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Isotretinoin Laboratory Monitoring in Acne Treatment
TAKE-HOME MESSAGE
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An international panel of expert dermatologists has published this Delphi consensus study to guide clinicians on appropriate laboratory monitoring for isotretinoin therapy. Initial and peak dose monitoring of alanine aminotransferase (ALT) and triglycerides were the only tests for which a consensus was reached. Monthly laboratory monitoring, other liver function and lipid testing, and hematologic studies were excluded by consensus.
- For healthy patients on isotretinoin, the initial and peak dose monitoring of ALT and triglycerides were the only laboratory tests for which a consensus was achieved.
abstract
This abstract is available on the publisher's site.
Access this abstract nowImportance
Although isotretinoin may rarely be associated with laboratory abnormalities such as hypertriglyceridemia, the optimal approach to laboratory monitoring is uncertain, and there is wide variation in clinical practice.
Objective
To establish a consensus for isotretinoin laboratory monitoring among a diverse, international cohort of clinical and research experts in acne.
Design, Setting, and Participants
Using a modified electronic Delphi process, 4 rounds of anonymous electronic surveys were administered from 2021 to 2022. For laboratory tests reaching consensus (≥70% agreement) for inclusion, questions regarding more time-specific monitoring throughout isotretinoin therapy were asked in subsequent rounds. The participants were international board-certified dermatologist acne experts who were selected on a voluntary basis based on involvement in acne-related professional organizations and research.
Main Outcomes and Measures
The primary outcome measured was whether participants could reach consensus on key isotretinoin laboratory monitoring parameters.
Results
The 22 participants from 5 continents had a mean (SD) time in practice of 23.7 (11.6) years and represented a variety of practice settings. Throughout the 4-round study, participation rates ranged from 90% to 100%. Consensus was achieved for the following: check alanine aminotransferase within a month prior to initiation (89.5%) and at peak dose (89.5%) but not monthly (76.2%) or after treatment completion (73.7%); check triglycerides within a month prior to initiation (89.5%) and at peak dose (78.9%) but not monthly (84.2%) or after treatment completion (73.7%); do not check complete blood cell count or basic metabolic panel parameters at any point during isotretinoin treatment (all >70%); do not check gamma-glutamyl transferase (78.9%), bilirubin (81.0%), albumin (72.7%), total protein (72.7%), low-density lipoprotein (73.7%), high-density lipoprotein (73.7%), or C-reactive protein (77.3%).
Conclusions and Relevance
This Delphi study identified a core set of laboratory tests that should be evaluated prior to and during treatment with isotretinoin. These results provide valuable data to guide clinical practice and clinical guideline development to optimize laboratory monitoring in patients treated with isotretinoin.
Additional Info
Isotretinoin Laboratory Monitoring in Acne Treatment: A Delphi Consensus Study
JAMA Dermatol 2022 Jun 15;[EPub Ahead of Print], E Xia, J Han, A Faletsky, H Baldwin, K Beleznay, V Bettoli, B Dréno, CL Goh, L Stein Gold, H Gollnick, MI Herane, S Kang, L Kircik, J Mann, A Nast, HH Oon, JA See, M Tollefson, G Webster, C Zip, J Tan, EB Tapper, D Thiboutot, A Zaenglein, J Barbieri, A MostaghimiFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Are you ordering monthly labs in your otherwise healthy patients taking isotretinoin for acne? How about a baseline complete blood count or complete metabolic panel? This Delphi consensus study from an international panel of experts augments the growing body of literature suggesting that we may be over-testing these patients.
The panel, consisting of 22 board-certified experts on acne based on research publications, agreed with a consensus of 89.5% that alanine aminotransferase (ALT) and triglycerides (TGs) should be tested within a month of initiating isotretinoin and again after the peak dose of isotretinoin had been reached. The panel agreed that ALT and TGs should neither be monitored monthly nor at the conclusion of isotretinoin treatment. No consensus was reached regarding monitoring of aspartate aminotransferase (AST) or total cholesterol.
The panel additionally reached a consensus that the remaining tests typically included in a basic metabolic panel, liver function panel, and complete blood count should not routinely be checked in otherwise healthy patients.
The bottom line: simplify your laboratory monitoring practice in typical acne patients being treated with isotretinoin. Order isolated tests rather than full panels. Monitor ALT and TGs at baseline and after peak dose is achieved, unless the results or the clinical picture suggest developing abnormalities. The result? Eliminate potentially wasteful testing, save patients the distress of frequent lab monitoring, and lower the cost of treatment.