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تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
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Fludarabine: Drug information

Fludarabine: Drug information
(For additional information see "Fludarabine: Patient drug information" and see "Fludarabine: Pediatric drug information")

For abbreviations, symbols, and age group definitions used in Lexicomp (show table)
ALERT: US Boxed Warning
Bone marrow suppression:

Fludarabine can severely suppress bone marrow function.

Autoimmune effects:

Instances of life-threatening and sometimes fatal autoimmune phenomena, such as hemolytic anemia, autoimmune thrombocytopenia/thrombocytopenic purpura, Evans syndrome, and acquired hemophilia, have been reported to occur after 1 or more cycles of treatment with fludarabine. Patients undergoing treatment with fludarabine should be evaluated and closely monitored for hemolysis.

Neurotoxicity:

When used at high doses in dose-ranging studies in patients with acute leukemia, fludarabine was associated with severe neurologic effects, including blindness, coma, and death. This severe CNS toxicity occurred in 36% of patients treated with dosages approximately 4 times greater (96 mg/m2/day for 5 to 7 days) than the recommended dosage. Similar severe CNS toxicity, including agitation, coma, confusion, and seizures, has been reported (0.2% or less) in patients treated at doses in the range of the dose recommended for chronic lymphocytic leukemia.

Combination with pentostatin:

In a clinical investigation using fludarabine in combination with pentostatin (deoxycoformycin) for the treatment of refractory chronic lymphocytic leukemia, there was an unacceptably high incidence of fatal pulmonary toxicity. Therefore, the use of fludarabine in combination with pentostatin is not recommended.

Experienced physician:

Fludarabine injection should be administered under the supervision of a qualified health care provider experienced in the use of antineoplastic therapy.

Brand Names: Canada
  • Fludara
Pharmacologic Category
  • Antineoplastic Agent, Antimetabolite;
  • Antineoplastic Agent, Antimetabolite (Purine Analog)
Dosing: Adult

Note: Prophylactic anti-infectives should be considered for patients with an increased risk for developing opportunistic infections. Consider hydration and prophylactic antihyperuricemic therapy in patients at risk for tumor lysis syndrome.

Acute myeloid leukemia, newly diagnosed

Acute myeloid leukemia, newly diagnosed (off-label use): IV: 30 mg/m2/day for 5 days (in combination with cytarabine ± G-CSF ± idarubicin (FA, FLAG, or FLAG-IDA regimens), followed by consolidation therapy (Ref).

C ore binding factor acute myeloid leukemia:

Patients ≤60 years of age: IV: 30 mg/m2/day for 5 days (in combination with filgrastim, cytarabine, and gemtuzumab ozogamicin), followed by postremission therapy of 30 mg/m2/day for 3 days (in combination with filgrastim, cytarabine, and gemtuzumab ozogamicin) for 6 postremission cycles (Ref).

Patients >60 years of age: IV: 30 mg/m2/day for 4 days (in combination with filgrastim, cytarabine, and gemtuzumab ozogamicin), followed by postremission therapy of 30 mg/m2/day for 3 days (in combination with filgrastim, cytarabine, and gemtuzumab ozogamicin) for 6 postremission cycles (Ref).

Acute myeloid leukemia, refractory or high/poor-risk patients

Acute myeloid leukemia, refractory or high/poor-risk patients (off-label use): IV: 30 mg/m2/day for 5 days (in combination with cytarabine and filgrastim [FLAG regimen]), may repeat once for partial remission (Ref) or 30 mg/m2/day for 5 days for 1 or 2 cycles (in combination with cytarabine, idarubicin, and filgrastim [FLAG-IDA regimen]) (Ref).

Chronic lymphocytic leukemia, previously untreated

Chronic lymphocytic leukemia, previously untreated (off-label dosing/combinations):

FC regimen: IV: 30 mg/m2/day for 3 days every 28 days for 6 cycles (in combination with cyclophosphamide) (Ref) or 20 mg/m2/day for 5 days every 28 days for 6 cycles (in combination with cyclophosphamide) (Ref).

FCR regimen: IV: 25 mg/m2/day for 3 days every 28 days for 6 cycles (in combination with cyclophosphamide and rituximab) (Ref).

