Temporal Trends and Clinician Variability in Potassium Monitoring of Healthy Young Women Treated for Acne With Spironolactone

Abstract

IMPORTANCEAlthough recent studies and guideline recommendations indicate that potassium level monitoring is of low usefulness for healthy young women being treated for acne with spironolactone, little is known about whether these recommendations have been implemented in clinical practice. OBJECTIVETo evaluate trends in rates of potassium level monitoring among young women treated for acne with spironolactone and clinician variability in monitoring practices. DESIGN, SETTING, AND PARTICIPANTSThis retrospective cohort study was conducted between January 1, 2008, and June 30, 2019, using data from the Optum deidentified Clinformatics Data Mart database. Participants comprised 108 547 healthy female patients aged 12 to 45 years who were treated for acne with spironolactone. MAIN OUTCOME AND MEASURESThe primary outcome was the proportion of women who received a test for baseline potassium level and the proportion of women whose potassium levels were monitored in the first 180 days of being treated for acne with spironolactone. For clinicians who had prescribed at least 5 courses of spironolactone, the percentage of clinicians who ordered baseline potassium testing or monitoring and the percentage of clinicians who always monitored potassium were compared between 2008 and 2015 vs between 2016 and 2018. RESULTSFor 108 547 women included in this cohort study, the mean (SD) age at the start of treatment was 30.7 (8.6) years, and the mean (SD) course duration was 159 (218) days. Between 2008 and 2018, the percentage of women whose potassium levels were monitored within 180 days of starting spironolactone by all clinicians decreased from 41.4% to 38.5%, with a decrease from 48.9% to 41.0% among dermatologists and from 39.7% to 37.7% among internists but with an increase from 71.4% to 75.4% among advanced practice clinicians (ie, nurse practitioners and physician assistants). The proportion of dermatologists who always monitored potassium decreased from 10.6% between 2008 and 2015 to 4.2% between 2016 and 2018. There was no significant difference in the proportion of internists who always monitored potassium from 2008 to 2015 (15.8%) vs from 2016 to 2018 (17.7%).CONCLUSIONS AND RELEVANCE Despite increasing evidence and guidelines supporting the elimination of potassium monitoring among healthy young women treated for acne with spironolactone, the present study findings suggest that potassium monitoring remains common, with substantial variability in clinician practices. There is a need for future implementation and dissemination research to understand underlying factors for this variation and to develop strategies to address this practice gap.

Potassium levels in women with polycystic ovary syndrome using spironolactone for long‐term

“…18 The guideline of the American Academy of Dermatology, updated in 2016, recommends against routine monitoring of serum potassium during acne treatment in patients at low risk of hyperkalemia, 23 although there is no clear consensus on this issue. 29 Recently, Sabbadin et al 30 published a study that evaluated the effects of a fixed dose of 100 mg of SPL in hyperandrogenic skin manifestations in women with PCOS, both during its use and after withdrawal, while also assessing adverse effects. Similar to our findings, the authors reported a low incidence of mild hyperkalemia (4.8%) and welltolerated minor adverse effects.…”

“…In women using SPL for acne treatment, no difference was found in the rate of hyperkalemia between similar populations taking and not taking SPL (0.72% in SPL users vs. 0.76% baseline rate in nonusers) 18 . The guideline of the American Academy of Dermatology, updated in 2016, recommends against routine monitoring of serum potassium during acne treatment in patients at low risk of hyperkalemia, 23 although there is no clear consensus on this issue 29 . Recently, Sabbadin et al 30 published a study that evaluated the effects of a fixed dose of 100 mg of SPL in hyperandrogenic skin manifestations in women with PCOS, both during its use and after withdrawal, while also assessing adverse effects.…”

Management of Acne Vulgaris

“…It is more commonly used in adult women and individuals with PCOS, but can be highly effective in patients without hyperandrogenism and has been shown to have similar effectiveness to oral antibiotics for acne . Spironolactone can cause hyperkalemia and therefore, should be prescribed cautiously in patients with known kidney disease or those taking certain medications (eg, potassium-sparing diuretics); however, recent studies show the rate of hyperkalemia in healthy young women taking spironolactone for acne is comparable to the baseline rate of hyperkalemia in this population . Due to potential feminization of male fetuses, based on the mechanism of action and data from animal reproduction studies, contraceptives are commonly prescribed concurrently to prevent pregnancy and for their concurrent antiandrogenic effects.…”

Spironolactone in dermatology

“…15 Finally, laboratory monitoring with the use of spironolactone should request serum electrolytes and potassium, mainly in women over 45 years of age, which is part of the recommendations made by the American Academy of Dermatology with the use of this drug in female acne. [16][17][18] Studies for the treatment of acne with have mostly focused on female patients over 25 years of age. Dhurat et al…”