tretinoin (retinoic acid)

Drug Name

Generic Name :  tretinoin (retinoic acid)

Brand Name: Avita, Renova, Retin-A, Retin-A Micro, Stieva-A (CAN), Vesanoid

Classification: Antineoplastic, Retinoid (topical form, see Appendix H, Topical drugs)

Pregnancy Category D 

Dosage & Route
ADULTS

Oral

  • 45 mg/m2/day PO administered in two evenly divided doses until complete remission is documented; discontinue therapy 30 days after complete remission is obtained or after 90 days, whichever comes first.

Topical

  • Apply once a day before bedtime. Cover entire affected area lightly, avoiding mucous membranes.
PEDIATRIC PATIENTS
  • Not recommended for use.
Therapeutic actions
  • Tretinoin is a trans-retinoic acid form of vitamin A. It stimulates mitosis and turnover of follicular epithelial cells and reduces their cohesiveness. This facilitates extrusion of existing comedones and prevents formation of new comedone. It also exhibits thinning effect on the stratum corneum. In acute promyelocytic leukemia, it induces cellular differentiation and decreases proliferations.
Indications
  • Induction of remission in acute promyelocytic leukemia
  • Topical treatment of acne vulgaris
  • Adjunctive agent for use in mitigation of fine wrinkles, mottled hyperpigmentation in select patients (topical)
  • Unlabeled uses: Hyperpigmentation of photoaged skin, post-inflammatory hyperpigmentation, facial actinic keratoses (topical)
Adverse effects
  • Initial exacerbation of symptoms, skin irritation, stinging on application, edema, blistering, crusting of the skin, erythema, scaling, photosensitivity, temporary hypo/hyperpigmentation. Oral: Hemorrhage, reversible hypercholesterolemia and/or hypertriglyceridemia, acidosis, hypothermia, pseudotumour cerebri, infection, dizziness, paresthesias, anxiety, dryness of skin and mucous membranes, nausea, vomiting, GI hemorrhage, mucositis, decreased appetite, rash, pruritus, increased sweating, alopecia, bone pain, peripheral edema, renal insufficiency, earache, visual disturbances, neurotoxicity.
  • Potentially Fatal: Retinoic acid syndrome, cardiac arrthythmia, disseminated intravascular coagulation, blood dyscrasias, cardiac arrest, cerebral hemorrhage.
Contraindications
  • Hypersensitivity to retinoids. Application to eczematous, sunburnt or abraded skin. Pregnancy, lactation.
Nursing considerations
Assessment
  • History: Allergy to retinoids or parabens; pregnancy, lactation; liver disease; hypercholesterolemia, hypertriglyceridemia, suicidal tendencies
  • Physical: Skin color, lesions, turgor, texture; joints—range of motion; orientation, reflexes, affect, ophthalmologic examination; mucous membranes, bowel sounds; R, adventitious sounds, auscultation; serum triglycerides, HDL, sedimentation rate, CBC and differential, urinalysis, pregnancy test, chest X-ray
Interventions
  • BLACK BOX WARNING: Ensure that patient is not pregnant before administering; arrange for a pregnancy test within 2 wk of beginning therapy. Advise patient to use two forms of contraception during treatment and for 1 mo after treatment is discontinued.
  • WARNING: Monitor patient for any suicidal ideation or tendencies. The risk of suicide should be explained and the Medguide brochure given as the patient signs the release affirming that he or she understands the potential risk.
  • Oral tretinoin is for induction of remission only; arrange for consolidation or maintenance chemotherapy for acute promyelocytic leukemia after induction therapy.
  • Arrange for baseline recording of serum lipids and triglyceride levels, LFTs, chest X-ray, CBC with differential and coagulation profile; monitor for changes frequently.
  • BLACK BOX WARNING: Discontinue drug and notify physician if LFTs are greater than five times upper range of normal, pulmonary infiltrates appear, or patient has difficulty breathing; serious adverse effects can occur.
  • WARNING: Discontinue drug if signs of papilledema occur; consult a neurologist for further care.
  • WARNING: Discontinue drug if visual disturbances occur, and arrange for an ophthalmologic examination.
  • WARNING: Discontinue drug if abdominal pain, rectal bleeding, or severe diarrhea occurs, and consult with physician.
  • Monitor triglycerides during therapy; if elevations occur, institute other measures to lower serum triglycerides—reduce weight, dietary fat; exercise; increase intake of insoluble fiber; decrease alcohol consumption.
  • WARNING: Keep high-dose steroids readily available in case of severe leukocytosis or liver damage.
  • Administer drug with meals; do not crush capsules.
  • Do not administer vitamin supplements that contain vitamin A.
  • Maintain supportive care appropriate for patients with acute promyelocytic leukemia—eg, monitor for and treat infections, prophylaxis for bleeding.
  • Topical form should be applied lightly to entire area before bed. Cleanse area thoroughly before use.
Teaching points
  • Take the oral drug with meals; do not crush capsules.
  • Frequent blood tests will be needed to evaluate the drug’s effects on your body.
  • This drug has been associated with severe birth defects and miscarriages; it should not be used by pregnant women. Use contraceptives during treatment and for 1 month after treatment is discontinued. If you think you are pregnant, consult your health care provider immediately.
  • You will not be permitted to donate blood while using this drug because of its possible effects on the fetus of a blood recipient.
  • Avoid the use of vitamin supplements containing vitamin A; serious toxic effects may occur. Limit alcohol consumption. You may also need to limit your intake of fats and increase exercise to limit the drug’s effects on blood triglyceride levels.
  • At bedtime, cleanse affected area well and apply topical form lightly to entire area.
  • You may experience these side effects: Dizziness, lethargy, headache, visual changes (avoid driving or performing tasks that require alertness); sensitivity to the sun (avoid sunlamps, exposure to the sun; use sunscreens and protective clothing); diarrhea, abdominal pain, loss of appetite (take drug with meals); dry mouth (suck sugarless lozenges); eye irritation and redness, inability to wear contact lenses; dry skin, itching, redness.
  • Report headache with nausea and vomiting, difficulty breathing, severe diarrhea or rectal bleeding, visual difficulties, suicidal ideas or feelings.