Fludarabine and Cyclophosphamide - SCAN

Haematology
Fludarabine and Cyclophosphamide Chemotherapy
This information is about Fludarabine and Cyclophosphamide chemotherapy,
which is a treatment for used for Chronic Lymphatic Leukaemia and some types
of non-Hodgkin lymphoma. Further information on these diseases is available in
separate information sheets.
Fludarabine and cycylophosphamide are commonly combined with the anti-body
treatment Rituximab to produce the FC-R combination. More detailed information
on Rituximab is available separately.
We try to answer most frequently asked questions, but please ask your doctor or
nurse when you are attending for treatment if you have any further questions.
Drugs that are used
The two drugs used are:-
Fludarabine (pronounced flu da ra been)
Cyclophosphamide (pronounced sigh clo fos fam ide)
These drugs destroy cancer cells by interfering with the internal workings of the
cells. They are known as cytotoxic chemotherapy drugs. Unfortunately these
drugs not only target cancer cells we want to get rid of, but also result in a certain
amount of damage to normal cells. This causes some of the possible side effects
discussed below. Fortunately not all patients get all of the possible side effects,
and some may have very few.
How is it given?
For this treatment both drugs are given in tablet form and should be swallowed
whole with plenty of water. The Cyclophosphamide should be taken in the
morning and the Fludarabine at lunchtime.
How Often?
The treatment is repeated every 4 weeks.
Each 4 week block is known as a cycle. Each cycle has 5 days of treatment
when you take your treatment tablets and then 23 days with no treatment tablets.
The number of cycles that you will have varies with several things such as the
overall plan for management of your disease, your response to the treatment,
and whether or not you have any significant side effects. This should be
discussed with your Doctor.
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Possible side effects
Each person's reaction to chemotherapy is unique. Some people have very few
side effects while others may experience more. The side effects described here
will not affect everyone who is having Fludarabine and Cyclophosphamide
chemotherapy. We have outlined the most common side effects that may occur,
but have not included those that are rare and therefore unlikely to affect you. If
you do notice any effects that you think may be due to your treatment but are not
listed here, please let your Doctor or Nurse know.
Lowered resistance to infection
Cyclophosphamide and Fludarabine can reduce the production of white blood
cells by the bone marrow, making you more prone to infection. This effect may
begin about 4 days into each treatment cycle, reaches its maximum at 10 - 14
days and then slowly recovers to normal as your next treatment cycle is due to
begin. You must contact us immediately if:
• Your temperature is above 38 ° C on 2 occasions one hour apart
• Your temperature is above 38.5 ° C at any time
• You suddenly feel unwell, even with a normal temperature.
While your immunity is low, you cannot fight infection very well yourself
and what would usually be minor infections can become serious and in
some cases life threatening if they are not treated promptly.
Because you will be at increased risk of developing some chest infections, you
will be prescribed an antibiotic called Cotrimoxazole (also known as Septrin) to
be taken 3 days a week. This antibiotic will continue for 6 months after you have
finished treatment with Fludarabine, and reduces the risk of developing these
chest infections. You will have a blood test before each cycle of chemotherapy to
make sure that your bone marrow cells have recovered. Occasionally it may be
necessary to delay your treatment if your blood count is too low.
Bruising or bleeding
Cyclophosphamide and Fludarabine can reduce the production of blood cells
known as platelets that help the blood to clot normally. Let us know if you have
any unexplained bruising or bleeding. If the platelet count has become low you
may need to have a transfusion of platelets.
Anaemia
Cyclophosphamide and Fludarabine can reduce the number of red cells in the
blood. This is known as anaemia and may make you feel tired and breathless. A
blood transfusion may occasionally be needed to correct this. If you need to
have a blood transfusion you will be given specially treated irradiated blood. This
is because Fludarabine treatment makes you more likely to have a reaction with
transfused blood products and this treatment reduces the risk.
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Feeling sick (nausea) and vomiting
With these tablets at these doses nausea and vomiting is fortunately not
common. It may however be a problem for some people, so you will be given a
supply of anti sickness drugs to take if you need to.
