A Common Drug With a Dangerous Side Effect: Acute Rhabdomyolysis Caused by the Synergistic Effect of Isotretinoin and Exercise in an Adolescent

Dasgupta, Kingshuk; Lim, Peter Paul; Reedstorm, Hannah

doi:10.7759/cureus.10929

Cited by 8 publications

(8 citation statements)

References 14 publications

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“…Isotretinoin has been associated with a range of musculoskeletal side‐effects, including precipitation of acne fulminans, arthralgia, Achilles tendonitis, 72 myalgia without CK elevation, and hyperCKaemia, both with and without development of rhabdomyolysis 47,73–82 …”

Section: Methodsmentioning

confidence: 99%

“…Isotretinoin has been associated with a range of musculoskeletal side-effects, including precipitation of acne fulminans, arthralgia, Achilles tendonitis, 72 myalgia without CK elevation, and hyperCKaemia, both with and without development of rhabdomyolysis. 47,[73][74][75][76][77][78][79][80][81][82] Myalgia and mild transient elevations in CK are common, and were observed in 20% of patients in a small series. 47 Significant elevations are much less frequent, with Manfredini et al 73 detecting CK over five times the upper reference range in 1Á2% of patients, and Landau et al 81 noting CK > 5000 IU L À1 in 1Á6% of patients (although Landau's was a military population).…”

Section: Evidence Foundmentioning

confidence: 99%

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Is routine laboratory testing in healthy young patients taking isotretinoin necessary: a critically appraised topic

Affleck

Jackson

Williams

et al. 2022

British Journal of Dermatology

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Summary Clinical question Is monitoring of liver function, lipids and full blood count necessary in healthy people taking isotretinoin? Background Routine blood testing was recommended in the original licence for Roaccutane™ (isotretinoin) in 1983. In recent years, less frequent monitoring has been suggested by various authors. Data sources We performed four individual systematic searches of the MEDLINE database, via PubMed, from origin to 2 May 2021, supplemented by a hand search of all references in the identified papers. Study selection Inclusion criteria were any description of clinical symptoms, laboratory abnormalities and/or physical findings, and any paper that explicitly described the patients as asymptomatic, during treatment with oral isotretinoin. Data extraction Two independent reviewers (J.A. and D.J.) assessed articles for eligibility of inclusion. Evaluation of the data was done also by two of the authors (A.A., D.J. and J.A.) for each section, with the aim to use the presented evidence including guidelines, databases, case series, case reports, cohort studies and randomized clinical trials to delineate the clinical presentation and frequency of adverse events that might be amenable to laboratory monitoring. Results We identified 407 papers in our searches and reviewed 125 papers in four sections. Overall, reported adverse events were very rare (< 1 in 10 000) and were either idiosyncratic or not preventable by monitoring, accompanied by symptoms, or seen in identifiable predisposed individuals who might benefit from monitoring because of pre‐existing conditions. Recommendation for clinical care We could not find evidence to support the benefit of monitoring to detect adverse events. We suggest that in healthy young people laboratory monitoring for oral isotretinoin is unnecessary and risks detecting nonserious biochemical abnormalities. However, we recognize that new information about adverse events may change that recommendation.

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Section: Methodsmentioning

confidence: 99%

Section: Evidence Foundmentioning

confidence: 99%

Is routine laboratory testing in healthy young patients taking isotretinoin necessary: a critically appraised topic

Affleck

Jackson

Williams

et al. 2022

British Journal of Dermatology

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“…Despite documented cases of elevated CK during isotretinoin therapy as far back as 1982, there are not yet guidelines for monitoring levels 164 . Numerous data points indicate a reason for concern: 50% of rhabdomyolysis cases are asymptomatic, the rhabdomyolysis triad of elevated CK, myalgias, and fatigue only occurs in ∼10% of cases, 20%–51% of patients on isotretinoin report fatigue and myalgias, and upward of 44% of patients on isotretinoin demonstrate an elevated CK at least once during therapy 164,174,179,180 . Elevations are usually in conjunction with an additional insult, most commonly exercise.…”

Section: Laboratory Abnormalities and Assessmentsmentioning

confidence: 99%

“…Elevations are usually in conjunction with an additional insult, most commonly exercise. Although causation has yet to be unequivocally established, several case reports have documented associations between isotretinoin and CK elevations as high as 80,000 (well above the criteria of five times the reference range seen in rhabdomyolysis) and at least one death 164,180,181 …”

