Merck Manual

Please confirm that you are a health care professional

honeypot link

Acute Lymphoblastic Leukemia (ALL)

(Acute Lymphocytic Leukemia)

By

Ashkan Emadi

, MD, PhD, University of Maryland;


Jennie York Law

, MD, University of Maryland, School of Medicine

Reviewed/Revised Oct 2023
View PATIENT EDUCATION
Topic Resources

Acute lymphoblastic leukemia (ALL) is the most common pediatric cancer; it also strikes adults of all ages. Malignant transformation and uncontrolled proliferation of an abnormally differentiated, long-lived hematopoietic progenitor cell results in a high circulating number of blasts, replacement of normal marrow by malignant cells, and the potential for leukemic infiltration of the central nervous system (CNS) and testes. Symptoms include fatigue, pallor, infection, bone pain, CNS symptoms (eg, headache), easy bruising, and bleeding. Examination of peripheral blood smear and bone marrow is usually diagnostic. Treatment typically includes combination chemotherapy to achieve remission, intrathecal and systemic chemotherapy and/or corticosteroids for CNS prophylaxis, and sometimes cerebral irradiation for intracerebral leukemic infiltration, consolidation chemotherapy with or without stem cell transplantation, and maintenance chemotherapy for up to 3 years to avoid relapse.

The American Cancer Society estimates that in the United States in 2023 there will be over 6500 new cases of acute lymphoblastic leukemia (ALL) and almost 1400 deaths will have occurred. Sixty percent of all ALL cases occur in children, with a peak incidence at age 2 to 5 years; a second peak occurs after age 50. ALL is the most common cancer in children, and represents about 75% of leukemias among children < 15 years of age. The risk declines slowly until the mid-20s and then begins to rise again slowly after age 50. ALL accounts for about 20% of adult acute leukemias. The average lifetime risk of ALL in both sexes is about 0.1% (1 in 1000 Americans). Hispanic populations have a higher incidence of ALL than other racial or ethnic populations due in part to polymorphisms in the ARID5B gene.

Pathophysiology of ALL

Similar to acute myeloid leukemia Acute Myeloid Leukemia (AML) In acute myeloid leukemia (AML), malignant transformation and uncontrolled proliferation of an abnormally differentiated, long-lived myeloid progenitor cell results in high circulating numbers... read more Acute Myeloid Leukemia (AML) , acute lymphoblastic leukemia is caused by a series of acquired genetic aberrations. Malignant transformation usually occurs at the pluripotent stem cell level, although it sometimes involves a committed stem cell with more limited capacity for self-renewal. Abnormal proliferation, clonal expansion, aberrant differentiation, and diminished apoptosis (programmed cell death) lead to replacement of normal blood elements with malignant cells.

Classification of ALL

In acute lymphoblastic leukemia, the precursor lymphoid neoplasms are broadly categorized based on their lineage into

  • B-lymphoblastic leukemia/lymphoma (B-ALL/LBL)

  • T-lymphoblastic leukemia/lymphoma (T-ALL/LBL)

Disease can manifest as a leukemia when neoplastic cells (lymphoblasts) involve blood and bone marrow (defined as > 20% bone marrow blasts) or as a lymphoma Overview of Lymphomas Lymphomas are a heterogeneous group of tumors arising in the reticuloendothelial and lymphatic systems. The major types are Hodgkin lymphoma Non-Hodgkin lymphoma See table . Lymphomas were once... read more when blasts infiltrate mainly extramedullary tissue.

The 2016 World Health Organization (WHO) classification of lymphoid neoplasms incorporates genetic data, clinical features, cell morphology, and immunophenotype, all of which have important implications for disease prognosis and management.

Symptoms and Signs of ALL

Symptoms and signs of acute lymphoblastic leukemia may be present for only days to weeks before diagnosis.

