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PRESCRIBING rights for Australian GPs continue to expand. Recent developments include the ability to seek authority to prescribe medical termination of pregnancy and medicinal cannabis.
Another topic of debate has been the prescription of isotretinoin for acne, which continues to be limited to dermatologists in Australia. The Australasian College of Dermatologists (ACD) advocates that only dermatologists be allowed to prescribe isotretinoin “because of the complexities involved in patient selection and management, in addition to its known teratogenic effects”.
Isotretinoin has been in use in Australia since the 1980s. It remains the most effective treatment of acne and is presently listed on the Pharmaceutical Benefits Scheme for severe cystic acne unresponsive to other therapy.
I was pleasantly surprised to learn that GPs in other countries can prescribe isotretinoin. New Zealand GPs and nurse practitioners have been able to prescribe subsidised isotretinoin since 2009. GPs are now the dominant prescribers in New Zealand and isotretinoin has become more accessible to socially disadvantaged groups. Pregnancy exposures to isotretinoin are similar when comparing GP and dermatologist prescriptions.
Here are some reasons why Australian GPs should be allowed to prescribe isotretinoin:
- GPs are experienced with the aspects of prescribing a medication like isotretinoin: careful patient selection, side effect counselling, blood test monitoring, follow-up and use of recall systems, mental health assessment, assisting patients institute contraceptive measures while using a teratogenic medication.
- GPs are experts on contraception.
- GPs advocate use of long-acting reversible contraception, with some GPs able to perform insertion of contraceptive implants and intrauterine devices.
- The New Zealand experience confirms that GPs can safely prescribe isotretinoin.
- GPs are more accessible than dermatologists.
- GP consultation fees are less than private dermatologists.
- Dermatology appointment wait times will be reduced.
The Royal Australian College of General Practitioners (RACGP) has previously made a submission to the Health Minister advocating GP prescription of isotretinoin. I advocate that GPs undergo a training course, created jointly by the ACD and RACGP, to gain authority to prescribe isotretinoin in a safely monitored environment with strict criteria to ensure best practice is followed.
The RACGP already has an online learning module “treatment of severe acne” that could be expanded to become the training course. Naturally, GPs will self-select to undergo this training and become isotretinoin prescribers.
Dr John O’Bryen is a GP, and Senior Lecturer at Griffith University and the University of Queensland.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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I agree GPs should be able to prescribe it. Cystic acne is easy to identify, so a specialist is not required.
Isotretinoin is the only drug that actually works in my experience having tried everything else.
Low dose is now the preferred isotretinoin treatment regiment (see NZ guidelines for prescribers) so side effects are as much of a problem. Pregnancy issue is the most dangerous risk, but dermatologists don’t make that any less of a risk.
The bottom line is that acne is a life destroying illness and the ridiculous cost of specialists in Australia is prohibitive to our poorer citizens being able to overcome it. Allowing GPs to prescribe isotretinoin is a progressive and safe decision.
A lot of people are suffering with painful cystic acne because they don’t have the funds or the time to source a specialist dermatologist and wait for an available appointment. Then once initial appointments are set up it costs a lot of money to go to prescreening appointments, and then the cost of the script, then the follow-up appointments. You basically have to have thousands of dollars to get an isotretinoin prescription. GPs can provide the same level of care, if not more as they are aware of all of your medical history, they are a lot more assessable if you need urgent medical advice, it just makes sense. My GP has been subscribing me the Pill for acne for years, why couldn’t they subscribe be isotretinoin for the same reason?
I’m a public health student and also frequent historical user of isotretinoin for cystic acne. After a few years I am having severe breakouts again, typical of my previous breakouts, and to get in to see my dermatologist will cost me $$$ and time waiting. I work professionally as a model so time is money in this instance as my skin is inhibiting my ability to do my job.
As a consumer, it would be much more beneficial for me to be able to access a prescription for this through my GP, and would still be able to undergo the usual bloods required beforehand. My GP also has my MHCP and contraception on file for monitoring with this medication.
Perhaps a middle ground could be found where an initial referral is required to see the dermatologist, but within 2 years (relapse is common with isotretinoin) can see a GP for a second round if necessary.
Any professionals have thoughts on this as a suggestion? Would be interested to know if I’m completely off the mark with my thoughts.
Dermatologists are paid HUNDREDS more for the same prescription a GP could provide. In fact, my GP provided more information about my skin and accutane than my dermatologist ever did. I’ve paid $500 for 10 minutes of his time. $500 for a PRESCRIPTION. It is so unfair and classist. LET GP’s PRESCRIBE ACCUTANE.