FR regimen: IV: 25 mg/m2/day for 5 days every 28 days for 6 cycles (in combination with rituximab) (Ref).

Chronic lymphocytic leukemia, refractory or progressive

Chronic lymphocytic leukemia, refractory or progressive (off-label dosing/combination):

FCR regimen: IV: 25 mg/m2/day for 3 days every 28 days for 6 cycles (in combination with cyclophosphamide and rituximab) (Ref).

Oral (Canadian product; not available in US): 40 mg/m2 once daily for 5 consecutive days every 28 days.

Chronic lymphocytic leukemia, Richters transformation

Chronic lymphocytic leukemia, Richters transformation (off-label dosing/combination): OFAR regimen: IV: 30 mg/m2/day for 2 days every 28 days for 6 cycles (in combination with oxaliplatin, cytarabine, and rituximab) (Ref).

Hematopoietic cell transplant, allogeneic, myeloablative conditioning regimen

Hematopoietic cell transplant, allogeneic, myeloablative conditioning regimen (off-label use): IV: 40 mg/m2/day for 4 days (in combination with busulfan) beginning 6 days prior to transplantation (Ref).

Hematopoietic cell transplant, allogeneic, nonmyeloablative conditioning regimen

Hematopoietic cell transplant, allogeneic, nonmyeloablative conditioning regimen (off-label use): IV: 30 mg/m2/day for 3 doses beginning 5 days prior to transplant (in combination with cyclophosphamide and rituximab) (Ref) or 30 mg/m2/day for 3 doses beginning 4 or 7 days prior to transplant (in combination with total body irradiation) (Ref). Refer to protocols for further details.

Hematopoietic cell transplant, allogeneic, reduced-intensity conditioning regimen

Hematopoietic cell transplant, allogeneic, reduced-intensity conditioning regimen (off-label use): IV: 30 mg/m2/day for 5 days (in combination with melphalan and alemtuzumab) prior to transplant (Ref) or 30 mg/m2/day for 6 days beginning 10 days prior to transplant or 30 mg/m2/day for 5 days beginning 6 days prior to transplant (in combination with busulfan with or without antithymocyte globulin) (Ref) or 30 mg/m2/day for 2 days beginning 4 days prior to transplant (in combination with cyclophosphamide and thiotepa) (Ref) or 25 mg/m2/day for 5 days (in combination with melphalan) prior to transplant (Ref).

Lymphodepleting therapy prior to chimeric antigen receptor T-cell immunotherapy

Lymphodepleting therapy prior to chimeric antigen receptor T-cell immunotherapy (off-label use):

Prior to axicabtagene ciloleucel: IV: 30 mg/m2/day for 3 days (in combination with cyclophosphamide) beginning 5 days (on days −5, −4, and −3) prior to chimeric antigen receptor (CAR) T-cell infusion on day 0 (Ref).

Prior to brexucabtagene autoleucel: IV: 30 mg/m2/day for 3 days (in combination with cyclophosphamide; for relapsed/refractory mantle cell lymphoma) beginning 5 days (on days −5, −4, and −3) prior to CAR T-cell infusion on day 0 (Ref) or 25 mg/m2/day for 3 days beginning 4 days (on days −4, −3, and −2) prior to CAR T-cell infusion on day 0 (in combination with cyclophosphamide; for relapsed/refractory B-cell precursor acute lymphoblastic leukemia) (Ref).

Prior to ciltacabtagene autoleucel: IV: 30 mg/m2/day for 3 days (in combination with cyclophosphamide) followed 2 to 4 days later by CAR T-cell infusion (Ref).

Prior to idecabtagene vicleucel: IV: 30 mg/m2/day for 3 days (in combination with cyclophosphamide) beginning 5 days (on days −5, −4, and −3) prior to CAR T-cell infusion on day 0 (Ref).

Prior to lisocabtagene maraleucel: IV: 30 mg/m2/day for 3 days (in combination with cyclophosphamide) followed 2 to 7 days later by CAR T-cell infusion (Ref).