The most common presenting symptoms are due to disrupted hematopoiesis with ensuing

  • Anemia

  • Thrombocytopenia

  • Granulocytopenia

Anemia can manifest with fatigue, weakness, pallor, malaise, dyspnea on exertion, tachycardia, and exertional chest pain.

Thrombocytopenia can cause mucosal bleeding, easy bruising, petechiae/purpura, epistaxis, bleeding gums, and heavy menstrual bleeding. Hematuria and gastrointestinal bleeding are uncommon. Patients can present with spontaneous hemorrhage, including intracranial or intra-abdominal hematomas.

Granulocytopenia or neutropenia can lead to a high risk of infections, including those of bacterial, fungal, and viral etiologies. Patients may present with fevers and a severe and/or recurrent infection.

Organ infiltration by leukemic cells results in enlargement of the liver, spleen, and lymph nodes. Bone marrow and periosteal infiltration may cause bone and joint pain, especially in children with ALL. CNS penetration and meningeal infiltration are common and can result in cranial nerve palsies, headache, visual or auditory symptoms, altered mental status, and transient ischemic attack/stroke.

Diagnosis of ALL

  • Complete blood count (CBC) and peripheral blood smear

  • Bone marrow examination

  • Histochemical studies, cytogenetics, and immunophenotyping

A diagnosis of acute lymphoblastic leukemia is made when blast cells of lymphoid origin are ≥ 20% of marrow nucleated cells or ≥ 20% of non-erythroid cells when the erythroid component is > 50%. If marrow cells are insufficient or unavailable, diagnosis can be made by the same criteria using a peripheral blood sample.

Bone marrow examination (aspiration and needle biopsy) is routinely done. Blast cells in the bone marrow are typically between 25 and 95% in patients with ALL.

Histochemical studies, cytogenetics, and immunophenotyping studies help distinguish the blasts of ALL from those of AML or other disease processes. Histochemical studies include staining for terminal deoxynucleotidyl transferase (TdT), which is positive in cells of lymphoid origin. Detection of specific immunophenotypic markers such as CD3 (for lymphoid cells of T cell origin) and CD19, CD20, and CD22 (for lymphoid cells of B cell origin) is essential in classifying the acute leukemias. Common cytogenetic abnormalities in ALL include t(9;22) in adults and t(12;21) and high hyperdiploidy in children (see table ).

Table

Less common cytogenetic abnormalities include the following:

  • t(v;11q23) /MLL or KMT2A rearranged, including t(4;11)/KMT2A-AF4

  • t(1;19)/E2A-PBX1 (TCF3-PBX1)

  • t(5;14)/IL3-IGH

  • t(8;14), t(8;22), t(2;8)/C-MYC rearranged

BCR-ABL-like acute lymphoblastic leukemia overlaps phenotypically with ALL in which the Philadelphia chromosome [a reciprocal balanced translocation between chromosomes 9 and 22, t(9;22)] is present (Ph+ ALL).

CT of the head is done in patients with CNS symptoms. CT of the chest and abdomen should be done to detect mediastinal masses and lymphadenopathy and may also detect hepatosplenomegaly. Echocardiography or multi-gated acquisition (MUGA) scanning is typically done to assess baseline cardiac function (prior to administration of anthracyclines, which are cardiotoxic).

Treatment of ALL

Treatment for newly diagnosed acute lymphoblastic leukemia generally consists of 3 to 4 cycles of chemotherapy blocks of non–cross-resistant chemotherapy for the first 9 to 12 months, followed by 2.5 to 3 years of maintenance chemotherapy.

