Fludarabine is a chemotherapy drug that is given as a treatment for some types of cancer. It is most commonly used to treat chronic lymphocytic leukaemia. This information describes fludarabine, how it is given and some of its possible side effects. It should ideally be read with our general information about chemotherapy and about your type of cancer or leukaemia.

If you have any further questions you can ask your doctor or nurse at the hospital where you are having your treatment, or speak to one of our cancer support service nurses.

Fludarabine is a clear fluid after being dissolved from powder.

It is also available as 10mg pink tablets.

Fludarabine may be given:

• By slow injection into a vein (intravenously) through a fine tube (cannula) inserted into the vein.
• Through a central line which is inserted under the skin into a vein near the collarbone, or into a PICC line which is inserted into a vein in the crook of the arm.
• As a drip (infusion) into the vein through a cannula. The infusion takes about 30 minutes.
• As tablets swallowed with plenty of water.

Chemotherapy is usually given as a course of several sessions (or cycles) of treatment over a few months. The length of your treatment and the number of cycles you have will depend on the type of cancer for which you are being treated. Your nurse or doctor will discuss your treatment plan with you.

Each person's reaction to chemotherapy is different. Some people have very few side effects, while others may experience more. The side effects described in this information will not affect everyone who is given fludarabine, and may be different if you are having more than one chemotherapy drug.

We have outlined the most common side effects and some of the less common ones, so you can be aware of them if they occur. However, we have not included those that are very rare and therefore extremely unlikely to affect you.

If you notice any effects which you think may be due to the drug, but which are not listed here, please discuss them with your doctor or chemotherapy nurse.

Lowered resistance to infection Fludarabine can reduce the production of white blood cells by the bone marrow, making you more prone to infection. This effect can begin from three days after treatment has been given and your resistance to infection may remain low for up to four weeks after the chemotherapy. Your immune system may not recover completely for many months after the treatment has finished.

Contact your doctor or the hospital straightaway if:

• your temperature goes above 38ºC (100.5ºF)
• you suddenly feel unwell (even with a normal temperature).

You will have regular blood tests to see how well your bone marrow is working. Occasionally it may be necessary to delay your treatment if the number of blood cells (the blood count) is still low.

While taking fludarabine you are at risk of developing a chest infection called pneumocystis. To help prevent this you will be given an antibiotic called co-trimoxazole (Septrin). You will need to take this during the fludarabine treatment and for a few months after treatment has finished.

Bruising or bleeding Fludarabine can reduce the production of platelets (which help the blood to clot). Let your doctor know if you have any unexplained bruising or bleeding, such as nosebleeds, blood spots or rashes on the skin, or bleeding gums.

Anaemia (low number of red blood cells) While having treatment with fludarabine you may become anaemic. This may make you feel tired and breathless. Let your doctor or nurse know if these effects are a problem.

Loss of appetite A dietitian or specialist nurse at your hospital can give advice about boosting appetite, how to cope with eating difficulties and maintain your weight.

Fever, chills and joint pain may occur from the time that the drug is given, but they do not usually last long. Your doctor may prescribe medicines to reduce these.

Tiredness and feeling weak You may feel very tired. It is important to allow yourself plenty of time to rest.

Feeling sick (nausea) and being sick (vomiting) If you do feel sick this may begin 2–3 hours after the treatment, however it does not usually last long. Your doctor can prescribe very effective anti-sickness (anti-emetic) drugs to prevent, or greatly reduce, nausea and vomiting. If the sickness is not controlled, or continues, tell your doctor; they can prescribe other anti-sickness drugs which may be more effective. Some anti-sickness drugs can cause constipation. Let your doctor or nurse know if this is a problem.

Raised levels of uric acid in the blood You may be given a drug called allopurinol to stop this happening. It may also help to drink plenty of fluids. While you are taking fludarabine your uric acid levels will be checked regularly by blood tests.

Your liver may be temporarily affected Fludarabine may cause changes in the way that your liver works, although your liver will return to normal when the treatment is finished. This is very unlikely to cause you any harm, but your doctor will monitor this carefully. Samples of your blood will be taken from time to time to check your liver is working properly.

Sight changes, headaches, confusion, weakness and agitation These side effects should be reported to your doctor.

Changes to the lungs Fludarabine may cause some changes to lung tissue. Tell your doctor if you smoke and if you notice any coughing or breathlessness.

Sore mouth and ulcers Your mouth may become sore, or you may notice small ulcers. Drinking plenty of fluids, and cleaning your teeth regularly and gently with a soft toothbrush, can help to reduce the risk of this happening. Tell your nurse or doctor if you have any of these problems, as special mouthwashes and medicines can be prescribed to prevent or clear any mouth infection.

Taste changes You may notice that your food tastes different. Normal taste will usually come back after the treatment finishes.

Diarrhoea This can usually be easily controlled with medicine but let your doctor know if it is severe or if it continues. It is important to drink plenty of fluids if you have diarrhoea.

Skin changes Fludarabine can cause a rash, which may be itchy. Your doctor can prescribe medicine to help with this.

Irritation of the bladder It is important to drink plenty of fluids. If you notice any blood in your urine, or pain on passing urine, tell your doctor.

Risk of blood clots Cancer can increase your risk of developing a blood clot (thrombosis), and having chemotherapy may increase this risk further. A blood clot may cause symptoms such as pain, redness and swelling in a leg, or breathlessness and chest pain. Blood clots can be very serious so it is important to tell your doctor straightaway if you have any of these symptoms. However, most clots can usually be successfully treated with drugs to thin the blood. Your doctor or nurse can give you more information.

Other medicines Some medicines can be harmful to take when you are having chemotherapy. Let your doctor know about any medications you are taking, including non-prescribed drugs such as complementary therapies and herbal drugs.

Fertility Your ability to become pregnant or father a child may be affected by taking this drug. It is important to discuss fertility with your doctor before starting treatment.

Contraception It is not advisable to become pregnant or father a child while taking fludarabine, as the developing foetus may be harmed. It is important to use effective contraception while taking this drug, and for at least a few months afterwards. Again, discuss this with your doctor.

• It is important to take your tablets at the right times. You must take them as directed by your doctor.
• Keep the tablets in the original packaging and store them at room temperature, away from heat and direct sunlight.
• Keep the tablets in a safe place where children cannot reach them, as fludarabine could harm them.
• If your doctor decides to stop the treatment, return any remaining tablets to the pharmacist. Do not flush them down the toilet or throw them away.
• If you are sick just after taking the tablets let your doctor know, as you may need to take another dose. Do not take another tablet without first telling your doctor.
• If you forget to take a tablet do not take a double dose. Inform your doctor and keep to your regular dose schedule.

This section is based on our Fludarabine factsheet which has been compiled using information from a number of reliable sources, including:

• Martindale: The Complete Drug Reference (35th edition). Eds. Sweetman et al. Pharmaceutical Press, 2007.
• British National Formulary (54th edition). British Medical Association and Royal Pharmaceutical Society of Great Britain, September 2007.
• The Medicines.org.uk website – www.medicines.org.uk (November 2007).
• The Chemotherapy Source Book (3rd edition). Ed. Perry. Lippincott, Williams and Wilkins, 2001.

For further references, please see general bibliography.