Fever, chills and joint pain
May occur shortly after taking these medicines, but do not usually last long. You
may be prescribed medicines to reduce these if it is a problem.
Raised levels of Uric acid in the blood
A drug called Allopurinol may be given to stop this happening, as high urate
levels in the blood can result in gout and rarely kidney damage. It may also help
to drink plenty of fluids.
Changes in eyesight, headaches and confusion, weakness or agitation
These occasionally may happen with Fludarabine. Report to your Doctor straight
away if this happens.
Changes to the lungs
Both of these drugs may rarely cause some changes to the lung tissues. This is
more likely to happen if you smoke. Let us know if you notice a cough or
increased breathlessness.
Your liver may be temporarily affected
Both of these drugs may cause changes in the way that your liver works, but it
will return to normal when treatment is finished. Your liver tests will be monitored
closely during your treatment.
Changes in the way your heart works
This is very uncommon with the doses of Cyclophosphamide that are usually
used, but can occasionally happen when high doses are used. If you have any
other risk factors, tests to see how well your heart is working may be carried out
before you start treatment.
Tiredness
Many people feel tired (fatigued) during chemotherapy, particularly towards the
end of treatment. This is a very common side effect and it is important to try and
get as much rest as you need.
Hair loss
There may be some hair loss or thinning with this treatment, but often it is not
severe. This usually starts about 3-4 weeks after your first treatment. As well as
scalp hair loss, you may have thinning or loss of eyebrows, eyelashes and other
body hair. This is temporary and your hair will start to grow again once your
treatment is finished. If hair loss is significant then speak to your nurse who will
give you information about a wig.
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Sore mouth
Your mouth may become sore or dry, or you may develop small ulcers during
this treatment. Drink plenty of fluids and clean teeth regularly and gently with a
soft toothbrush to help reduce the risk of this happening. Tell your nurse if you
have a problem with a sore mouth. You may be given mouthwashes or
medicines to prevent or treat mouth soreness and ulcers.
Taste
You may notice that your food tastes different, but normal taste will return once
your treatment is finished.
Irritation of the bladder
It is important to drink plenty of fluids to minimise this. If you notice any blood in
your urine or pain on passing urine, tell your Doctor or Nurse.
Diarrhoea
This may occasionally be a problem, but can usually be easily controlled with
medicines. Let us know if it is severe or persistent. It is important to drink plenty
of fluids (at least 2 or 3 litres a day) to replace those that you are losing.
Skin changes
During treatment and for several months afterwards you will be more sensitive to
the sun and your skin will burn more easily than usual. You can still go out in the
sun but wear a high protection factor sun cream and cover up with clothes.
Rarely your skin may darken during treatment. If it does it will usually return to
normal over a few months once treatment is completed.
Many people find that their skin becomes drier than usual during treatment.
Simple moisturising creams can help this. Fludarabine may cause a rash that
may be itchy. Let us know if this happens as prescription of antihistamines may
help.
Nail changes
Your nails may become darker and white lines may appear on them. They may
also become dry. These changes grow out with the nails over a few months
once treatment is finished.
Additional information
Some medicines can be harmful to take when you are having chemotherapy. Let
your doctor know about any medicines 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 this
treatment. It is important to discuss this with your doctor before starting treatment
if this is of concern to you.
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Contraception
It is not advisable to become pregnant or father a child while having this
treatment as the developing baby may be harmed. It is important to use effective
contraception while taking these drugs, and for at least 6 months afterwards, and
it may be advisable to delay starting a family for about 12 months after your
treatment to make sure that you are fully recovered. Discuss this with your nurse
or doctor if you have any concerns.
Loss of periods in women
Due to the effect of chemotherapy on the ovaries you may find that your periods
become irregular or stop. In younger women this is often temporary but if you are
closer to your menopause it may be permanent. This will result in menopausal
symptoms such as hot flushes and sweats and vaginal dryness.
Second cancers
For people treated with chemotherapy there is a small increase in the risk of
developing other cancers at a later date. With this treatment this risk is very low
and after about 10 years falls back towards the background risk shared by the
whole population.
Reviewer: Dr John Davies
Review Date: April 2012
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