Chemotherapy

The 4 general phases of chemotherapy for acute lymphoblastic leukemia include

  • Remission induction

  • Postremission consolidation

  • Interim maintenance and intensification

  • Maintenance

The goal of induction treatment is complete remission, defined as < 5% blast cells in the bone marrow, an absolute neutrophil count > 1000/mcL (> 1 × 109/L), a platelet count > 100,000/mcL (> 100 × 109/L), and no need for blood transfusion. In patients with complete remission, a low measurable residual disease (also known as minimal residual disease or MRD) is the most important prognostic factor (1 Treatment references Acute lymphoblastic leukemia (ALL) is the most common pediatric cancer; it also strikes adults of all ages. Malignant transformation and uncontrolled proliferation of an abnormally differentiated... read more Treatment references ). Measurable or minimal residual disease is microscopic disease that is not detected by standard assays but can be measured by more sensitive assays. A low measurable residual disease (MRD negativity) is defined variably (based on the assay used) as < 0.01 to 0.1% leukemic cells in bone marrow.

Components of induction therapy include

  • A high-dose corticosteroid (eg, dexamethasone, prednisone)

  • An anthracycline (eg, daunorubicin, doxorubicin, idarubicin)

  • Vincristine

Some regimens use a corticosteroid to reduce disease burden prior to intensive induction. In younger adults, a regimen that includes asparaginase and/or cyclophosphamide for induction, similar to treatment protocols used in children, may increase rates of response and achievement of undetectable minimal residual disease. If complete remission is not achieved after induction, some regimens recommend a second induction course to try to get more patients to complete remission before consolidation.

For patients with Philadelphia chromosome–positive (Ph+) ALL, a tyrosine kinase inhibitor (eg, imatinib, dasatinib) can be added to the drug regimen. For patients with CD20 positive B-lymphoblastic leukemia, rituximab can be added.

The goal of consolidation is to prevent leukemic regrowth. Consolidation therapy usually lasts a few months and combines regimen-specific courses of non–cross-resistant drugs that have different mechanisms of action. For adults with Ph+ ALL, allogeneic stem cell transplantation Hematopoietic Stem Cell Transplantation Hematopoietic stem cell (HSC) transplantation is a rapidly evolving technique that offers a potential cure for hematologic cancers ( leukemias, lymphomas, myeloma) and other hematologic disorders... read more is recommended as consolidation therapy.

Interim maintenance and late/delayed intensification therapy are used after consolidation therapy. These phases of therapy incorporate a variety of chemotherapeutic agents with different doses and schedules that are less intense than induction and consolidation.

Most regimens include maintenance therapy with monthly vincristine, weekly methotrexate, daily mercaptopurine, and 5 days/month corticosteroid. Therapy duration is usually 2½ to 3 years.

CNS prophylaxis starts during induction and continues throughout all phases of treatment. Because lymphoblasts often infiltrate the cerebrospinal fluid and meninges, all regimens include CNS prophylaxis and treatment with intrathecal methotrexate, cytarabine, and hydrocortisone in combination or as monotherapy. High doses of systemic methotrexate and/or cytarabine penetrate the CNS, providing extra CNS prophylaxis if regimens include these drugs. Cranial nerve or whole-brain irradiation was previously often done for patients at high risk of CNS disease (eg, high WBC count, high serum lactate dehydrogenase, B-cell phenotype), but its use has been decreasing in recent years.

Medically frail patients with ALL

About one third of patients with acute lymphoblastic leukemia are older adults (> 65). Older ALL patients are more likely to have precursor B-cell ALL and have higher risk and more complex cytogenetics, including Philadelphia chromosome positive (Ph+) or t(v;11q23) MLL or KMT2A rearranged disease.

Some, but not all, older patients can tolerate standard induction therapy. Subsequent treatment regimens (CNS prophylaxis, postremission consolidation or intensification, and maintenance) depend on the individual patient's comorbidities and performance status. For example, older patients with several comorbidities and poor performance status may undergo gentler induction therapy without consolidation or maintenance. In older patients with Ph+ ALL, tyrosine kinase inhibitors (eg, imatinib, dasatinib) plus corticosteroids given with either low-intensity or no chemotherapy have resulted in 95 to 100% complete remission rate, with a 45 to 50% 2-year relapse free survival and about 70% 2-year overall survival. For older patients with ALL who are in their first complete remission, nonmyeloablative or reduced-intensity conditioning allogeneic hematopoietic stem cell transplantation Hematopoietic Stem Cell Transplantation Hematopoietic stem cell (HSC) transplantation is a rapidly evolving technique that offers a potential cure for hematologic cancers ( leukemias, lymphomas, myeloma) and other hematologic disorders... read more is an option.

