Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Dangerous Drug
- Mark S Schreiner (20 January 2007)
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What a change!
- Tom Sargent (20 January 2007)
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Re: Dangerous Drug
- David P Jones (21 January 2007)
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Use lymecycline as first line antibiotic for acne
- Julian Law (25 January 2007)
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Minocycline: an appropriate second line antibiotic for acne?
- Katharine Emma Wilkinson, Jayalakshmi Aiyengar, John D. Wilkinson (7 February 2007)
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What about minocycline-induced autoimmune hepatitis?
- Thomas J Ford (11 February 2007)
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Cutting the cost
- John R GILBERT (30 April 2007)
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Allergic Reactions to Minocycline & Future
- Sylvia E Atwell (13 August 2008)
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Mark S Schreiner, Associate Professor of Anesthesia in Pediatrics The Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
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I couldn't agree more with McManus et al. that minocycline should play no role in the treatment of acne. When my daughter developed a lupus like syndrome while taking minocycline for acne, I was caught unawares. And I was not the only one fooled. With an elevated titer indicating possible infection with Lyme Disease two family physicians couldn't pin down the cause of her worsening symptoms. Fortunately, a third physician (not counting myself) was wise enough to make a diagnosis. With so many less toxic drugs available, why would such a dangerous drug be used for the longterm treatment of a minor condition. Competing interests: None declared |
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Tom Sargent, Family Doctor Bo'ness West Lothian EH51 0DH
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One of the problems of having qualified a good few years ago is the effect that the training one got across the board can change without being noticed. As a student vagotomy and drainage was the best management for ulcers. The change to proton pump inhibitors has been very obvious. The change in acne management has been less so. I can recall getting a row from the prescribing advisers for using expensive doxycycline so was used to giving minocin after tetracycline but it was expensive too. Cost comparison tables even yet are not always studied. The one in the change page 20th January 2007 makes interesting reading. Common or garden tetracycline the most expensive of the lot! This one page is going to cause a big change as acne is almost as common as dyspepsia for a GP. I was going to add a reference but I’m not sure if your reference at the top left of the page is correct. I keep signing prescriptions as 2006 too! Tom Sargent
Competing interests: None declared |
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David P Jones, General practitioner Bangor, Gwynedd. LL57 1AH
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Treating acne generally involves treating teenagers. In order to have compliance with the regime, it has to be easy to take, and have no side effects. From the health economists viewpoint, it has also to be value for money. Over the years, I have observed that teenagers don't like the more than once a day dosing with oxytetracycline or tetracycline, and combined with having to time it between meals it has made compliance with this antibiotic poor, with resulting poor clinical response and failure to return for follow up. Their quality of life suffers and they loose confidence in their physician, instead trying a host various lotions and potions and doubtful dietary and lifestyle changes. Using a simple, once a day regime with an antibiotic that has no side effects (to note) and can be taken at the convenince of the patient, the response has generally been good, faith restored and dodgy treatments discarded. Although minocycline fulfills the once daily regime, I have always been concerned with the monitoring strictness, which leaves either doxycline or lymecycline, and having to take care with former with regard to sunlight exposure, lymecycline falls into the first line category. It is also reassuring to see that it is value for money compared with the others. Competing interests: None declared |
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Julian Law, General Practitioner Kyle of Lochalsh IV40 8DD
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An audit in my practice revealed that some of my collegues were unaware of the potential problems with minocin and the need for regular monitoring as outlined in the British National Formulary. Following the audit the prescribing of minocin decreased markedly. Over the years I have seen several patients who have developed problems with the drug. Lymecycline offers a convenient once daily dosage, does not have restrictions with regard to foods (like oxytetracycline) and does not require regular blood testing. I have rarely encountered problems with it other than headaches and nausea with lymecycline. Competing interests: None declared |
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Katharine Emma Wilkinson, Research Fellow, Dermatology Department of Dermatology, Allergy and Wound Care, Amersham Hospital, Whielden Street, HP7 0JD, Jayalakshmi Aiyengar, John D. Wilkinson
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A recent review in the BMJ(1)advises against the use of minocycline as a first line oral antibiotic in acne, a position with which we concur. The increasing proportion of patients carrying strains of Proprioni acnes resistant to tetracycline was noted, but the practical considerations of this were felt to be unclear since Proprioni bacterial sensitivity was reported to be rarely tested in clinical practice. One of us (JDW) has been routinely testing for P. acnes sensitivity in patients referred into secondary care for over 20 years. We therefore undertook a preliminary audit of case notes to determine the relative levels of P. acnes resistant to tetracycline, minocycline and erythromycin along with an assessment of whether changing the antibiotic, in cases of P. acnes resistance, led to a clinical improvement in patients’ acne. We have analysed 20 case notes where there was details of P. acnes sensitivity testing. 7 (35%) patients exhibited resistance to tetracycline, 14 (70%) were resistant to erythromycin, but no patient was resistant to minocycline. In 6 patients resistant to either tetracycline or erythromycin only 2 (30%) showed good clinical improvement on changing to minocycline. We believe, therefore, that the role of minocycline as a second line treatment of patients with acne who either have proven P. acnes resistance or who have failed to respond to an adequate trial of standard tetracycline treatment remians uncertain. A larger number of case notes need to be examined. 1)McManus P, Iheanacho I: British Medical Journal 20Jan2007 volume 334, p154 Competing interests: None declared |
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Thomas J Ford, Final Year Medical Student University of Dundee, Ninewells Hospital And Medical School, Dundee, DD1 9SY
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This article stuck
a chord with me having just clerked a 21 year old female patient who developed
jaundice and malaise after 9 months of acne treatment with minocycline.
