·       Arsenic Trioxide will be added to formulary for induction of remission and consolidation in patients with acute promyelocytic leukemia (APL) who are refractory or have relapsed from retinoid and anthracycline chemotherapy.  APL must be characterized by the presence of the t (15; 17) translocation or PML/RAR-alpha gene expression. Use of this agent will be restricted to certified oncologists.

·       All patients will have an ECG to document the QT interval and current medications will be screened by the pharmacists for propensity to cause QT interval prolongation. http://www.torsades.org

·       Arsenic trioxide will only be administered in the oncology unit or in the outpatient infusion center.

·       A list of medications with risk of Torsade de Pointes will be provided to the patient by nursing staff.

·       ECG will be repeated weekly during therapy.

·       If administered in the outpatient infusion center, documentation of weekly ECG will be required by the infusion center.

·       If absolute QT is >500 msec, risk factors will immediately be corrected (electrolytes, concomitant drugs) and will reassess risk/benefit of continuing versus suspending arsenic trioxide.

·       If syncope, rapid or irregular heartbeat occur: hospitalize and monitor the patient continuously, and hold TRISENOX® until QTc is <460 msec and symptoms resolve.

·       5-HT₃ receptor antagonists will be used with caution as some cause QT interval prolongation (Anzemet should not be used).

·       Electrolytes will be monitored and kept above the following values:

·       Potassium  4 meq/l

·       Magnesium 1.8 mg/dl

·       The patient will be monitored for APL differentiation syndrome:

·       Fever, fluid retention, musculoskeletal pain, pulmonary infiltrates and pleural or pericardial effusions, with or without leukocytosis, and dyspnea.

·       Patient weight will be recorded daily and monitored for >2 lbs. gain in 24 hours by nursing staff.

·       The patient will be taught signs and symptoms of APL differentiation syndrome by nursing staff and will be asked to report any signs and symptoms.

·       At the first sign of APL differentiation syndrome, dexamethasone 10 mg BID will be administered and continued for at least 3 days until signs and symptoms have abated.

 Depot Lupron is recommended for outpatient use, as its action is time dependent and is indicated for treatment of chronic conditions that may be treated on an outpatient basis.  Depot Lupron provides serum levels that plateau within two days after dosing and remain relatively stable for 4-5 weeks.  Injection of Depot Lupron initially stimulates pituitary gonadotropins followed by prolonged suppression.  Repeated dosing at monthly intervals results in decreased secretion of gonadal steroids; consequently, tissues and functions that depend on gonadal steroids for their maintenance become quiescent. The biological effect is strictly time-dependent and not concentration-dependent.

·        Pharmacy will not routinely stock Depot Lupron.

·        Pharmacy will order and provide Lupron Depot 7.5 mg strength for patients who are hospitalized and who are not anticipated to be discharged within the next 5 days.  Pharmacists will determine if the patient is nearing discharge before dispensing Lupron.

·        Lupron will only be dispensed for FDA approved indications.  Pharmacists will verify the indication before dispensing Lupron.