Targeted immunotherapy drugs that are available for treatment of relapsed or refractory ALL are increasingly used for treatment of older patients with ALL in clinical trials or clinical practice.

Older patients with ALL probably tolerate asparaginase more poorly than younger patients do.

Relapsed or refractory ALL

Leukemic cells may reappear in the bone marrow, CNS, testes, or other sites. Bone marrow relapse is particularly ominous. Although a new round of chemotherapy may induce a second remission in the majority of children and about one third of adults, subsequent remissions tend to be brief. Chemotherapy helps only a few patients with early bone marrow relapse to achieve long disease-free second remissions or cure.

New immunotherapy approaches show impressive results in relapsed/refractory ALL. Antibodies, such as blinatumomab, that bring T cells into close proximity to leukemic blasts demonstrate activity in relapsed ALL. Chimeric antigen receptor T Modified T cells Systemic cancer therapy includes chemotherapy (ie, conventional or cytotoxic chemotherapy), hormone therapy, targeted therapy, and immune therapy (see also Overview of Cancer Therapy). The number... read more (CAR-T) cells, engineered and generated from the patient's T cells, induce remission in patients with relapsed ALL with remarkable efficacy, albeit with significant toxicity (2 Treatment references Acute lymphoblastic leukemia (ALL) is the most common pediatric cancer; it also strikes adults of all ages. Malignant transformation and uncontrolled proliferation of an abnormally differentiated... read more Treatment references ).

Available immunotherapies for relapsed or refractory ALL include

  • Blinatumomab

  • Inotuzumab ozogamicin

  • Tisagenlecleucel

Blinatumomab, a biospecific CD19-directed CD3 T-cell engager, prolongs overall survival for children and adults with relapsed or refractory B-cell precursor ALL, whether Ph+ or Ph-. Life-threatening toxicities may include cytokine release syndrome Cytokine release syndrome Adverse effects are common in patients receiving any cancer therapy, particularly cytopenias, gastrointestinal effects, and tumor lysis and cytokine release syndromes. Patients may also have... read more and neurologic toxicities (eg, seizures, encephalopathy with altered consciousness, and disordered speech, coordination, and/or balance). Interrupting or stopping blinatumomab with or without use of high-dose dexamethasone may be necessary. The most common neurologic symptoms after blinatumomab use are headache and tremor (3 Treatment references Acute lymphoblastic leukemia (ALL) is the most common pediatric cancer; it also strikes adults of all ages. Malignant transformation and uncontrolled proliferation of an abnormally differentiated... read more Treatment references ).

Inotuzumab ozogamicin, a CD22-directed antibody-drug conjugate with calicheamicin, is also available for adults with relapsed or refractory B-cell precursor ALL. One study found significantly higher remission rates after 1 to 2 cycles of therapy with inotuzumab ozogamicin than with standard chemotherapy (4 Treatment references Acute lymphoblastic leukemia (ALL) is the most common pediatric cancer; it also strikes adults of all ages. Malignant transformation and uncontrolled proliferation of an abnormally differentiated... read more Treatment references ). Inotuzumab may cause hepatotoxicity, including fatal and life-threatening veno-occlusive disease and is associated with higher post-transplant non-relapse mortality.

Brexucabtagene autoleucel, a CD19-directed genetically modified autologous T cell immunotherapy, can be used to treat adult patients with relapsed or refractory B-cell precursor ALL. Complications, including cytokine release syndrome Cytokine release syndrome Adverse effects are common in patients receiving any cancer therapy, particularly cytopenias, gastrointestinal effects, and tumor lysis and cytokine release syndromes. Patients may also have... read more and neurologic toxicities, may be life threatening.

