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ATRA and arsenic: chemotherapy-free treatment for APL | CION Cancer Clinics
ATRA and arsenic trioxide are the main treatment for most people with APL. Both act on the faulty PML-RARA gene, making the leukaemia cells grow up and die off, often with no standard chemotherapy. The course starts in hospital and needs regular heart and blood checks. This page explains how each medicine works, the phases, the side effects and who the plan may not suit. At CION Cancer Clinics, every leukaemia, MDS and MPN case is reviewed by our haematologist and discussed at a tumour board before a plan is agreed.
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Medically reviewed by Dr. Basudev PokhrelConsultant Haematologist · last reviewed September 2026, next review due September 2027
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On this page
- How do ATRA and arsenic treat APL without chemotherapy?
- What does each medicine do, and what does it cause?
- What are the phases of ATRA and arsenic treatment?
- How does this compare with ATRA plus chemotherapy?
- What do people fear about arsenic treatment, and what is true?
- Who may this treatment not suit, and what can this page not tell you?
- Common questions about ATRA and arsenic for APL
The short answer
How do ATRA and arsenic treat APL without chemotherapy?
ATRA and arsenic trioxide both act on the faulty PML-RARA gene that drives APL. Used together, they make the leukaemia cells grow up and die off, and for many people with APL they have replaced standard chemotherapy as the main treatment.
Why this works for APL and not other leukaemias
Most leukaemias are driven by a mix of gene changes, so treatment has to kill fast-dividing cells broadly. APL is different. Almost every case is driven by one joined gene. ATRA and arsenic both break down the faulty protein that gene makes, from two different angles. That is why the combination is so effective for this one disease.
What "chemotherapy-free" does and does not mean
It means no standard chemotherapy drugs for most people whose APL is judged lower risk. It does not mean a gentle or easy course. The first weeks are spent in hospital, and both medicines need regular heart, blood and liver checks. Some people, often those with a high white count at diagnosis, have a chemotherapy medicine added.
How the medicines are given
ATRA is taken as capsules by mouth. Arsenic trioxide is usually given as a drip into a vein, in hospital or as a day-care visit. Oral forms of arsenic are used in some countries. Your team will explain which form is planned and why.
The medicines
What does each medicine do, and what does it cause?
Doses and schedules are set by your haematologist for your weight, heart and kidney health. This page does not give them, and they should never be changed at home.
ATRA (all-trans retinoic acid)
A vitamin A based medicine that pushes the stuck cells to grow up. It starts to settle the clotting problem quickly.
Common effects
- Headache
- Dry skin, lips and eyes
- Raised blood fats and liver tests
Arsenic trioxide
A licensed medicine that breaks down the faulty protein and helps clear the leukaemia cells, including the ones that would cause relapse.
Needs watching for
- Changes in heart rhythm on ECG
- Low potassium or magnesium
- Tingling in hands and feet
When chemotherapy is added
For higher-risk APL, a medicine such as idarubicin or a similar drug may be added to control a rising white count. Your team will explain if this applies.
Shared risk: differentiation syndrome
Both medicines can trigger a reaction as the cells grow up, with fever, breathlessness, weight gain and swelling. It is treatable when caught early, so it is checked for every day.
Not sure whether this applies to you?
Ask an oncologistThe treatment course
What are the phases of ATRA and arsenic treatment?
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Before the first arsenic dose
An ECG, blood salts, kidney and liver tests, and a list of every other medicine you take. Some common medicines affect heart rhythm and may need changing by the doctor.
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Induction: getting into remission
The first and most intensive phase, usually in hospital. The aim is to control the clotting problem and clear leukaemia cells from the marrow. Remission means no leukaemia can be found with standard tests.
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A marrow or blood check
Once counts recover, tests check the response. Early results can look messy while cells are still growing up, so the team reads them with care.
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Consolidation: keeping it away
Further courses of ATRA and arsenic, often given as day-care, with breaks in between. Most people spend more time at home in this phase.
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Follow-up testing
PML-RARA tests on blood or marrow at set points show whether the faulty gene stays undetectable. Your team will give you the schedule.
Side by side
How does this compare with ATRA plus chemotherapy?
ATRA with arsenic trioxide
ATRA with chemotherapy
Usual first choice for lower-risk APL in current guidance
Used where arsenic is not suitable or not available, and in some higher-risk cases
Less hair loss and fewer severe infections for most people
Longer spells of very low counts and more infection risk
Heart rhythm and blood salts need close checks
Heart pumping function is checked because of the chemotherapy
Many day-care visits during consolidation
Often longer admissions during each course
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Report these the same hour, day or night
Breathlessness, fever, rapid weight gain or new swelling, chest pain, fainting or a racing or fluttering heart, bleeding, severe headache or confusion. If you are at home, call the ward number you were given or go to the nearest emergency department, or call 108. Say which medicines are being taken. Do not stop ATRA or arsenic yourself; the team decides whether to pause.
Commonly believed
What do people fear about arsenic treatment, and what is true?
"Arsenic is poison. The doctor is taking a risk."