Section: Laboratory Abnormalities and Assessmentsmentioning

confidence: 99%

Isotretinoin update

Marson

Baldwin

2021

Dermatological Reviews

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Background Acne is a common, chronic inflammatory condition seen in nearly all teenagers and many adult females, with a global lifetime prevalence between 70‐85%. While a majority of individuals with acne can be appropriately managed with a combination of topical therapies, oral antibiotics, and/or oral anti‐androgens, 10‐20% of individuals will have acne severe enough to warrant isotretinoin. When necessary, isotretinoin is highly effective and the only drug to offer the likelihood of a durable response. Aims To review the literature regarding known adverse effects of isotretinoin therapy and nuances during and post‐isotretinoin therapy important to patient care. Materials and Methods A literature search was conducted for original, English‐language case reports, case series, original studies and/or meta‐analyses published between 1982‐2021 on isotretinoin, related adverse effects, and laboratory assessment and treatment nuances during and after a course of isotretinoin. Results Adverse events categories include mucocutaneous (e.g., xerosis, cheilitis, epistaxis), ocular (xerophthalmia, nyctalopia, blepharitis, conjunctivitis), non‐specific gastrointestinal, musculoskeletal (myalgia, pre‐mature epiphyseal plate closure, DISH), neurologic (idiopathic intracranial hypertension, hearing loss, tinnitus). Most adverse events are mild, self‐limiting, and/or resolve with drug discontinuation. Teratogenicity is of utmost concern especially given the risk of patient nonadherence to iPLEDGE precautions. Laboratory testing at baseline and after month 2 of therapy or upon reaching maximum daily dose may be sufficient. Utilizing creatine kinase and gamma‐glutamyl transferase in lieu of aspartate aminotransferase and alanine aminotransferase may better assess hepatic function during treatment. Improved formulations of isotretinoin may improve absorption and decrease reliance on patient adherence to a high‐fat diet. Dermabrasion and fully ablative laser procedures should be avoided in the immediate post‐isotretinoin period. Discussion Although adverse events associated with isotretinoin therapy are common, a majority of side effects are limited, self‐resolving (with completion of treatment course) without long‐term implications, and/or easily managed. Unfortunately, the advent of the internet and social media has given a platform to misleading law‐firm claims and medical pseudoscience inaccuracies that may frighten patients in need of treatment, ultimately delaying or even preventing therapy. Conclusion It is important that physicians are knowledgeable about the nuances of isotretinoin therapy, including efficacy, real potential adverse events, and appropriate laboratory monitoring. By honing this expertise, physicians may confidently counsel and guide patients through a course of isotretinoin to achieve a more permanent solution for their acne and improve their quality of life.

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“…Systemic retinoids, though highly effective, have a number of documented adverse side effects, including cheilitis, xerosis with pruritus, teratogenicity, bone toxicity (such as diffuse idiopathic skeletal hyperostosis syndrome-like changes), hepatoxicity, psychiatric effects, and muscle pain [ 2 , 3 ]. Though muscle side effects are recognized, patients rarely develop rhabdomyolysis [ 4 ]. We present a case of an active duty military female patient with rhabdomyolysis following treatment with isotretinoin.…”

Section: Introductionmentioning

confidence: 99%

Rhabdomyolysis Caused by Isotretinoin and Exercise in an Otherwise Healthy Female Patient

Raneses¹,

Schmidgal²

2022

Cureus

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Acne vulgaris is one of the most common skin conditions treated by healthcare providers. Isotretinoin is a well-known and effective treatment for nodulocystic and scarring acne. Rarely, and usually in combination with exercise, patients treated with isotretinoin can develop rhabdomyolysis, a potentially life-threatening breakdown of muscle associated with elevated creatine kinase (CK). Here, we report a rare case of a female patient developing rhabdomyolysis three months after starting exercise and isotretinoin. She was treated with supportive care and medication was discontinued, resulting in a full recovery. Careful inquiry into the patient's exercise habits, along with a thorough review of systems at each visit can help identify high-risk patients. Routine monitoring of liver enzymes, specifically aspartate aminotransferase elevations, may provide a prompt to check a patient’s CK. Though regular monitoring of CK is not currently recommended, given the prevalence of regular exercise in certain patient populations, this case reinforces the importance of counseling patients on this potential side effect.

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A Common Drug With a Dangerous Side Effect: Acute Rhabdomyolysis Caused by the Synergistic Effect of Isotretinoin and Exercise in an Adolescent

Cited by 8 publications

References 14 publications

Is routine laboratory testing in healthy young patients taking isotretinoin necessary: a critically appraised topic

Is routine laboratory testing in healthy young patients taking isotretinoin necessary: a critically appraised topic

Isotretinoin update

Rhabdomyolysis Caused by Isotretinoin and Exercise in an Otherwise Healthy Female Patient

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