Compliance of BAD advice on the safe prescribing of Isotretinoin

Nada Khalil (FY2), Leah Mapara (Dermatology SpR), Randa Alhajar (Dermatology Consultant)

Background

• Oral Isotretinoin (Roaccutane) is a very effective treatment used for moderate and severe acne vulgaris. It is also being used for other conditions e.g. hidradenitis suppurativa, seborrhoea and rosacea.

• Careful assessment and close monitoring is imperative when prescribing this medication given its side effects and teratogenic nature. The British Association of Dermatology (BAD) have created clinical guidelines on the safe introduction and continued use of isotretinoin. There are 5 clinical audit points based

BAD Audit points

1. Female patients of childbearing potential receiving isotretinoin will have signed the ‘acknowledgement of PPP information’ form indicating that they have received appropriate information.

2. All patients will have had serum lipids checked prior to starting treatment and at least once during treatment.

these that every specialist prescribing isotretinoin must adhere

Aims and objectives

1. Assess the safety of isotretinoin introduction in Northwick Park (NPH) and Ealing Hospital (EH) Dermatology clinics

2. Assess the safety of monitoring isotretinoin therapy in NPH/EH Dermatology clinics

3. Identify areas of improvement within clinical practice when prescribing and monitoring isotretinoin

4. Promote safe practices among clinicians when prescribing isotretinoin

Previous audit (Jan- April 2018):

• Based on 38 patients – 9 males, 29 Females from Northwick Park Hospital only

• Variable compliance with BAD guidance.

• 100% compliance with lipid levels monitoring

• Poorer outcomes with pregnancy testing 5 weeks after course completed and documentation of mood at baseline an during treatment.

Interventions implemented since last audit

3. All females of childbearing potential will have pregnancy tests before treatment and at monthly intervals and at 5 weeks after treatment.

4. The number of pregnancies occurring in patients taking isotretinoin with a target of 0% pregnancies as the standard to be achieved (note these must be reported on the yellow card system).

5. There will be documentation of mental health and mood state for all patients commencing isotretinoin, both at the assessment for treatment and at each follow-up appointment.

Results of re-audit

Methods

Audit population identified:

• Dermatology patients who had been prescribed isotretinoin between 01/09/2020-01/05/2021

• Exclusion criteria: missing clinical records, incomplete records

• Seen in Dermatology clinics at NPH/Ealing

Clinical records analysed and relevant information recorded:

• GCIS and EPRO for clinic letters.

• ICE for blood results

• Clinic pregnancy test book and EPRO for pregnancy tests (Also B-HCG due to Covid and tele appointments)

• Overall improvement since last audit in all audit domains.

• 100% compliance with audit points 2-4

• Need to ensure better documentation of mood disorder prior to starting treatment

To improve compliance further:

• Continue Roaccutane pharmacy led clinic with checklist

• SHO acne clinic for new patients– newly created guideline using 2021 NICE guidelines has been created to use in clinic.

• Hand out Roaccutane alert cards to patients

• Every patient should receive BAD leaflet – may help reduce drop out rate/reduce DNAs

• Upload pharmacy Isotretinoin check list on EPRO – all documentation in one place