Arsenic trioxide is a licensed medicine, made to a pharmaceutical standard and given in carefully set amounts with regular monitoring. Its use in APL is backed by large studies and international guidance. It is not the same as arsenic in contaminated groundwater.
"No chemotherapy means the treatment is weaker."
For lower-risk APL, the ATRA and arsenic combination has done at least as well as ATRA with chemotherapy in trials, with fewer serious infections. Weaker is the wrong word. It is more targeted.
"Vitamin A tablets from the pharmacy would do the same job."
ATRA is a specific form of vitamin A made for this use. Ordinary vitamin A supplements do not treat APL and can be harmful in large amounts. Do not add any supplement without asking.
"The counts are normal, so the remaining courses are optional."
Consolidation is what keeps APL from coming back. Missing courses raises the chance of relapse. Talk to the team about any cost or travel problem before skipping anything.
Being straight with you
Who may this treatment not suit, and what can this page not tell you?
ATRA and arsenic are not the right plan for everyone with APL. The decision is made by the haematologist with the full reports in front of them.
When the plan may change
Pregnancy is a major one, because ATRA and arsenic can harm an unborn baby at certain stages. Serious heart rhythm problems, very poor kidney function, and some medicines that cannot be stopped also change the choice. A very high white count at diagnosis often means chemotherapy is added. Tell the team if there is any chance of pregnancy.
What this page cannot tell you
It cannot tell you how long your course will be, how you will respond, or what your outlook is. Those depend on your risk group, how the early weeks go, and the follow-up gene tests.
Where CION fits
CION's haematology team, led by Dr. Basudev Pokhrel, can review your reports, explain the plan, and coordinate day-care courses and access to medicines with the treating hospital. Availability of arsenic trioxide varies, so ask early.
Questions we are asked
Common questions about ATRA and arsenic for APL
Will I lose my hair with ATRA and arsenic?
Hair loss is much less common than with standard chemotherapy. Some thinning and dry skin can happen, mostly from ATRA. If a chemotherapy medicine is added to your plan, hair loss becomes more likely. Ask your team which applies to you so you can prepare.
Why do I need so many ECGs?
Arsenic trioxide can lengthen a part of the heart's electrical cycle, shown on an ECG as the QT interval. If it lengthens too much, a dangerous heart rhythm can follow. Regular ECGs and blood salt tests let the team adjust treatment early. It is a routine safety check, not a sign of trouble.
Can I take my other medicines during treatment?
Bring every medicine, including ayurvedic, homoeopathic and over-the-counter ones, to the team. Some antibiotics, anti-sickness medicines and heart medicines affect heart rhythm alongside arsenic. The team will decide what continues. Do not stop your usual medicines on your own either.
Can I eat normally on ATRA?
Most people can eat a normal home diet. Take ATRA the way the team tells you in relation to meals. Avoid vitamin A supplements and large amounts of liver. Keep drinking fluids. If vomiting stops you keeping capsules down, tell the team the same day.
Can men and women have children after this treatment?
Many people treated for APL go on to have children, and ATRA with arsenic is thought to be gentler on fertility than chemotherapy. Both medicines can harm a pregnancy during treatment, so reliable contraception is needed. Discuss fertility and timing with your haematologist before starting if possible.
Is arsenic trioxide available in India?
Yes, arsenic trioxide is made and used in India, though stock can vary between hospitals and cities. Hospitals that treat APL regularly usually know how to source it. If there is a delay, ask the team what the safe alternative is rather than waiting without treatment.
Is ATRA and arsenic treatment covered by schemes?
Leukaemia care is often covered under Aarogyasri, PM-JAY, CGHS, ECHS, EHS and cashless insurance, but which medicines and how many courses are covered can change. Check the current rules for your scheme. Call the helpline with your card details and we will help you check.
What happens if APL comes back after this treatment?
Relapse is uncommon, and follow-up gene tests are designed to catch it early, sometimes before counts change. Further treatment options exist, including arsenic again for some people and, in selected cases, a stem cell transplant at a specialist centre. Your haematologist will explain the choices.
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Dr. Basudev Pokhrel reviews blood counts, transfusion needs and blood disorders, and works with the CION tumour board on blood cancers.
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Sources
- American Cancer Society — Treating Acute Promyelocytic (M3) Leukemia
- National Cancer Institute — Adult Acute Myeloid Leukemia Treatment (PDQ) - Patient Version
- Cancer Research UK — Acute myeloid leukaemia (AML)
- Leukemia & Lymphoma Society — Acute Myeloid Leukemia (AML)
This page is general information, not a prescription. Do not change or stop any treatment based on what you read here. If anything is worrying you, contact your own treating team — or call our helpline and we will help you reach the right specialist.
Keep reading
Related pages
Differentiation Syndrome: A Reaction to Watch ForThe main reaction both medicines can causeAPL Maintenance and Follow-Up MonitoringWhat happens after the courses endAPL Treatment Cost and Drug Availability in IndiaCost, schemes and sourcing the medicinesAPL: The Most Curable Leukaemia and the Most UrgentThe basics of APL
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