Tretinoin (Vesanoid®, All-Trans-Retinoic Acid, ATRA)
About Tretinoin (Vesanoid®, All-Trans-Retinoic Acid, ATRA)
Tretinoin belongs to a class of drugs known as retinoids. Retinoids are drugs that are relatives of vitamin A. Retinoids control normal cell growth, cell differentiation (the normal process of making cells different from each other), and cell death. This occurs during embryonic development and, in certain tissues, later in life. In APML, the cells are "stuck" in an immature form, making thousands of copies of this immature cell that cannot function. Tretinoin causes the cells to get "unstuck" and mature. This can slow or stop the growth of cancer cells.
How to Take Tretinoin
Tretinoin comes as a capsule to take orally (by mouth). The capsules should be taken whole with a glass of water, and should not be opened, crushed or chewed. It is typically taken twice a day for up to 90 days. The dose is based on your body size.
This medication also comes in a topical form used in the treatment of acne. The information in this article relates to the oral form only.
Storage and Handling
Store your medication in the original, labeled container at room temperature and in a dry location (unless otherwise directed by your healthcare provider or pharmacist). This medication needs to be protected from light and therefore should not be stored in a pillbox. Keep containers out of reach of children and pets.
Where do I get this medication?
Tretinoin is available through select specialty pharmacies. Your oncology team will work with your prescription drug plan to identify an in-network specialty pharmacy for distribution of this medication and shipment directly to your home.
This medication may be covered under your prescription drug plan. It is a generic medication, but can be very expensive. Talk with your oncology social worker to help you find resources to help with financial burden, if they are available.
Possible Side Effects of Tretinoin
There are a number of things you can do to manage the side effects of tretinoin. Talk to your doctor or nurse about these recommendations. They can help you decide what will work best for you. These are some of the most common side effects:
Retinoic Acid Syndrome
This is a syndrome resulting from the changes tretinoin causes to blood cell production in patients with leukemia. Symptoms of the syndrome include: fever (temperature >100.5F), sudden weight gain and/or swelling, low blood pressure, bone pain, and fluid build up around the heart, lungs, and chest, causing shortness of breath or difficulty breathing. The symptoms typically occur after 7-12 days on the medication. This syndrome is treated with high doses of IV steroids (like dexamethasone). Your healthcare providers will monitor for these signs or symptoms, but it is also important for you to tell your doctor or nurse promptly if you experience any of these symptoms.
Increased White Blood Cell Count
This is also called hyperleukocytosis. Generally, it does not cause any problems, nor does it require stopping the treatment. Your healthcare provider will monitor your white blood count during treatment.
Headache and Muscle or Joint Pain/Ache
Headache is the most common side effect associated with tretinoin. It most commonly occurs several hours after the dose. Your doctor or nurse can recommend over-the- counter medications to treat the headache. These headaches tend to occur around the time of the medication and resolve before the next dose. If your headache is persistent or severe, notify your healthcare provider right away. There is a very rare side effect of tretinoin that is associated with severe, persistent headache.
Nausea and/or Vomiting
Talk to your doctor or nurse so they can prescribe medications to help you manage nausea and vomiting. In addition, dietary changes may help. Avoid things that may worsen the symptoms, such as heavy or greasy/fatty, spicy or acidic foods (lemons, tomatoes, oranges). Try antacids, (e.g. milk of magnesia, calcium tablets such as Tums), saltines, or ginger ale to lessen symptoms.
Call your doctor or nurse if you are unable to keep fluids down for more than 12 hours or if you feel lightheaded or dizzy at any time.
This medication can cause bleeding from the intestinal wall. Signs of this includes: blood in the stool or black/tar like stools, coughing up blood, vomiting blood, vomit that looks like coffee grounds, fever, severe pain in the abdomen or new abdominal swelling. If you experience any of these, contact your healthcare provider immediately or go to the emergency room.
Fatigue is very common during cancer treatment and is an overwhelming feeling of exhaustion that is not usually relieved by rest. While on cancer treatment, and for a period after, you may need to adjust your schedule to manage fatigue. Plan times to rest during the day and conserve energy for more important activities. Exercise can help combat fatigue; a simple daily walk with a friend can help. Talk to your healthcare team for helpful tips on dealing with this side effect.
These include muscle aches, fever, chills, and feeling tired. Notify your provider if you are experiencing any of these side effects.
This medication can cause slow or abnormal heartbeats or an abnormal heart rhythm. Notify your healthcare provider right away if you feel abnormal heartbeats or if you feel dizzy or faint. Tretinoin can also cause high or low blood pressure. Your provider will monitor your blood pressure throughout treatment.
These include dryness, itching, rash, and cracking, dry lips. This dryness can also affect any mucous membranes, such as the lining of your mouth and nose. Use an alcohol free moisturizer on your skin and lips; avoid moisturizers with perfumes or scents. Your doctor or nurse can recommend a topical medication if itching is bothersome. If your skin does crack or bleed, be sure to keep the area clean to avoid infection. A nasal saline spray and regular mouth rinsing can help sooth dryness. Be sure to notify your healthcare provider of any rash that develops, as this can be a reaction. They can give you more tips on caring for your skin.
These include earache, feeling of fullness and, less commonly, hearing loss. Notify your provider of any changes to your ears or of any hearing loss.
Peripheral Neuropathy (Numbness or Tingling in the Hands and/or Feet)
Peripheral neuropathy is a toxicity that affects the nerves. It causes a numbness or tingling feeling in the hands and feet, often in the pattern of a stocking or glove. This can get progressively worse with additional doses of the medication. In some people, the symptoms slowly resolve after the medication is stopped, but for some it never goes away completely. You should let your healthcare provider know if you experience numbness or tingling in the hands and feet, as they may need to adjust the doses of your medication.
Other Side Effects
This medication can cause a temporary increase in the amount of cholesterol and triglycerides in your blood, which reverses when treatment ends. Your provider will monitor your liver function, which can be affected while on this treatment.
Some patients will experience dizziness. You should not drive or operate machinery until you know how this medication affects you.
This medication can affect your vision and may make your eyes more sensitive to light. If you develop any vision changes, notify your provider.
Exposure of an unborn child to this medication could cause birth defects, so you should not become pregnant or father a child while on this medication. Effective birth control is necessary during treatment and for at least one month after treatment. Even if your menstrual cycle stops or you believe you are not producing sperm, you could still be fertile and conceive. You should not breastfeed while receiving this medication.