Other agents have been available, but clinically meaningful outcomes have not been convincingly demonstrated (ie, the approvals were based upon response rate but there were no trials verifying an improvement in disease-related symptoms or increased survival) for these. Examples include:

  • Liposomal vincristine (a vinca alkaloid): For adults with Ph- ALL in at least 2nd relapse or that has progressed despite ≥ 2 antileukemia therapy—marketing has been discontinued

  • Clofarabine (a purine nucleoside analog): For patients age 1 to 21 years with relapsed or refractory ALL after ≥ 2 prior regimens

  • Nelarabine (a purine nucleoside) analog prodrug of guanosine arabinoside: For T-cell ALL that has not responded to or has relapsed after ≥ 2 prior regimens

Stem cell transplantation Hematopoietic Stem Cell Transplantation Hematopoietic stem cell (HSC) transplantation is a rapidly evolving technique that offers a potential cure for hematologic cancers ( leukemias, lymphomas, myeloma) and other hematologic disorders... read more following reinduction chemotherapy or immunotherapy offers the greatest hope of long-term remission or cure if an HLA-matched sibling is available. Cells from other relatives or from matched, unrelated donors are sometimes used. Transplantation is rarely used for patients > 65 years because it is much less likely to be successful and because adverse effects are much more likely to be fatal.

CNS relapse treatment includes intrathecal methotrexate (with or without cytarabine or corticosteroids) twice weekly until all signs disappear. The role of continued intrathecal drug use or CNS irradiation is unclear.

Testicular relapse may be evidenced clinically by painless firm swelling of a testis or may be identified on biopsy. If unilateral testicular involvement is clinically evident, the apparently uninvolved testis should undergo biopsy. Treatment is radiation therapy of the involved testis and administration of systemic reinduction therapy.

Supportive care

Supportive care is similar in the acute leukemias and may include

  • Transfusions

  • Antimicrobials

  • Hydration and urine alkalinization

  • Psychologic support

Transfusions of red blood cells and sometimes platelets are administered as needed to patients with bleeding or anemia. Prophylactic platelet transfusion is done when platelets fall to < 10,000/mcL (< 10 × 109/L). Anemia (hemoglobin < 7 or 8 g/dL [< 70 to 80 g/L]) is treated with transfusions of packed red blood cells. Granulocyte transfusions are not routinely used.

Antimicrobials are often needed for prophylaxis and treatment because patients are immunosuppressed; in such patients, infections can progress quickly with little clinical prodrome. After appropriate studies and cultures have been done, febrile patients with neutrophil counts < 500/mcL (< 0.5 × 109/L) should begin treatment with a broad-spectrum bactericidal antibiotic that is effective against gram-positive and gram-negative organisms (eg, ceftazidime, piperacillin/tazobactam, meropenem). Fungal infections, especially pneumonias, may develop and are difficult to diagnose, so chest CT to detect fungal pneumonia should be done early (ie, within 72 hours of presentation with neutropenic fever, depending on the degree of suspicion). Empiric antifungal therapy should be given if antibacterial therapy is not effective within 72 hours. There is a significant drug-drug interaction between vincristine, which is commonly used in all ALL treatment regimens, and azole antifungals. In patients with refractory pneumonitis, Pneumocystis jirovecii infection Pneumocystis jirovecii Pneumonia Pneumocystis jirovecii, an atypical fungus, is a common cause of pneumonia in immunosuppressed patients, especially in those infected with human immunodeficiency virus (HIV) and in those... read more <i >Pneumocystis jirovecii</i> Pneumonia or a viral infection should be suspected and confirmed by bronchoscopy and bronchoalveolar lavage and treated appropriately.