Agree with the root-cause, more dermos needed, and this would fix the problem. The vacuum is allowing a proliferation of GP run skin cancer clinics purporting to be specialists without a fellowship in the discipline. The public (and sadly many of our GP colleagues) dont know the difference. If the AMC hasn’t recognised and accredited a ‘college’, then the certificates they dispense are worthless and deceptive. The skin cancer GPs could be first in the queue for an expanded dermatology training program.
I might be on my own but as a GP I would not feel comfortable starting isotretinoin. I have not been trained nor had adequate experience, and I’d feel medicolegally exposed. I have seen many patients started on various regimes due to nuance differences, some start with steroids, others with antibiotics. What next – nurse practitioners prescribing isotretinoin, pharmacists handing it out over the counter? There should be more dermatologists trained so wait times are shorter, and private fees reduced with more competition. Also the Medicare rebate to patients for a specialist review is only $33.75, leaving too much out of pocket. The government and dermatology college should address this to improve access to care.
Agree with this. While we’re at it, we should also allow GPs to prescribe Botox for migraine and hyperhidrosis, and non-psychiatrists to prescribe clozapine. In the case of Botox, it’s really easy to do, and as long as the patients meet criteria, they should be allowed to have it. In the case of clozapine, we routinely prescribe drugs that can and do cause cytopenias (e.g. azathioprine, among others) without undue issues, so why restrict clozapine only to psychiatrists?
An Australia-based neurologist
Personally my major concern is the limitation on our ability to order MRI scans.
Appropriate ordering of MRI scan by GP will result in fewer unnecessary referrals to specialists.
If there is concern regarding cost perhaps a patient should be limited to one MRI per calendar year per body part
Agree with Dr JOHN O’BRYEN. This medication is an effective Streamlined Authority and withholding it can cause just as much psychological harm into adulthood than physiological risks.
The authority form lumps it with clomiphene and anabolic steroids (these should be tightly regulated) and the form is still the same from 2016. It seems easier to prescribe psychostimulants, testosterone and modafanil!
Time for a review.
All of my young adult patients get a blood test and prophylactic contraceptives (oral in females) prior to having isotretinoin prescribed in the past. They don’t mind paying private fees (there are generic brands now) and just don’t want to be on ineffective tetracyclines and topical retinoids for their nodulocystic acne.
Interesting that 0.1% adapalene ge (Differin) is now OTC (S3) via pharmacists.
Sometimes the monopoly from dermatologists seems a bit like when urologists were the only ones to prescribe sildenafil. The dermatologists in the area also seem to coprescribe dermabrasion and extemporaneous moisturisers with isotretinoin.
I was told I could prescribe the medication if I paid Australasian College of Dermatologists membership fees!
A non-dermatologist Australian Physician Specialist
Isotretrinoin has to be administered under guidelines blood tests ,psychological assessments without a doubt but it is not a difficult drug to monitor .Methotrexate,amiodarone .warfarin all have serious consequences if not monitored and these drugs are used frequently in general practice
High doses for severe acne should be collaborated or referred to dermatologist .
Without a doubt low socioeconomic groups are subjected to a lifetime of psychological consequences due to disfiguring scarring .This is discriminatory to Australian disadvantaged patients with moderate acne and public hospital dermatology have long waiting lists so patients are routinely lost to follow up and prescibed less effective medications/topicals with poor compliance and poor patient outcomes
As a GP I’ve been keen to prescribe Isotretinoin for years. Its incredibly frustrating to have to refer when earlier appropriate treatment fails. Adverse mental health outcomes can be an issue for uncontrolled acne sufferes too.
I am more expert with prescribing contraception than any specialist I’ve met. I can review people frequently to check response and compliance with initial treatments. I agree with having a training process and perhaps the institution of a system similar to mental health where trained and untrained GP’s are differentiated – easy to do. This occurs for Opiate replacement therapy and RU486 etc also.
Non-dermatologist specialists like paediatricians, endocrinologists and adolescent medicine physicians should be allowed to prescribe isotretinoin too as regional dermatologist access is limited and we are appropriately trained.
1. Are you sure it is acne? Not rosacea or perioral dermatitis?
2. Have all pre-roaccutane therapies been tried, and for the appropriate duration? Has patient been compliant with the acne therapies?
2. Will the threshold for acne severity for prescribing isotretinoin for be lowered if GPs are enabled to prescribe isotretinoin?
3. What is the incidence of adverse effects? Pregnancy, GI, hepatic, metabolic. (I think the association with depression/suicide is casual, not causal)
4. Is it possible that GPs will prescribe isotretinoin privately if the patient does not meet PBS criteria (severe cystic acne)? Isotretinoin 20mg x 30 capsules = $45 (private), $40 (PBS, no concession, not much cheaper than private)
5. What do MDOs think of this?
6. What is ACD’s view on this?