I enjoy fasting and almost never eat breakfast. If I take my Accutane with a spoon of coconut oil, would it still be effective?

Accutane does absorb best with fatty foods.  I think a spoonful of a healthy oil would help if otherwise fasting, but may not be sufficient to achieve maximum absorption.  Since patients are prescribed accutane twice daily, you can discuss this with your treating doctor and one option is to give a smaller dose in the morning to take with your spoonful of oil and a larger dose in the evening, to take with the larger meal.  I would also consider something like a spoonful of peanut or almond butter in the morning.  You should also look into a brand of accutane called Absorica, which also comes as Absorica LD (low dose), and is formulated with a lipid capsule to maximize absorption.  You can try to get one of these options if this brand is affordable with your insurance.  It should have better absorption than the generics regardless of the food intake.  Best of luck!