ACCUTANE AND TRIGLYCERIDES ------------------------------------------ (1) At what triglyceride level is it appropriate to stop accutane? (2) Should triglyceride levels be performed fasting or non-fasting? ------------------------------------------- TRIGLYCERIDE LEVELS AND STOPPING ACCUTANE ------------------------------------------- I want to poll the group on the following: When triglycerides begin to rise to high levels for a patient on an appropriate dose of Accutane, at what level do you consider stopping the drug (400, 500, 600, 700, ???????). Jeff Marmelzat, M.D. ------------------ Historically, I have reduced the dose at 500, and D/C'd Accutane at 1000. I am curious, though, what approach others have taken... Dan Mitchell, MD --------------- No hard and fast rule, but about 500. William Liss MD --------------- 300 JoelShelly ---------- It's been my practice to decrease the dose of Accutane by half if theTG's rise above 350 or so. If there is an abrupt, steep rise to 400 (or more, heaven forbid) I'll discontinue the Rx, repeat the labs, advise a stricter diet, and then begin Rx again at a much lower dose, monitoring the lipids more closely. Over the years I've only had a very few patients who have had really high lipid levels on Accutane, and (except for one healthy male teenager) they all were overweight females. I now monitor this group of patients even more closely than normal, and emphasize the need to adhere to a low fat diet. Robert I. Rudolph, M.D., FACP ------------------------- I lower the dose of Accutane if triglycerides go above 500; I think that number was in the early guidlines. Hal Rehbein ----------- Encourage dietary control above 180, decrease dose as you rise above 250 toward 800. Above 800 means increased risk for pancreatitis, so D/C if unable to gain control by lowering dose. Levels of 600 at fasting may mean higher levels after meals. Recall that it may be total dose over time, not the dose per day that brings ultimate results with Accutane. If you have to reduce dose, increase duration. Jerry Eisner MD -------------- I tend to stop the drug fairly early...300 or above. Elliot Puritz MD -------------- Over 400. Eliot Mostow MD --------------- When Tgs are 400-500 I instruct patients about fatty foods & give them a handout about diets. At 600-700 I lower their Accutane dose & do the dietary manipulations. Above 700 I stop Accutane. PleasantPd@aol.com ------------------- in SI units our normal range is 0.5 - 1.9 mmol / L - I start to cut back Accutane if the TG is > 5, d/c if > 7. Be sure the patient was fasting - Monday bloodwork after weekend of beer & pizza tends to be kind of high. KC Smith MD FRCPC Similar answer, though a bit less conservative: I begin to sweat at 500, talk about diet changes, make sure specimens are truly fasting, and would probably chicken out at the 1000 level. Doesn't happen often to me, thankfully. Not a bad screen for previously undiagnosed familial hypertriglyceridemia, I suspect. Mark Ling, M.D., Ph.D. ------------------ Triglycerides = 500 Dose decreases by 1/2, 550 dose discontinued altogether in this office. mlbgj1994@MEM.po.com --------------------- Any value above three hundred I put the patient on a low fat diet with no alcohol; above five hundred I increase the frequency of labs to q 2 weeks; above 700 I reduce the dose in half; above 800 I stop the Accutane. I have stopped Accutane just once in 13 1/2 years of use for triglycerides. I'd like to know who has actually seen a case of pancreatitis thought to be induced by the hypertriglyc- eridemia associated with Accutane! Pat Condry MD ------------- Esteemed colleagues: May I suggest: 1. Fasting TG levels pre-Accutane and repeat after 1 month on Rx. If normal don't follow unless dose is raised. 2. Ask for family history of hyperlipidemia pre-Rx. If the fasting TG level is high there is usually a pre-existing condition or one that will be unmasked by use of the drug. This will reveal who needs closer monitoring. 3. If TG levels go up: a. Lo-fat diet. b. Consider: Marsden, J.: Effect of dietary fish oil on hyperlipidemia due to isotretinoin & etretinate. Human Toxicology 1987, May6(3):219-22. As much as 70% decrease in TG's. c. Lopid (Gemfibrozil) works great for me. It is specific for TG correction and can be used throughout the Accutane course. The product lit. on this states that pancreatitis is rare with TG levels <1000. I mostly use this drug & diet if I see a problem. I've never terminated Rx due to TG problems, and with this Rx they can usually be kept below everyone's "comfort level" of 500. Gene Sienkiewicz, M. D. --------------------- I think these are great suggestions and guidelines with a possible caveat to #1. I had a patient with no family or personal history of hyperchol/TG whose TG was 240 after the first 2 months and then went to 750-900. He did go down with modest diet changes and lopid and completed the course. Although elevations usually ocurr early they may happen later in the course. Of course this is anecdotal and I do not know how many people this may happen to and whether the risk of later elevated TGs outweighs the cost of the lab tests. David J. Altman, MD, PhD ---------------------- --------- ?FASTING --------- I would like to ask how many of you order "fasting lipids"? The reason I ask is because teenagers rarely fast. My tendency has been to order random lipids. I had one slightly overweight boy with triglycerides of 1000 non fasting. When he fasted they were 300. Any thoughts? Haines Ely MD ------------- I order fasting lipids because all of our protocols for managing lipids and estimating risk (eg. pancreatitis) are based on fasting lipids - random lipids are "random" and provide a lot less useful information for the same amount of blood, pain and money. I tell them "nothing except water from bedtime until you get you bloodwork done at 7 AM when our lab opens", and this has not been a problem for anyone. I think that a 14 hour fast is unreasonable and would produce compliance problems, without much incremental value. KC Smith MD FRCPC I've always insisted that the baseline and subsequent lipid profiles be obtained fasting (for at least 12 hours). I always tell the parents and the patients (especially teenage boys) that this is, by far, the most difficult part of their therapy program. The patients always wince when I describe the fasting, but I've had no rebellions so far! Robert I. Rudolph, M.D. -------------------- Trying to make decisions on non-fasting lipids is like trying to building a house on quicksand--definitely not worth the money or the effort. Mark Naylor, M.D. --------------- I usually begin dietary manipulations at 500, stop drug at 800, and I nearly always draw NON-Fasting levels (both baseline and follow-up.) I'm not so concerned about the atherosclerotic possibilities as I am the pancreatic ones, and I doubt that the pancreas cares whether the level it sees is fasting or not. Scott D. Clark MD --------------- I think that the pancreas does "care" to a certain extent in that I believe "peak" levels are not as indicative of pancreatitis risk as are "trough" or what the pancreas experiences constantly. GI/hepatologists have said (I do not know if there are any studies supporting it or if it is simply _anecdote_!) that the state of the pancreas and situation involved are factors and pancreatitis with high TG from retinoids is much rarer than with hepatic, genetic, pancreatic reasons. Also patients without any familial hyperTG or personal history of hyperTG can have very high rises with accutane, but this may or may not indicate future risk for non-iatrogenic hyperTG. Fasting TG are important if you want to avoid D/C treatment unecessarily, and rather high TGs (700-1000) can be tolerated for a few months especially with diet alteration and hypolipidemics. I think it is all relative to the patient, their medical history, and severity of dermatological disease. David J. Altman, MD, PhD ---------------------- Re the question about fasting lipids or not: My preaccutane test is not fasting, and they are rarely out of the ordinary. This saves the patient one visit to the office. If they are elevated, I know the reason. Tests after accutane is started are usually fasting. William Liss MD --------------