Should bloodwork be repeated in a patient on isotretinoin (Accutane) after one month?

From the Guidelines

No, routine monitoring of complete blood count is unwarranted for a patient who has been on Accutane for approximately one month. According to recent evidence, mild increases in triglycerides are observed in about a quarter of patients treated with isotretinoin, but severe abnormalities are infrequent and subsequent changes to lipid levels are uncommon once a stable dose has been achieved 1. A reasonable approach is to check triglycerides and liver enzymes at baseline and two months into treatment, with more frequent monitoring with dose changes or as otherwise clinically indicated 1.

Key Considerations

• The patient's bloodwork should include lipid panel and liver function tests, as Accutane commonly affects triglycerides, cholesterol, and liver enzymes.
• If the patient's results show significant abnormalities, more frequent monitoring may be necessary, and dosage adjustments might be required.
• For female patients of childbearing potential, a pregnancy test should also be repeated monthly before dispensing the next prescription, as Accutane is highly teratogenic.
• The metabolic changes from isotretinoin typically begin to appear within the first few weeks of treatment, and early detection of abnormalities can prevent more serious complications while allowing the beneficial acne treatment to continue with appropriate adjustments.

Monitoring Schedule

• Baseline laboratory tests should be obtained before starting treatment.
• Triglycerides and liver enzymes should be checked at baseline and two months into treatment.
• More frequent monitoring may be necessary with dose changes or as otherwise clinically indicated.

From the FDA Drug Label

Lipids Pretreatment and follow-up blood lipids should be obtained under fasting conditions. After consumption of alcohol, at least 36 hours should elapse before these determinations are made It is recommended that these tests be performed at weekly or biweekly intervals until the lipid response to isotretinoin is established. Liver Function Tests Since elevations of liver enzymes have been observed during clinical trials, and hepatitis has been reported, pretreatment and follow-up liver function tests should be performed at weekly or biweekly intervals until the response to isotretinoin has been established

For a patient on Accutane for approximately one month, follow-up bloodwork should be repeated during a follow-up. This includes lipid tests and liver function tests, which should be performed at weekly or biweekly intervals until the response to isotretinoin is established 2.

From the Research

Laboratory Monitoring for Isotretinoin Therapy

• The study 3 suggests that in healthy patients with normal baseline lipid panel and liver function test results, repeated studies should be performed after 2 months of isotretinoin therapy.
• If findings are normal after 2 months, no further testing may be required, as stated in the study 3.
• Another study 4 found that most mild elevations of liver enzymes during isotretinoin therapy do not worsen, and acne patients with isotretinoin may not need continued testing when experiencing low-grade liver enzyme abnormalities.
• The study 5 evaluated changes in lipids and liver enzymes in 322 acne patients treated with oral isotretinoin and found statistically significant increases in triglyceride and low-density lipoprotein levels, while high-density lipoprotein levels decreased.

Timing of Bloodwork

• The study 3 recommends repeating bloodwork after 2 months of isotretinoin therapy, which is later than the patient's current 1-month mark.
• The study 4 found that most abnormalities in liver enzymes occurred during the first month of therapy, but does not specify the need for bloodwork at the 1-month mark.
• The study 6 repeated blood analyses in follow-up visits after 10 and 20 weeks, but does not provide guidance on the optimal timing for bloodwork in the first month of therapy.

Laboratory Tests

• The study 7 suggests that ALT and AST may not be useful for monitoring isotretinoin therapy, and that GGT and CK may be of greater value in managing patients.
• The study 5 found that isotretinoin had a greater effect on lipids than liver enzymes, and recommends close follow-up for patients on isotretinoin therapy.