acitretin
Sources réglementaires consultées
Indications approuvées
- Psoriasis sévère chez l’adulte ; réserver aux femmes non enceintes en âge de procréer qui ne répondent pas aux autres traitements ou ne peuvent pas les recevoir.
Contre-indications
Absolues
- Grossesse ou possibilité de grossesse sans prévention stricte ; allaitement ; insuffisance hépatique ou rénale grave ; hyperlipidémie chronique ; hypersensibilité aux rétinoïdes.
- Utilisation concomitante de méthotrexate, tétracyclines, vitamine A ou autres rétinoïdes.
Mises en garde cliniques
- Mise en garde majeure · Tératogène humain puissant. Les femmes en âge de procréer doivent utiliser simultanément deux méthodes contraceptives efficaces dès 1 mois avant, pendant et pendant 3 ans après le traitement ; obtenir deux tests de grossesse négatifs avant l’instauration, les répéter chaque mois pendant le traitement puis tous les 3 mois pendant 3 ans après. Ne pas donner de sang pendant le traitement ni pendant 3 ans après sa fin. Éviter l’alcool pendant le traitement et pendant 2 mois après. Surveiller la fonction hépatique et les lipides ; rechercher une hypertension intracrânienne, des troubles visuels et des effets osseux. — DailyMed acitretin capsules set ID a6546625-acb8-460e-b34e-f795bfb3680a
Interactions médicamenteuses
- ModéréeAlcool
Mécanisme: Il favorise la formation d’étrétinate, dont la demi-vie est beaucoup plus longue et qui est hautement tératogène.
Recommandation: Les femmes en âge de procréer doivent l’éviter pendant le traitement et pendant 2 mois après.
https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=a6546625-acb8-460e-b34e-f795bfb3680a
- SévèreMinipilule progestative
Mécanisme: L’acitrétine peut réduire son effet contraceptif.
Recommandation: Ne pas l’utiliser comme méthode contraceptive pendant le traitement.
https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=a6546625-acb8-460e-b34e-f795bfb3680a
- ModéréePhénytoïne
Mécanisme: L’acitrétine peut réduire partiellement la liaison de la phénytoïne aux protéines plasmatiques et augmenter sa fraction libre.
Recommandation: Surveiller la réponse et les signes de toxicité de la phénytoïne ; ajuster uniquement sous supervision clinique.
https://cima.aemps.es/cima/dochtml/ft/74727/FT_74727.html
- ModéréeGlyburide et autres antidiabétiques
Mécanisme: Chez 3 volontaires sur 7, l’acitrétine a renforcé l’effet hypoglycémiant du glyburide ; sans glyburide, aucun effet sur la tolérance au glucose n’a été détecté.
Recommandation: Surveiller étroitement la glycémie chez les personnes diabétiques.
https://api.fda.gov/drug/label.json?search=openfda.spl_set_id:08ce9fdd-1e84-4043-b085-91053f975b64
Effets indésirables
Communs (≥1%)
Chéilite et sécheresse des muqueuses · Desquamation, sécheresse cutanée, prurit ou alopécie · Anomalies lipidiques et des tests hépatiques · Arthralgie
Rares mais graves
Hépatite ou ictère · Hypertension intracrânienne · Cécité nocturne ou kératite ulcéreuse
Grossesse et allaitement
Contre-indiquée pendant la grossesse et l’allaitement. Éviter toute grossesse pendant le traitement et pendant au moins 3 ans après l’arrêt.
Bibliographie récente (PubMed)
Plaque psoriasis is a chronic, immune-mediated inflammatory skin disease that has considerable effects on patients' physical, psychological and social well-being. It is strongly influenced by genetic predisposition, with HLA-C*06:02 showing the strongest association, particularly in those with early-onset disease. Additional susceptibility loci, including IL23A, IL12B and IL17RA, are linked to dysregulation of the IL-23-T helper 17 axis, which contributes to chronic inflammation and keratinocyte hyperproliferation. Plaque psoriasis is frequently associated with psoriatic arthritis and other comorbidities, such as cardiovascular disease, metabolic syndrome and psychiatric disorders, all of which contribute to increased morbidity and mortality. Management strategies are tailored to disease severity and the presence of comorbidities. For mild disease, topical therapies remain the first-line treatment, including corticosteroids, vitamin D analogues and topical calcineurin inhibitors. New non-steroidal agents, such as topical PDE4 and aryl hydrocarbon receptor agonists, offer additional options. In moderate-to-severe disease, oral systemic therapies, such as methotrexate, ciclosporin, acitretin, apremilast and deucravacitinib, provide a range of immunomodulatory effects. Biologic therapies targeting TNF, IL-17, IL-23 and IL-12/23 have demonstrated high efficacy in improving both cutaneous and systemic inflammation. Current research on systemic therapies is focused on the development of additional inhibitors of the Tyk2 pathway and inhibitors to IL-23 receptor, IL-17, and TNF. Early screening for psoriatic arthritis, proactive cardiovascular risk reduction and multidisciplinary care are crucial to optimizing long-term outcomes. Ongoing research continues to advance precision medicine approaches, with the goal of enhancing treatment durability and improving quality of life for individuals living with psoriasis.
Oral psoriasis therapies include both older traditional immunosuppressants, such as methotrexate, cyclosporine, and acitretin, as well as newer, more targeted agents, such as apremilast, deucravacitinib, and oral interleukin-23 receptor antagonists. Patients may prefer oral therapies to injectable therapies based on the route of administration. Both older and newer oral psoriasis therapies can be utilized effectively in the treatment of psoriasis. Here, we will review oral agents used in the treatment of psoriasis as well as provide commentary on their role in our current, evolving psoriasis treatment paradigm. A maternal acitretin dose of 0.65 mg/kg daily produced low levels in milk in one woman. Because there is no published experience with the safe use of acitretin during breastfeeding, current expert opinion recommends avoiding acitretin during breastfeeding.[1] Various topical agents that are less likely to be absorbed by the mother may be preferred during breastfeeding, especially while nursing a newborn or preterm infant. Only water-miscible cream or gel products should be applied to the breast because ointments may expose the infant to high levels of mineral paraffins via licking.[2]
For psoriatic patients who need to receive nonlive or live vaccines, evidence-based recommendations are needed regarding whether to pause or continue systemic therapies for psoriasis and/or psoriatic arthritis. To evaluate literature regarding vaccine efficacy and safety and to generate consensus-based recommendations for adults receiving systemic therapies for psoriasis and/or psoriatic arthritis receiving nonlive or live vaccines. Using a modified Delphi process, 22 consensus statements were developed by the National Psoriasis Foundation Medical Board and COVID-19 Task Force, and infectious disease experts. Key recommendations include continuing most oral and biologic therapies without modification for patients receiving nonlive vaccines; consider interruption of methotrexate for nonlive vaccines. For patients receiving live vaccines, discontinue most oral and biologic medications before and after administration of live vaccine. Specific recommendations include discontinuing most biologic therapies, except for abatacept, for 2-3 half-lives before live vaccine administration and deferring next dose 2-4 weeks after live vaccination. Studies regarding infection rates after vaccination are lacking. Interruption of antipsoriatic oral and biologic therapies is generally not necessary for patients receiving nonlive vaccines. Temporary interruption of oral and biologic therapies before and after administration of live vaccines is recommended in most cases.