Prior to tisagenlecleucel : IV: 25 mg/m2/day for 3 days (in combination with cyclophosphamide; for relapsed/refractory diffuse large B-cell lymphoma) followed 2 to 11 days later by CAR T-cell infusion (Ref) or 30 mg/m2/day for 4 days (in combination with cyclophosphamide; for relapsed/refractory B-cell acute lymphoblastic leukemia) followed 2 to 14 days later by CAR T-cell infusion (Ref).

T-cell large granular lymphocytic leukemia, relapsed/refractory

T-cell large granular lymphocytic leukemia, relapsed/refractory (off-label use): IV: 25 mg/m2/day for 3 days every 28 days for 4 to 6 cycles (Ref).

T-cell prolymphocytic leukemia

T-cell prolymphocytic leukemia (off-label use): FMC-A regimen: IV: 25 mg/m2 on days 1, 2, and 3 every 28 days (in combination with mitoxantrone and cyclophosphamide [FMC]) for 2 to 4 cycles; if response demonstrated after initial 2 FMC cycles, then an additional 2 cycles of FMC were administered, followed by alemtuzumab consolidation; if stable disease or progression observed after initial 2 FMC cycles, then proceeded directly to alemtuzumab (Ref).

Waldenström macroglobulinemia

Waldenström macroglobulinemia (off-label use):

Fludarabine monotherapy: IV: 25 mg/m2/day for 5 days every 28 days for 2 cycles after achieving complete or maximum response, up to a maximum of 8 cycles (Ref) or 30 mg/m2/day for 5 days every 28 days for at least 4 cycles; patients with a response received 4 additional cycles or 2 cycles beyond the maximum response level (whichever occurred earlier) (Ref).

FR regimen: IV: 25 mg/m2 once daily for 5 days during weeks 5, 9, 13, 19, 23, and 27 (in combination with rituximab) (Ref).

FCR regimen: IV: 25 mg/m2/day on days 2 to 4 every 28 days (in combination with cyclophosphamide and rituximab) for up to 6 cycles (Ref).

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Adult

Chronic lymphocytic leukemia :

IV:

CrCl ≥80 mL/minute: No dosage adjustment necessary (administer the usual dose of 25 mg/m2).

CrCl 50 to 79 mL/minute: Reduce dose to 20 mg/m2.

CrCl 30 to 49 mL/minute: Reduce dose to 15 mg/m2.

CrCl <30 mL/minute: Use is not recommended.

Oral (Canadian product; not available in US):

CrCl 30 to 70 mL/minute: Reduce dose by up to 50%.

CrCl <30 mL/minute: Use is contraindicated.

The following adjustments have also been recommended: IV:

Krens 2019:

eGFR >70 mL/minute: No dosage adjustment necessary.

eGFR 30 to 70 mL/minute: Reduce dose to 80% of the original dose.

eGFR <30 mL/minute: Use is not recommended.

Hemodialysis: Reduce dose to 80% of the original dose; start dialysis 12 hours after fludarabine administration.

Aronoff 2007:

CrCl 10 to 50 mL/minute: Reduce dose to 75% of usual dose.

CrCl <10 mL/minute: Reduce dose to 50% of usual dose.

CAPD: Reduce dose to 50% of usual dose.

CRRT: Reduce dose to 75% of usual dose.

Dosing: Hepatic Impairment: Adult

There are no dosage adjustments provided in the manufacturer's labeling; however, dosage adjustment for hepatic impairment is not likely necessary (Ref).

Dosing: Obesity: Adult

American Society of Clinical Oncology guidelines for appropriate systemic therapy dosing in adults with cancer with a BMI ≥30 kg/m2 (Note: Excludes hematopoietic cell transplantation and CAR T-cell lymphodepletion dosing): Utilize patient's actual body weight for calculation of BSA- or weight-based dosing; manage regimen-related toxicities in the same manner as for patients with a BMI <30 kg/m2; if a dose reduction is utilized due to toxicity, may consider resumption of full, weight-based dosing (or previously tolerated dose level) with subsequent cycles only if dose escalations are allowed in the prescribing information, if contributing underlying factors (eg, hepatic or renal impairment) are sufficiently resolved, AND if performance status has markedly improved or is considered adequate (Ref).

