The incidence has been estimated to 1:11000-1:30000 prescriptions (1). The effects are usually reversible but may persist for a long time (months to in extreme cases years) after exposure (1). The most common symptoms are icterus and itching. The classical symptoms of allergic reactions such as fever, eosinophilia, swollen lymph nodes and eczema are missing in most patients, and the mechanism has therefore been suggested to be a toxic one (1).

Liver enzyme elevation has been reported in 7-13 per cent of patients treated with isotretinoin (3). The reaction is usually mild and transient in nature. No data are available on the risk of aggravating the patients liver affection if isotretinoin treatment is started in a patient who has previously reacted for flucloxacillin. Nor are there any theoretical reasons to expect such an effect. It is though advisable to wait with isotretinoin treatment until the enzymes have returned to normal and to follow liver function after initiation of isotretinoin treatment. 1 Information från Läkemedelsverket 1994; (6): 349 2 Drugline nr 10843 (year 1994) (enclosed) 3 Drugline nr 09790 (year 1994) (enclosed)