Use of All Trans Retnoic Acid (ATRA) Via Nasogastric Tube (NGT) in Patients Unable to Swallow in Treatment of Acute Promyelocytic Leukemia (APL): A Case Series

ATRA is the critical component of treatment of APL, and when used in combination with anthracycline chemotherapy can induce remission in over 90% of patients. At initial presentation, patients are at high risk for bleeding or disseminated intravascular coagulation, which may be exacerbated by immediate chemotherapy. Except in patients with marked leukocytosis, ATRA should precede chemotherapy. ATRA is available as 10 mg capsules and should be ingested orally and not crushed. The capsules cannot, therefore, be used in patients unable to swallow, or administered by NGT.

We present two APL cases where patients unable to swallow and acutely bleeding, received ATRA via NGT. ATRA capsules were opened, the free powder aspirated into a glass syringe, and the remaining capsule contents suspended in soy bean oil and aspirated into the same syringe (Shaw, 1995).

A 33-year-old female with juvenile onset diabetes and blindness presented with fever vaginal bleeding and coma with response only to painful stimuli. Her white blood count (WBC) was 0.5 k/MicroL with 27% bands, 20% lymphocytes and 10% promyelocytes; platelets were 18 K and PT/PTT was 14.7/33. Bone marrow (BM) was replaced by cells with granular cytoplasm and bilobed nuclei. PML-RARa was not detected by cytogenetics and fluorescent in situ hybridization (FISH), but was by PCR. Daunorubicin was administered and the ATRA oil suspension was given on 14 successive days. Hematologic recovery had occurred by day 16, PCR was negative for PML-RARa by 20, and following consolidation she remains in complete hematologic and cytogenetic remission after 7 months. MRI revealed white matter changes but after IV-HGG she regained consciousness.

A 66-year-old man with coronary artery disease presented with fever, rectal bleeding and pulmonary hemorrhage, which required intubation and mechanical ventilation. WBC was 7.9 with 3% bands, 19% lymphocytes and 22% promyelocytes. Platelet count was 13 and PT/PTT was 9.6/23.6. BM confirmed APL, with FISH positive for PML- RARa. He was started on ATRA oil suspension via NG tube and daunorubicin. By day 27 FISH was PML-RARa negative, but he continued to require ventilatory support for 3 weeks and succumbed to pneumonia and septic shock.

In two patients unable to swallow and bleeding, ATRA administration as an oil suspension via NGT was safe and effective, inducing cytogenetic remission in both. IV liposomal ATRA is not FDA approved and no other parenteral formulation is available.

No relevant conflicts of interest to declare.