Should I represcribe Acitretin (Soriatane) to a patient with a history of psoriasis who responded well to it for 2 years, and if so, do I still need to monitor liver function?

Acitretin Represcription and Monitoring for Psoriasis Relapse

Yes, you should represcribe acitretin for this patient with recurrent psoriasis after discontinuation, and you must continue to monitor liver function tests every 3 months throughout the treatment course. 1

Rationale for Represcription

Acitretin is effective for psoriasis treatment, particularly when the patient has previously demonstrated a good response. The relapse after discontinuation is common and expected with acitretin therapy, as it treats but does not cure psoriasis.

Effectiveness and Indications

• Acitretin is particularly effective for pustular and erythrodermic psoriasis (84% effectiveness) 1
• For plaque psoriasis, acitretin may be less effective as monotherapy but still beneficial for patients who previously responded well 2
• Acitretin has the advantage of not being immunosuppressive, making it suitable for long-term therapy 2

Monitoring Requirements

Liver Function Testing

• LFTs must be monitored monthly for the first 3 months, then every 3 months during continued therapy 1
• Elevations of transaminases occur in 13-16% of patients treated with acitretin 1
• Severe increases in liver function tests are rare but may indicate toxic hepatitis induced by acitretin 1

Additional Monitoring

• Complete blood count (CBC) and renal function tests should be checked every 3 months 1
• Lipid profile should be monitored on the same schedule as LFTs (monthly for 3 months, then every 3 months) 1
• Pregnancy test if indicated (though not relevant for this male patient) 1

Dosing Considerations

• Standard dosing is 10-50 mg/day given as a single dose 1
• Lower doses (≤25 mg/day) are often used to minimize adverse effects 1
• Response is relatively slow with 3-6 months required to achieve maximal response 1
• Consider the previous effective dose that worked for this patient

Potential Side Effects to Monitor

• Mucocutaneous effects: cheilitis, xerosis, pruritus, dry mouth, alopecia 1
• Ocular effects: xerophthalmia, night blindness 1
• Musculoskeletal: joint pain, myalgia 1
• Metabolic: hypertriglyceridemia (25-50% of patients) 1, 3
• Hepatic: abnormal LFTs 1
• Neurological: headache, pseudotumor cerebri (rare) 1

Important Precautions

• Avoid concomitant administration of vitamin A supplements due to risk of hypervitaminosis A 1
• Caution with alcohol consumption as it can convert acitretin to etretinate (longer half-life) 4
• Avoid combination with methotrexate due to increased risk of hepatotoxicity 1
• Avoid combination with tetracyclines due to risk of increased intracranial pressure 1

Management of Hypertriglyceridemia

If the patient develops elevated triglycerides:

• Implement lifestyle modifications (low-fat diet, exercise, alcohol restriction) 3
• Monitor triglyceride levels more frequently if elevated 3
• Consider dose reduction if triglycerides are significantly elevated 5
• Consider discontinuation if severe hypertriglyceridemia develops (>500 mg/dL) due to risk of pancreatitis 3

Conclusion

For this patient who responded well to acitretin for two years and experienced relapse upon discontinuation, represcription is appropriate with continued monitoring of liver function tests and other parameters as outlined above. The established efficacy and safety profile for long-term use makes acitretin a suitable option for ongoing management of this patient's psoriasis.