Table 3.
Management of special situations
| Recommendation | Level of evidence–grade of recommendation | Changes compared with the 2009 recommendations |
|---|---|---|
| Older patients | ||
| 3.1. Elderly patients in good clinical condition treated with chemotherapy-based regimens should be managed with a treatment approach similar to that used in younger patients, but slightly attenuated in dose intensity; although the experience with chemotherapy-free approaches in this setting is very limited, it seems reasonable to follow a similar strategy for patients with non–high-risk APL | IIa–B | Slightly modified |
| Patients with severe comorbidities | ||
| 3.2. Older and younger patients with severe comorbidities unfit for chemotherapy (especially anthracyclines) are candidates to receive ATO-based treatment schedules | III–B | Unchanged |
| Children | ||
| 3.3. ATRA at 25 mg/m2/d is the recommended dose in children and adolescents | IIa–B | Unchanged |
| Pregnant women | ||
| 3.4. Management of APL in pregnancy requires the involvement of the patient, hematologist, obstetrician, and neonatologist | III–B | Unchanged |
| 3.5. Retinoids are highly teratogenic and should be avoided in the first trimester unless the patient decides to have a termination of pregnancy | III–B | Unchanged |
| 3.6. ATRA can be used in the second and third trimesters of pregnancy | III–B | Unchanged |
| 3.7. Arsenic derivatives are highly embryotoxic and are contraindicated at any stage of pregnancy | IV–C | Unchanged |
| 3.8. In patients presenting in the first trimester and not wishing to have a termination of pregnancy, induction therapy with daunorubicin alone can be offered | IV–C | Unchanged |
| 3.9. Although chemotherapy appears reasonably safe in the second and third trimester of pregnancy, it is associated with an increased risk of abortions and premature delivery, and induction of labor between cycles of chemotherapy should be considered | III–B | Unchanged |
| 3.10. Stringent fetal monitoring, with particular emphasis on cardiac function, is recommended for patients receiving ATRA with or without chemotherapy during pregnancy | IV–C | Unchanged |
| 3.11. For deliveries before 36 wk of gestation, antenatal corticosteroids before preterm delivery are recommended to reduce the risk of fetal morbidity and mortality associated with respiratory distress syndrome | IIb–B | Unchanged |
| 3.12. After successful delivery, breastfeeding is contraindicated if chemotherapy or ATO is needed | IV–C | Unchanged |
| 3.13. Female patients with APL should be advised against conceiving while exposed to ATRA or ATO for consolidation and maintenance therapy | IV–C | Unchanged |
| Management of therapy-related APL | Unchanged | |
| 3.14. Patients with tAPL should be treated like those with de novo APL, but modifications may be necessary taking into account cardiac toxicity and prior anthracycline exposure | III–B | Unchanged |
tAPL, therapy-related APL.