Posaconazole, a 2nd-generation triazole antifungal drug, is indicated for primary prophylaxis in patients age > 13 years who are at high risk of developing invasive Aspergillus and Candida infections because of immunosuppression (eg, hematopoietic stem cell transplant recipients with graft-versus-host disease). In patients with drug-induced immunosuppression (eg, prolonged use of corticosteroids for ALL treatment), sulfamethoxazole/trimethoprim (TMP/SMX), dapsone, atovaquone, or pentamidine is indicated to prevent P. jirovecii pneumonia. Acyclovir or valacyclovir prophylaxis is generally recommended for all patients.

Hydration, urine alkalinization with IV sodium bicarbonate, and allopurinol or rasburicase can prevent and treat the hyperuricemia, hyperphosphatemia, hypocalcemia, and hyperkalemia (ie, tumor lysis syndrome Tumor Lysis and Cytokine Release Syndromes Adverse effects are common in patients receiving any cancer therapy, particularly cytopenias, gastrointestinal effects, and tumor lysis and cytokine release syndromes. Patients may also have... read more ) caused by the rapid lysis of leukemic cells during initial therapy in ALL. Hyperuricemia is minimized by reducing the conversion of xanthine to uric acid by giving allopurinol (a xanthine oxidase inhibitor) or rasburicase (a recombinant urate-oxidase enzyme) before starting chemotherapy. Patients with G6PD deficiency Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an X-linked enzymatic defect common in people with African ancestry that can result in hemolysis after acute illnesses or intake of oxidant... read more Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency may develop severe hemolysis from rasburicase, which is contraindicated in these patients.

Psychologic support may help patients and their families with the shock of illness and the rigors of treatment for a potentially life-threatening condition.

Treatment references

Prognosis for ALL

Prognostic factors help determine treatment protocol and intensity.

Favorable prognostic factors are

  • Age 3 to 9 years

  • WBC count < 25,000/mcL (< 25 × 109/L) or < 50,000/mcL (< 50 × 109/L) in children

  • Leukemic cell karyotype with high hyperdiploidy (51 to 65 chromosomes), t(1;19), and t(12;21)

  • No CNS disease at diagnosis

Unfavorable factors include

  • Leukemic cell karyotype with 23 chromosomes (haploidy), with < 46 chromosomes (hypodiploidy), or with 66 to 68 chromosomes (near triploidy)

  • Leukemic cell karyotype with t(v;11q23) MLL (KMT2A) rearranged, including t(4;11)/KMT2A-AF4

  • Leukemic cell karyotype t(5;14)/IL3-IG

  • Leukemic cell karyotype t(8;14), t(8;22), t(2;8) C-MYC rearranged

  • Presence of the Philadelphia (Ph) chromosome t(9;22) BCR-ABL1

  • Increased age in adults

  • BCR/ABL1-like molecular signature

Regardless of prognostic factors, the likelihood of initial remission is 95% in children and 70 to 90% in adults. Of children, > 80% have continuous disease-free survival for 5 years and appear to be cured. Of adults, < 50% have long-term survival. Factors contributing to poorer clinical outcomes in adults compared with children include the following:

  • Less ability to tolerate intensive chemotherapy

  • More frequent and severe comorbidities

  • Higher risk ALL genetics that confer chemotherapy resistance

  • Poorer adherence to ALL treatment regimens, which include frequent (often daily or weekly) out-patient chemotherapy and doctor visits

  • Less frequent use of pediatric-inspired treatment regimens

Most investigatory protocols select patients with poor prognostic factors for more intense therapy because the increased risk of and toxicity from treatment are outweighed by the greater risk of treatment failure leading to death.

Key Points

  • Acute lymphoblastic leukemia (ALL) is the most common cancer in children but also occurs in adults.

  • Central nervous system (CNS) involvement is common; most patients receive intrathecal chemotherapy and corticosteroids and sometimes CNS radiation therapy.

  • Response to treatment is good in children, with cure possible in > 80% of children but in < 50% of adults.

  • Repeat induction chemotherapy, immunotherapy, and stem cell transplantation may be helpful for relapse.

More Information

The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.