American Society for Blood and Marrow Transplantation practice guideline committee position statement on chemotherapy dosing in obesity: Utilize actual body weight for calculation of BSA in fludarabine dosing for hematopoietic cell transplant conditioning regimens in adults (Ref).

Dosing: Adjustment for Toxicity: Adult

Hematologic or nonhematologic toxicity (other than neurotoxicity): Consider treatment delay or dosage reduction. Patients with bone marrow impairment may require dosage reductions for excess toxicity.

Hemolysis: Discontinue treatment (corticosteroids may or may not effectively control hemolytic episodes).

Neurotoxicity: Consider treatment delay or discontinuation.

Dosing: Older Adult

Refer to adult dosing. Monitor closely for excess toxicity; may require reduced doses.

Dosing: Pediatric

(For additional information see "Fludarabine: Pediatric drug information")

Refer to individual protocols; details concerning dosing in combination regimens should also be consulted.

Acute lymphocytic leukemia or AML, relapsed

Acute lymphocytic leukemia (ALL) or AML, relapsed: Limited data available: Children and Adolescents: IV:

Continuous IV infusion: 10.5 mg/m2 bolus followed by 30.5 mg/m2/day for 48 hours in combination with cytarabine (Ref)

Intermittent IV dosing: 25 mg/m2 once daily for 5 days in combination with cytarabine and daunorubicin was used for ALL (Ref)

Stem cell transplant conditioning regimen, reduced-intensity

Stem cell transplant (allogeneic) conditioning regimen, reduced-intensity (hematologic malignancy): Limited data available: Children and Adolescents: IV: 30 mg/m2 once daily for 6 doses beginning 7 to 10 days prior to transplant (in combination with busulfan and thymoglobulin (Ref)

Stem cell transplant conditioning regimen, reduced-toxicity

Stem cell transplant (allogeneic) conditioning regimen, reduced-toxicity (myeloid malignancies and non-malignant diseases [eg, sickle cell disease]): Limited data available: Children and Adolescents: IV: 30 mg/m2 once daily for 6 doses days -8 to -3 (in combination with busulfan and alemtuzumab) (Ref)

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing adjustment for toxicity: The presented dosing adjustments are based on experience in adult patients; specific recommendations for pediatric patients are limited. Refer to specific protocol for management in pediatric patients if available.

Adult:

Hematologic or nonhematologic toxicity (other than neurotoxicity): Consider treatment delay or dosage reduction.

Hemolysis: Discontinue treatment.

Neurotoxicity: Consider treatment delay or discontinuation.

Dosing: Kidney Impairment: Pediatric

Infants, Children, and Adolescents: The following guidelines have been used by some clinicians (Ref): IV:

GFR >50 mL/minute/1.73 m2: No adjustment required

GFR 30 to 50 mL/minute/1.73 m2: Administer 80% of dose.

GFR <30 mL/minute/1.73 m2: Not recommended.

Hemodialysis: Administer 25% of dose

Continuous ambulatory peritoneal dialysis (CAPD): Not recommended.

Continuous renal replacement therapy (CRRT): Administer 80% of dose.

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Reported adverse reactions are for adults and may be derived from higher than approved dosing.

>10%:

Dermatologic: Skin rash (15%)

Gastrointestinal: Diarrhea (15%), nausea and vomiting (36%)

Hematologic & oncologic: Bone marrow depression (>30%, including anemia, bone marrow aplasia [trilineage], neutropenia, pancytopenia, thrombocytopenia)

Infection: Infection (33%, including herpes zoster infection [reactivation], opportunistic infection, reactivation of latent Epstein-Barr virus, upper respiratory tract infection [2%])

Nervous system: Chills (11%), neurotoxicity (21%, including agitation, asthenia [9%], blindness, cerebral hemorrhage, coma, confusion, optic neuritis, optic neuropathy, peripheral neuropathy, seizure, visual disturbance [3%], wrist-drop), pain (20%)

Respiratory: Pulmonary toxicity (35%, including acute respiratory distress syndrome, pneumonia [16%], pneumonitis, pulmonary fibrosis, pulmonary hemorrhage, pulmonary hypersensitivity reaction, respiratory distress, respiratory failure)

