Prescribing Roaccutane

Delancey

I've heard ( I forget where and from whom ) that the anti acne drug Roaccutane ( hope my spelling is ok ) may not be prescribed by GP's/Junior Doctors and can only be dispensed on foot of a Consultants prescription . Is this in fact the case ? If so , what other drugs are ' restricted' in this way ?

locum-motion

delancey42 wrote: »

I've heard ( I forget where and from whom ) that the anti acne drug Roaccutane ( hope my spelling is ok ) may not be prescribed by GP's/Junior Doctors and can only be dispensed on foot of a Consultants prescription . Is this in fact the case ? If so , what other drugs are ' restricted' in this way ?

Yes, you're correct.
A prescription for Roaccutane may only be initiated by a consultant.
There are a lot of drugs where the same applies.
I have absolutely no intention of providing a list.
I suggest if you have a similar question about another specific drug, ask it again.

clartharlear

Do consultants readily give out prescriptions for roaccutane to those who present with acne?
In other words, if a GP gives a referral because of acne, will the consultant nearly always provide a prescription?

Because, if so, then why not let the GP prescribe?

angeldelight

Actually I find that really interesting - at what level is it restricted? Because it's not restricted according to the SPC. All it has to be is by a doctor with experience of using it and who fully understands the risk, surely some GPs could claim to have that? And it says can be done "under the supervision of" said doctors - again could a junior doctor claim he was prescribing it under that caveat?

Also under the prescribing and dispensing requirements there is nothing about the level of doctor who can prescribe..

sam34

angeldelight wrote: »

And it says can be done "under the supervision of" said doctors - again could a junior doctor claim he was prescribing it under that caveat?

i dont know about roaccutane, but the anti-psychotic drug clozaril can only be initiated by a consultant. a junior doctor can continue a prescription for it, and can alter doses but they cannot commence someone on it.

locum-motion

angeldelight wrote: »

Actually I find that really interesting - at what level is it restricted? Because it's not restricted according to the SPC. All it has to be is by a doctor with experience of using it and who fully understands the risk, surely some GPs could claim to have that? And it says can be done "under the supervision of" said doctors - again could a junior doctor claim he was prescribing it under that caveat?

Also under the prescribing and dispensing requirements there is nothing about the level of doctor who can prescribe..

Sorry, angeldelight is right and I was wrong.

angeldelight

locum-motion wrote: »

Sorry, angeldelight is right and I was wrong.

Btw not trying to nitpick, but will be pharmacist in 8ish weeks (fingers crossed) so was checking for my own reference!

eth0_

clartharlear wrote: »

Do consultants readily give out prescriptions for roaccutane to those who present with acne?
In other words, if a GP gives a referral because of acne, will the consultant nearly always provide a prescription?

Because, if so, then why not let the GP prescribe?

No...if the GP can't resolve your acne issue, they'll refer you to a dermatologist for tests and to try a different drug. Roaccutane is not prescribed lightly due to its side effects. You'd need to have really treatment resistant acne before you'll be put on Roaccutane.

plodder

I've had trouble getting this dispensed for my son on a couple of occasions at McCabes. First time, they said it has to have a separate prescription on each occasion. After checking into it, they realised that regulation only applies to girls. So, that was fine. However, the other day, a different branch are claiming it's illegal for it to be prescribed by a GP. I understand that a lot of GPs won't prescribe it, and that's fair enough, but if a GP is experienced with it, and decides to prescribe it, can they refuse to dispense? I've looked at the regulations and I don't see any such restriction. It also looks from the replies above they are wrong unless something has changed .. ?

Vorsprung

Looked at the SPC last night and it states that only those experienced with it and its monitoring should be prescibing it. Asked the wife to have a look in the pharmacy where she works, their SOP requires that a dermatologis initiate it but that they will accept continutation scripts from GPs.

I think you'd be on pretty shaky ground if you initiated it without a lot of direct experience.

chocksaway

Pretty sure it has a black box warning due to incidents of depression and suicide. Maybe thats why they don't prescribe it

Gael23

Vorsprung wrote: »

Looked at the SPC last night and it states that only those experienced with it and its monitoring should be prescibing it. Asked the wife to have a look in the pharmacy where she works, their SOP requires that a dermatologis initiate it but that they will accept continutation scripts from GPs.

I think you'd be on pretty shaky ground if you initiated it without a lot of direct experience.

Thats the case with a number of Drugs where in the first instance a Conaultant must prescribe it. But of like me you have a medical card, you give the consultants script to your GP so I dopont know how you can prove it was originally prescribed by a consultant

plodder

Vorsprung wrote: »

Looked at the SPC last night and it states that only those experienced with it and its monitoring should be prescibing it. Asked the wife to have a look in the pharmacy where she works, their SOP requires that a dermatologis initiate it but that they will accept continutation scripts from GPs.

I think you'd be on pretty shaky ground if you initiated it without a lot of direct experience.

