Isotretinoin: Time to reconsider blood test best practices
Isotretinoin (Accutane) revolutionized the world of acne treatment when it appeared in the 1980s. More than three decades later, it remains a mainstay in the United States despite continuing fears about miscarriages and birth defects. At the same time, it remains a hassle for many patients.
In addition to enduring common side effects like dryness, patients often must follow up with regular, ongoing blood tests. And, not all dermatologists consider the tests to be necessary.
Skepticism about testing is mounting. In the January 2016 issue of JAMA Dermatology, a meta-analysis questions the need for monthly tests.
âWe hope this study is an opportunity for providers to change their approaches to isotretinoin monitoring,â says study co-author Joslyn S. Kirby, M.D., M.Ed., M.S., associate professor, Pennsylvania State University, University Park, Penn.
Health risk realities
At issue: Does isotretinoin really pose a risk to health that can be monitored via blood tests? Dermatologists assumed there was a risk when the drug first appeared on the market. Indeed, âthere are clear associations between systemic retinoids (synthetic vitamin A, including isotretinoin) and hepatitis, hypertriglyceridemia, and leukopenia,â says Arash Mostaghimi, M.D., M.P.A., M.P.H., instructor in dermatology and internal medicine, Harvard Medical School, Boston, Mass.
âWhile these are class effects, the data, specifically for isotretinoin, are limited. The goal of testing was to monitor for these unlikely but potentially serious side effects,â Dr. Mostaghimi says.
But guidelines for monitoring arenât clear.
âThe package insert recommends baseline fasting lipids and hepatic panels with repeated testing at weekly or biweekly intervals until âthe response has been established,ââ Dr. Kirby says. âThere are no specific recommendations for monitoring of blood counts.â
Indeed, Dr. Kirby says the inspiration for the study came from her encounters with varying approaches to labs for isotretinoin patients.
âI performed tests monthly, earlier in my career, because the people around me were doing the same thing. After moving to Penn State, people around me were testing less frequently based on their accumulated experience,â she says. âThis highlighted the effect of local practice on my decisions and the variability in practice patterns among groups, and it prompted me to look for high-level evidence to guide my decisions. I developed this study based on what I found.â