Her ALT was in the thousands and she had positive serological markers consistent
with autoimmune hepatitis. Her liver function normalised within one month of
cessation of therapy. Case reports and reviews that discuss
autoimmune hepatitis developing after prolonged therapy with minocycline support a causal relationship (1-3). Whilst
adverse reactions involving the liver are well recognised after large doses of
intravenous tetracycline, minocycline carries a far
greater risk of these effects than other tetracyclines
(4). Some dermatologists argue that doctors should
not change their prescribing for acne due to the rarity and apparent reversibility
of this side effect (5). However from this patient’s perspective, her symptoms
were both debilitating and worrying. Indeed irreversible cirrhosis and deaths
have also been reported (2,6). In a submission to the
BMJ, another young female gave a vivid account of her devastating symptoms lasting
over two years after acne therapy with minocycline
(7). Although side effects of minocycline involving
the liver are rare, they cause the patients to suffer significant morbidity. I support
the conclusion of McManus et al: minocycline should
not be used as the first line oral antibiotic in acne. References 1 Krawitt E.
L. Medical Progress: Autoimmune Hepatitis.
N Engl J Med. 2006; 354:54-66. 2
Lawrenson RA, Seaman HE, Sundstrom
A, Williams TJ, Farmer RD. Liver damage associated with minocycline
use in acne: a systematic review of the published literature and pharmacovigilance data. Drug Saf.
2000 Oct;23(4):333-49. 3 Gough A, Chapman S, Wagstaff K, Emery P, Elias E. Minocycline
induced autoimmune hepatitis and systemic lupus erythematosus-like
syndrome. BMJ 1996;312:169-172. 4 Meynadier
J, Alirezai M. Systemic antibiotics for acne. Dermatol 1998;196(1):135-9 5 Cunliffe
WJ. Minocycline for
acne: Doctors should not change the way they prescribe for acne. [Letter] BMJ. 1996 Apr:312(7038):1101. 6 Chamberlain MC, Schwarzenberg SJ, Akin EU, Kurth MH. Minocycline-induced autoimmune hepatitis with subsequent cirrhosis. J Pediatr
Gastroenterol Nutr.
2006 Feb;42(2):232-5. 7 Tumoana R. ‘Minocycline induced autoimmune hepatitis and arthritis’ BMJ
Rapid response 18 September 1999. Response to comment on
Gough et al. BMJ 1996; 312:169-172. Competing interests: None declared |
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John R GILBERT, Family doctor Seabury Medical centre, Malahide, Co Dublin
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I was puzzled to see that oxytetracycline was not the cheapest in your article. Unusually, it is cheaper here in Ireland than in the UK. However, in the last 20 years, most of my patients have responded to 250 mg twice daily which halves the cost again and, presumably, reduces the risk of side effects. Competing interests: None declared |
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Sylvia E Atwell, Administrative Asst. MCBOCC 33040
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Nobody seems to have discussed the serious allergic reactions caused by this drug. I was prescribed Minocycline for purported rosacea (which I don't have). After about 3 weeks of taking this medication I had a severe allergic reaction wherein I broke out in hives all over my body and it took 3 trips to the ER within 48 hours to clear it up. My dermatology insists it wasn't the medication but the ER doctor differed. A few years later, my teenage son was prescribed the same medication and had a worse reaction after about 3 weeks. The dermatologist still insisted it was not the medication. Needless to say we don't go there anymore. Also, my son and I are both now "hypersensitive" and break out in sporadic hives for no apparent reason without warning or ability to pinpoint a trigger. We both went through extentive allergy testing and we were told that we are now hypersensitive and it's a common side effect of this medication. So we both carry benadryl forever.... nobody tells you this! Competing interests: None declared |
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