Consensus reached on lab monitoring for patients taking isotretinoin for severe acne

Isotretinoin is the most effective treatment for severe acne, producing long-term acne remission after about six months of therapy. Mucocutaneous dryness and joint aches are the most common adverse effects, although rare and more serious adverse effects such as pancreatitis, mood changes and teratogenicity have also been reported. Concerns have also been raised about possible isotretinoin-induced laboratory abnormalities including hypertriglyceridemia (possibly leading to pancreatitis), transaminitis, thrombocytopenia and leukopenia. However, the optimal approach to laboratory monitoring for isotretinoin is uncertain and no recent consensus standards are available. A wide variation in monitoring exists in clinical practice, with some physicians frequently ordering lab tests that may be clinically unimportant or of low clinical value. Read: Helping patients proceed with caution: Phone apps for skin diseases To establish a consensus for isotretinoin laboratory monitoring, investigators used a modified electronic Delphi process among a diverse, international cohort of clinical and research experts in acne. The participants were international board-certified dermatologist acne experts who were selected on a voluntary basis based on their involvement in acne-related professional organizations and research. The 22 participants from five continents had a mean time in practice of 23.7 years and represented a variety of practice settings. Four 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. Survey participation rates ranged from 90%–100% throughout the four-round study. Consensus for isotretinoin laboratory monitoring was reached for the following (in generally healthy individuals without underlying abnormalities or preexisting conditions warranting further investigation): Check alanine aminotransferase (ALT) within a month prior to isotretinoin 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 isotretinoin 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 (GGT; 78.9%), bilirubin (81.0%), albumin (72.7%), total protein (72.7%), low-density lipoprotein (LDL; 73.7%), high-density lipoprotein (HDL; 73.7%) or C-reactive protein (77.3%). No consensus was reached for monitoring aspartate aminotransferase (AST), alkaline phosphatase, creatine kinase or total cholesterol. The authors conclude that their study identifies a core set of laboratory tests that should be evaluated prior to and during treatment with isotretinoin in patients with severe acne. They suggest that their results are applicable globally, as they were derived from experts from five continents and diverse practice settings. Given the wide variation in current monitoring patterns, their results provide valuable data to guide clinical practice and aid in the development of clinical guidelines to optimize laboratory monitoring in patients treated with isotretinoin for acne. Their results have the potential to decrease the number and frequency of laboratory tests, resulting in a reduction in associated costs, including indirect costs such as missed time from work. Additional research is required to determine best practices for performing laboratory tests for which no consensus was reached. Read: Is melanoma over-diagnosed in white patients? Reference 1. Xia E, Han J, Faletsky A, et al. Isotretinoin laboratory monitoring in acne treatment. A Delphi consensus study. JAMA Dermatol 2022; published online June 15, 2022. https://jamanetwork.com/journals/jamadermatology/fullarticle/2793099 (accessed June 28, 2022)

Consensus reached on lab monitoring for patients taking isotretinoin for severe acne

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