PracticeUpdate Dermatology February 2019

EDITOR’S PICKS 11

Reevaluating the Need for Routine Laboratory Monitoring in Isotretinoin Patients Journal of the American Academy of Dermatology Take-home message • This retrospective study included 903 patients using isotretinoin for acne (62.9% women), with a mean age of 28.6 years. Patients were started on twice-daily isotretinoin 10 to 20 mg and increased to a maximum dose of 40 to 80 mg twice daily for a duration of 4 to 9 months. There was no clinically significant anemia, thrombocytopenia, or leukopenia observed. Elevations in triglycerides, ALT, and AST resolved at follow-up upon completion of isotretinoin treatment. Risk factors for increased triglyceride levels included obesity (BMI >30), increased baseline triglyceride levels, and concomitant medications. Increases in both ALT and AST occurred in 7 patients, which were all attributed to concomitant alcohol use. • Given that transient alterations of lipid and liver aminotransferases levels tend to be clinically insignificant, and repeated laboratory monitoring may cause financial and emotional burden for patients, the authors recommend reducing the tests to baseline, at 2 to 3 months, and upon completion of the isotretinoin treatment course. InYoung Kim MD, PhD

COMMENT By Anna A. Wile MD A growing body of evidence argues against monthly laboratory monitor- ing for patients on isotretinoin. The authors of this article support this notion after evaluating 903 patients treated with isotretinoin. No clinically significant ane- mia, thrombocytopenia, or leukopenia was noted in the study, and elevated ALT or AST was uncommon. However, elevated triglycerides were seen in 21.8% of patients, which, in my opinion, is common. Similar findings were cited in two recent articles, “Laboratory Monitoring During Isotretinoin Therapy for Acne: A Systematic Review and Meta-Analysis,” by Lee et al and “Standard- ized Laboratory Monitoring with Use of Isotretinoin in Acne,” by Hansen et al. 1,2 All three articles conclude that monthly labora- tory monitoring for isotretinoin is excessive. Changing old standards of care may be

but forgo a full cholesterol panel? Maybe even drop CBCs altogether? Despite ini- tial unease, I believe we can challenge ourselves to find a new laboratory monitor- ing regimen that is based in evidence and proven to keep patients safe. References 1. Lee YH, Scharnitz TP, Muscat J, et al. Laboratory monitoring during isotretinoin therapy for acne: A systematic review and meta-analysis. JAMA Dermatol 2016;152(1):35-44. 2. Hansen TJ, Lucking S, Miller JJ, et al. Standardized laboratory monitoring with use of isotretinoin in acne. J Am Acad Dermatol 2016;75(2):323-328.

uncomfortable, but it may be appropri- ate. Any dermatologist would likely find the study well-designed and the evidence sound. However, when it comes to translat- ing the article’s recommendations to daily practice, many will hesitate. I admit, I like the security and reassurance that monthly laboratory monitoring offers. I even find myself using it as a tactic to reassure anx- ious parents. However, our discomfort is not an excuse to ignorewarranted changes that save healthcare dollars and decrease patient discomfort. Even if we are not yet comfortable with the article’s recommenda- tion of “testing at 2–3months, after reaching the peak dose, and upon completion of the treatment course,” we could consider other judicious changes. Couldwe checkASTand ALT every other month instead of monthly? Could we continuemonitoring triglycerides

Dr. Wile is a Dermatologist at Rush Health System in Meridian, Mississippi.

Abstract Oral isotretinoin, a vitamin A derivative, is a very effective treatment for acne vulgaris. Routine labo- ratorymonitoring has become part of the standard regimen for isotretinoin use due to concerns for the development of transaminitis, leukopenia, thrombocytopenia, and lipid abnormalities. This retrospective analysis identified 1,015 patients who were diagnosed with acne vul- garis and had mention of systemic isotretinoin therapy in their medical record from 2010-2017 at Massachusetts General Hospital and Brigham and Women’s Hospital. e-Evaluating the Need for Routine Laboratory Monitoring in Isotretinoin Patients: A Retrospec- tive Analysis. J Am Acad Dermatol 2018 Oct 10;[EPub Ahead of Print], R Shah, D Kroshinsky.

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VOL. 3 • NO. 1 • 2019