Drugs Mentioned In This Article

Drug Name Select Trade
AK-Dex, Baycadron, CUSHINGS SYNDROME DIAGNOSTIC , Dalalone, Dalalone D.P, Dalalone L.A, Decadron, Decadron-LA, Dexabliss, Dexacort PH Turbinaire, Dexacort Respihaler, DexPak Jr TaperPak, DexPak TaperPak, Dextenza, DEXYCU, DoubleDex, Dxevo, Hemady, HiDex, Maxidex, Ocu-Dex , Ozurdex, ReadySharp Dexamethasone, Simplist Dexamethasone, Solurex, TaperDex, ZCORT, Zema-Pak, ZoDex, ZonaCort 11 Day, ZonaCort 7 Day
Deltasone, Predone, RAYOS, Sterapred, Sterapred DS
Cerubidine
Adriamycin, Adriamycin PFS, Adriamycin RDF, Rubex
Idamycin PFS
Oncovin, Vincasar PFS
Cyclophosphamide, Cytoxan, Neosar
Gleevec
Sprycel
RIABNI, Rituxan, RUXIENCE, truxima
Jylamvo, Otrexup, Rasuvo, RediTrex, Rheumatrex, Trexall, Xatmep
Purinethol, PURIXAN
Cytosar-U
A-Hydrocort, Ala-Cort, Ala-Scalp, Alkindi, Anucort-HC, Anumed-HC, Anusol HC, Aqua Glycolic HC, Aquaphor Children's Itch Relief, Aquaphor Itch Relief, Balneol for Her, Caldecort , Cetacort, Colocort , Cortaid, Cortaid Advanced, Cortaid Intensive Therapy, Cortaid Sensitive Skin, CortAlo, Cortef, Cortenema, Corticaine, Corticool, Cortifoam, Cortizone-10, Cortizone-10 Cooling Relief, Cortizone-10 External Itch Relief, Cortizone-10 Intensive Healing, Cortizone-10 Plus, Cortizone-10 Quick Shot, Cortizone-5 , Dermarest Dricort, Dermarest Eczema, Dermarest Itch Relief, Encort, First - Hydrocortisone, Gly-Cort , GRx HiCort, Hemmorex-HC, Hemorrhoidal-HC, Hemril , Hycort, Hydro Skin, Hydrocort, Hydrocortisone in Absorbase, Hydrocortone, Hydroskin , Hydroxym, Hytone, Instacort, Lacticare HC, Locoid, Locoid Lipocream, MiCort-HC , Monistat Complete Care Instant Itch Relief Cream, Neosporin Eczema, NuCort , Nutracort, NuZon, Pandel, Penecort, Preparation H Hydrocortisone, Proctocort, Proctocream-HC, Procto-Kit, Procto-Med HC , Procto-Pak, Proctosert HC , Proctosol-HC, Proctozone-HC, Rectacort HC, Rectasol-HC, Rederm, Sarnol-HC, Scalacort, Scalpicin Anti-Itch, Solu-Cortef, Texacort, Tucks HC, Vagisil Anti-Itch, VANICREAM HC, Walgreens Intensive Healing, Westcort
Blincyto
BESPONSA
KYMRIAH
Clolar
Arranon
Ceptaz, Fortaz, Tazicef, Tazidime
Zosyn, Zosyn Powder
Merrem
Noxafil
Primsol, Proloprim, TRIMPEX
Aczone
Mepron
NebuPent, Pentam
Sitavig, Zovirax, Zovirax Cream, Zovirax Ointment, Zovirax Powder, Zovirax Suspension
Valtrex
Alka-Seltzer Heartburn Relief, Baros, Neut
Aloprim, Zyloprim
Elitek
View PATIENT EDUCATION
NOTE: This is the Professional Version. CONSUMERS: View Consumer Version
quiz link

Test your knowledge

Take a Quiz! 
iOS ANDROID
iOS ANDROID
iOS ANDROID
TOP