Is it safe to use Acitretin (Anti-Psoriatic Medication) with Anti-Tuberculosis Treatment (ATT)?

Acitretin Use with Anti-Tuberculosis Treatment (ATT)

Acitretin can be safely used with Anti-Tuberculosis Treatment (ATT) as there are no documented direct interactions between these medications, but careful monitoring of liver function is essential due to the potential for additive hepatotoxicity.

Rationale for Compatibility

Acitretin is a non-immunosuppressive systemic retinoid used for psoriasis treatment, making it a preferred option for patients with conditions requiring ATT compared to immunosuppressive alternatives like methotrexate or cyclosporine 1. The key considerations when using these medications together include:

• Acitretin does not compromise immune function, unlike other systemic psoriasis treatments 1
• No specific contraindications exist for combining acitretin with ATT in current guidelines 2
• Acitretin's metabolism is primarily hepatic, with excretion via renal and biliary routes 3

Monitoring Requirements

When using acitretin with ATT, implement this enhanced monitoring schedule:

1. Baseline assessment before starting combination therapy:

   • Liver function tests (LFTs)
   • Complete blood count (CBC)
   • Lipid profile
   • Renal function tests

2. During treatment:

   • LFTs and lipid profile: Weekly for first month, then every 2 weeks for second month, then monthly 2
   • CBC and renal function: Monthly 2
   • Monitor for symptoms of hepatotoxicity: jaundice, abdominal pain, nausea, fatigue

Potential Concerns and Management

1. Hepatotoxicity

Both acitretin and several ATT medications (particularly isoniazid, rifampin, and pyrazinamide) can cause liver injury:

• Acitretin causes elevations in transaminases in 13-16% of patients 2
• Pyrazinamide can cause hepatotoxicity at a rate of about 1% 2

Management:

• Consider lower starting doses of acitretin (10-25mg/day) 2
• Discontinue both medications if significant LFT elevations occur (>3x upper limit of normal)
• Consider alternative psoriasis treatments if hepatotoxicity develops

2. Lipid Abnormalities

Acitretin commonly causes hypertriglyceridemia and hypercholesterolemia 2:

Management:

• Implement lifestyle modifications (low-fat diet, exercise, alcohol restriction)
• Consider lipid-lowering therapy if levels remain significantly elevated
• Reduce acitretin dose if triglycerides exceed 500 mg/dL

3. Drug Interactions

While no direct interactions between acitretin and ATT are documented, be aware of these potential issues:

• Avoid vitamin A supplementation due to risk of hypervitaminosis A 2
• Alcohol should be strictly avoided as it can convert acitretin to etretinate, which has a much longer half-life 4
• Monitor glucose levels if patient is also on glibenclamide, as acitretin may potentiate its glucose-lowering effect 2

Dosing Considerations

• Start with lower acitretin doses (10-25mg/day) when using with ATT 2
• Titrate based on clinical response and tolerability
• Consider combination therapy with UVB phototherapy to enhance efficacy while maintaining lower acitretin doses 2

Special Populations

1. Women of childbearing potential:

   • Acitretin is absolutely contraindicated due to teratogenicity
   • Requires contraception for 3 years after discontinuation 2

2. Patients with pre-existing liver disease:

   • Consider alternative psoriasis treatments
   • If acitretin is necessary, use lowest effective dose with more frequent monitoring

Conclusion

Acitretin with ATT is a viable treatment option, particularly valuable because acitretin is non-immunosuppressive. The key to safe co-administration is vigilant monitoring of liver function and appropriate dose adjustments based on clinical and laboratory parameters.