Alitretinoin

Alitretinoin, or 9-cis-retinoic acid, is a form of vitamin A. It is also used in medicine as an antineoplastic (anti-cancer) agent developed by Ligand Pharmaceuticals. It is a first generation retinoid. Ligand gained Food and Drug Administration (FDA) approval for alitretinoin in February 1999.
Medical uses
Kaposi’s sarcoma
In the United States, topical alitretinoin is indicated for the treatment of skin lesions in AIDS-related Kaposi's sarcoma. Alitretinoin is not indicated when systemic therapy against Kaposi's sarcoma is required. It has received EMA (11 October 2000) and FDA (2 March 1999) approval for this indication.
Chronic hand eczema
Alitretinoin has been granted prescription rights in the UK (08/09/2008) for in chronic hand eczema as used by mouth.
In May 2009 the National Institute for Health and Clinical Excellence (NICE) issued preliminary guidance on the use of alitretinoin for the treatment of severe chronic hand eczema in adults. The recommendation stated that only patients with severe chronic hand eczema who are unresponsive to potent topical corticosteroids, oral immunosuppressants or phototherapy should receive the drug. Final NICE guidance was expected in August 2009.
Adverse effects
Systemic use
Very common (>10% frequency):
Headache
Hypertriglyceridemia
High density lipoprotein decreased
Hypercholesterolemia
Common (1-10% frequency):
Anaemia
Increased iron binding capacity
Monocytes decreased
Thrombocytes increased
TSH decreased
Free T4 decreased
Flushing
Conjunctivitis
Dry eye
Eye irritation
Transaminase increased
Dry skin
Dry lips
Cheilitis
Eczema
Dermatitis
Erythema
Hair loss
Joint pain
Muscle pains
Blood creatine phosphokinase increased
Uncommon (0.1-1% frequency):
Blurred vision
Cataracts
Nose bleeds
Itchiness
Rash
Skin exfoliation
Asteatotic eczema
Exostosis
Ankylosing spondylitis
Rare (<0.1% frequency):
Benign intracranial hypertension
Vasculitis
Unknown frequency:
Anaphylactic reactions
Hypersensitivity
Depression
Mood changes
Suicidal ideation
Decreased night vision
Topical use
Very common (>10% frequency):
Rash (77%)
Pain (34%)
Itchiness (11%)
Common (1-10% frequency):
Exfoliative dermatitis
Oedema
Skin changes
Paraesthesia
Contraindications
Pregnancy is an absolute contraindication as with most other vitamin A products, it should also be avoided when it comes to systemic use in any women that is of childbearing potential and not taking precautions to prevent pregnancy. Toctino (the oral capsule formulation of alitretinoin) contains soya oil and sorbitol. Patients who are allergic to peanut, soya or with rare hereditary fructose intolerance should not take this medicine. It is also contraindicated in nursing mothers. The oral formulation of alitretinoin is contraindicated in patients with:
Hepatic insufficiency
Severe chronic kidney disease
Uncontrolled hypercholesterolemia
Uncontrolled hypertriglyceridemia
Uncontrolled hypothyroidism
Hypervitaminosis A
Hypersensitivity to any excipients in alitretinoin
Interactions
It is a CYP3A4 substrate and hence any inhibitor or inducer of this enzyme may alter plasma levels of alitretinoin. It should not be given to patients with excess vitamin A in their system as there is a potential for its actions on the retinoid X receptor to be exacerbated. It may also interact with tetracyclines to cause benign intracranial hypertension.
Overdose
Alitretinoin is a form of vitamin A. Alitretinoin has been administered in oncological clinical studies at dosages of more than 10-times of the therapeutic dosage given for chronic hand eczema. The adverse effects observed were consistent with retinoid toxicity, and included severe headache, diarrhoea, facial flushing and hypertriglyceridemia. These effects were reversible.
Mechanism of action
Alitretinoin is believed to be the endogenous ligand (a substance that naturally occurs in the body that activates this receptor) for retinoid X receptor, but it also activates the retinoic acid receptor.
References
External links
Retinoids
Antineoplastic drugs
Cyclohexenes