Just to be clear, I'm the punter trying to get the prescription filled, not the doctor prescribing it. If the pharmacy requires the scrip to be initiated by a dermatologist then ok, though I question their right to do that really. Who are they to judge whether a particular doctor has the right experience or not? What annoyed me was the suggestion that it was illegal. I don't think it is illegal. And frankly, from talking to this GP, she has significant experience with the medication, including its use by her own children. We discussed the psychological risks, and I trusted her judgment on that aspect.

jumpguy

chocksaway wrote: »

Pretty sure it has a black box warning due to incidents of depression and suicide. Maybe thats why they don't prescribe it

No causal link between isotretinoin (i.e roaccutane) and suicide have ever been found. Suicidal ideation has been found to be more common in those with severe acne. Trying to untangle whether it's the drug or whether people are depressed due to their acne is very difficult. As well as that, isotretinoin can very rapidly alter the appearance of someone with acne (i.e by clearing up their acne) and any big change like that would be a risk factor for suicide (life change in general being a risk factor...) Also, at the beginning of isotretinoin treatment, acne can actually paradoxically flare up - a low dose is used initially to try to minimise this but I don't know how effective it is at reducing the flare-up (I'm not a doctor!)

It's actually a great pity that it's impossible to conclusively establish or disprove the link, because I think it frightens parents and their children away from what is the only drug that can definitively alter the natural course of severe, treatment-resistant acne. Speaking personally, I've had a few friends who had extremely bad acne and had their lives transformed by the drug, it's wonderful. Unfortunately that side doesn't get much coverage.

Probably the main reason dermatologists would be only allowed prescribe it is that first of all it's only indicated for treatment-resistant acne after a failed course of systemic antibiotics, then it's highly teratogenic so girls need to be on a contraceptive to take it (I don't know if it's necessary to prescribe the pill but I'd say it's certainly offered). It's hepatotoxic and can cause hyperlipidaemia so liver enzymes and blood lipids need to be periodically monitored, and finally patients are to be counselled on things like myalgias, initial acne flare-up after starting treatment, dry skin and decreased night-vision which are common side-effects. So you need to know a good bit about the drug to safely prescribe it.

All those side effect might sound a bit mad. Interestingly the drug is actually just a chemically altered version of good aul vitamin A which accounts for the physiology behind many of the side-effects. For example, vitamin A is stored in the liver explaining the hepatotoxicity and is recruited to the eye to improve our rods (or is it cones...) sensitivity to light when it's dark, explaining the decreased night vision. I don't think anybody's too sure why it's toxic to sebaceous glands, which is the mechanism by which it controls acne.

plodder

jumpguy wrote: »

No causal link between isotretinoin (i.e roaccutane) and suicide have ever been found. Suicidal ideation has been found to be more common in those with severe acne. Trying to untangle whether it's the drug or whether people are depressed due to their acne is very difficult. As well as that, isotretinoin can very rapidly alter the appearance of someone with acne (i.e by clearing up their acne) and any big change like that would be a risk factor for suicide (life change in general being a risk factor...) Also, at the beginning of isotretinoin treatment, acne can actually paradoxically flare up - a low dose is used initially to try to minimise this but I don't know how effective it is at reducing the flare-up (I'm not a doctor!)

It's actually a great pity that it's impossible to conclusively establish or disprove the link, because I think it frightens parents and their children away from what is the only drug that can definitively alter the natural course of severe, treatment-resistant acne. Speaking personally, I've had a few friends who had extremely bad acne and had their lives transformed by the drug, it's wonderful. Unfortunately that side doesn't get much coverage.

Probably the main reason dermatologists would be only allowed prescribe it is that first of all it's only indicated for treatment-resistant acne after a failed course of systemic antibiotics, then it's highly teratogenic so girls need to be on a contraceptive to take it (I don't know if it's necessary to prescribe the pill but I'd say it's certainly offered). It's hepatotoxic and can cause hyperlipidaemia so liver enzymes and blood lipids need to be periodically monitored, and finally patients are to be counselled on things like myalgias, initial acne flare-up after starting treatment, dry skin and decreased night-vision which are common side-effects. So you need to know a good bit about the drug to safely prescribe it.

All those side effect might sound a bit mad. Interestingly the drug is actually just a chemically altered version of good aul vitamin A which accounts for the physiology behind many of the side-effects. For example, vitamin A is stored in the liver explaining the hepatotoxicity and is recruited to the eye to improve our rods (or is it cones...) sensitivity to light when it's dark, explaining the decreased night vision. I don't think anybody's too sure why it's toxic to sebaceous glands, which is the mechanism by which it controls acne.

I'd agree with pretty much all of this and had been advised of same. My son is actually near the end of the course, and it's been very effective, but at the beginning the dry-skin side-effect happened almost immediately, before any improvement in the condition. That definitely affected his mood, one or two mornings, which was something we were looking out for.

I took a look at the legal regulations around all this, and it's interesting that isotretinoin is one of a minority of drugs that have specific legal regulations (due to the teratogenic effect in its case) and maybe that's where the idea that they legally have to be prescribed by specialists only, came from. But, as I said above, I don't think that is actually the case. As far as I can see, the law doesn't really make any distinction between GPs and specialists. They are all 'registered medical practitioners'. But, I'm not a lawyer either. So, I could have missed something..