More than two-thirds of US hospitals surveyed did not have all-trans retinoic acid (ATRA) immediately available to treat patients with suspected acute promyelocytic leukemia (APL), according to a study published in the Journal of the National Comprehensive Cancer Network.

The study authors noted that APL is “the most curable” acute leukemia, but the 30-day mortality rate is high, at 15% to 25%. The National Comprehensive Cancer Network therefore recommends that patients receive ATRA as soon as APL is suspected.

“Delaying ATRA administration seems to contribute to increased hemorrhagic complications and an early death rate,” the authors wrote.

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For their study, the authors surveyed 120 randomly selected hospitals from 6 geographic regions of the United States. Two hospitals were excluded due to lack of response.

The survey consisted of 3 questions, asked of the hospital’s inpatient pharmacist:

  • Does your hospital treat acute leukemia, or does it refer to other hospitals?
  • Do you have ATRA (oral), 10 mg tablets on the formulary or immediately available in stock as a nonformulary request?
  • If no, why not?

Overall, 31% of the hospitals reported having ATRA immediately available. Neither hospital size nor academic status were associated with the availability of ATRA.

However, there were geographic differences in ATRA availability. Hospitals in the Northwest were most likely to have ATRA immediately available (65%), while hospitals in the central US were the least likely to have the drug (20%). 

Hospitals that were a leukemia treatment center were much more likely to have ATRA available (58%) than were referring hospitals (14%).

There were 3 common reasons why hospitals did not have ATRA immediately available, which included that the drug had not been requested by a physician recently, the inpatient pharmacist was not familiar with ATRA, and the hospital relied on other institutions to provide ATRA.

“Our findings should spur an investigation into the impact of early access to ATRA on morbidity and mortality in APL,” the study authors wrote. “Furthermore, a call from hematologists nationwide to their formulary committees is warranted to ensure that this lifesaving medication is available to patients in a timely manner.”


Greer MJ, Foucar CE, Devata S, et al. Clinical availability of ATRA for patients with suspected acute promyelocytic leukemia: Why guidelines may not be followed. J Natl Compr Canc Netw. Published online August 17, 2021. doi:10.6004/jnccn.2021.7013