Equitable Outpatient Monitoring of High Risk Medications: Disparities in Laboratory Monitoring of Isotretinoin Use by Race, Ethnicity, and Sex

From the 2022 HVPA National Conference

Nancy Nkansah-Mahaney MD, PharmD, MBA (Johns Hopkins Hospital), Divya Manoharan BA, Anna Chien MD


Moderate to severe acne is associated with significant psychosocial distress in patients. Though isotretinoin is a highly effective and safe treatment, it is considered high risk and requires monitoring for teratogenicity, hyperlipidemia, and elevated liver function.1 Aside from mandatory monthly pregnancy screening, testing for other laboratory abnormalities is not standardized and falls to provider discretion. Given the rarity of lab abnormalities, recent literature has suggested limiting non-pregnancy laboratory testing. Further evaluation of isotretinoin laboratory monitoring and the extent to which there are racial/ethnic/gender differences could guide efforts to ensure equitable, high-value care and medication access.2


The objective of this study is to evaluate the frequency of isotretinoin laboratory monitoring and characterize the extent to which differences exist by race, ethnicity, and gender.


Using the Johns Hopkins Hospital electronic medical record and EPIC Slicer Dicer software, two populations were evaluated: patients taking isotretinoin, and patients taking isotretinoin with no metabolic, cardiovascular, leukopenic, hepatic, or renal comorbidities. Given the impact of COVID-19 on clinical practices, analyses was performed at two time points: pre-COVID-19 (PC), 12/6/2018-12/5/2019, and during COVID-19 (DC), 12/6/2020-12/5/2021. A total of 5071 patients met initial inclusion criteria (PC: ages 12-72, 51.6% male, 72.3% Caucasian; DC: ages 12-72, 51.5% male, 70.1% Caucasian); after excluding legacy patients, 975 patients met final inclusion criteria. Pearson’s Chi Square and odds ratio (OR) tests were used to evaluate the association between outpatient laboratory monitoring (complete blood count (CBC), comprehensive metabolic panel (CMP), lipid panel, and pregnancy test) and race, ethnicity, and sex.


African-American, Asian, and Hispanic patients were more likely to receive laboratory testing than Caucasian patients (OR PC: 1.80, 2.23, 1.72, respectively; DC: 2.10, 1.90, 1.69, respectively); this higher likelihood of testing in African-American, Asian and Hispanic patients persisted after excluding patients with comorbidities (OR PC: 1.77, 2.21, 1.70, respectively; DC:
2.05, 1.91, 1.72, respectively). Non-Caucasian populations were ordered CBC, CMP, and lipid panels significantly more frequently (p<0.001) than Caucasian populations. These disparities were less pronounced for female as compared to male patients with comorbidities (OR PC: 1.13, DC: 1.17) and without (OR PC: 1.14, DC: 1.18).


These findings reveal racial/ethnic disparities in laboratory monitoring independent of comorbidities, suggesting that non-Caucasian patients bear an additional testing burden. This may represent an overall practice of increased testing of non-Caucasian patients, not specific to dermatology. Disparities persisted even in the setting of reduced laboratory monitoring due to the COVID-19 pandemic. These data reveal a need for testing standardization to promote equitable, high-value care.

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