Miscellaneous: Fever (60%)

1% to 10%:

Cardiovascular: Aneurysm (1%), deep vein thrombosis (1%), edema (8%), phlebitis (1%)

Dermatologic: Diaphoresis (1%), pruritus (1%), seborrhea (1%)

Endocrine & metabolic: Dehydration (1%), hyperglycemia (1%)

Gastrointestinal: Anorexia (7%), constipation (1%), dysphagia (1%), esophagitis (3%), gastrointestinal hemorrhage (3%), stomatitis (2% to 9%)

Genitourinary: Dysuria (4%), hematuria (2%), proteinuria (1%), urinary tract infection (2%)

Hematologic & oncologic: Hemorrhage (1%), tumor lysis syndrome (1%)

Hepatic: Abnormal hepatic function tests (1%, including increased liver enzymes), hepatic failure (1%)

Hypersensitivity: Anaphylaxis (1%)

Nervous system: Cerebellar syndrome (1%), depression (1%), difficulty thinking (1%), fatigue (10%), headache (3%), malaise (8%), paresthesia (4%), sleep disturbance (1%), transient ischemic attacks (1%)

Neuromuscular & skeletal: Arthralgia (1%), myalgia (4%), osteoporosis (2%)

Otic: Hearing loss (2%)

Renal: Altered kidney function test (1%), kidney failure (1%)

Respiratory: Bronchitis (1%), cough (10%), dyspnea (9%), epistaxis (1%), hemoptysis (1%), hypoxia (1%), sinusitis (5%)

<1%: Hematologic & oncologic: Myelofibrosis

Postmarketing:

Cardiovascular: Cardiac arrythmia, heart failure

Dermatologic: Erythema multiforme, malignant neoplasm of skin (new onset or exacerbation), pemphigus, Stevens-Johnson syndrome, toxic epidermal necrolysis

Endocrine & metabolic: Lactic acidosis (Smith 2019)

Gastrointestinal: Increased pancreatic enzymes

Genitourinary: Hemorrhagic cystitis

Hematologic & oncologic: Acquired blood coagulation disorder, acute myelocytic leukemia, autoimmune hemolytic anemia (Tsiara 1997), autoimmune thrombocytopenia (Sen 1999), Evan syndrome (Sen 1999), hemolysis (autoimmune) (Sen 1999), hemophagocytic lymphohistiocytosis (Jayakody Arachchillage 2014), immune thrombocytopenia, myelodysplastic syndrome (Yamazaki 2012)

Immunologic: Epstein-Barr-associated lymphoproliferative disorder

Infection: JC virus infection (reactivation: progressive multifocal leukoencephalopathy) (Vidarsson 2002), mycobacterium infection (including tuberculosis [extrapulmonary abscess]) (Leung 2005), reactivation of HBV (Yağci 2000)

Ophthalmic: Vision loss (Virgo 2019)

Respiratory: Interstitial pneumonitis (Garg 2002), pulmonary neoplasm (nodule) (Garg 2002)

Contraindications

There are no contraindications listed in the manufacturer's US labeling.

Canadian labeling: Hypersensitivity to fludarabine or any component of the formulation; severe renal impairment (CrCl <30 mL/minute); decompensated hemolytic anemia; concurrent use with pentostatin.

Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Warnings/Precautions

Concerns related to adverse effects:

• Autoimmune effects: Life-threatening (and sometimes fatal) autoimmune effects, including hemolytic anemia, autoimmune thrombocytopenia/thrombocytopenic purpura, Evans syndrome, and acquired hemophilia, have occurred. This has occurred in patients with and without a history of autoimmune hemolytic anemia or a positive Coombs test, and who may or may not be in remission from their disease. Following fludarabine discontinuation, hemolytic effects recurred in most patients when rechallenged with fludarabine.

• Bone marrow suppression: Severe bone marrow suppression (anemia, thrombocytopenia, and neutropenia) may occur; may be cumulative. The median time to nadir was 13 days (range: 3 to 25 days) for granulocytes and 16 days (range: 2 to 32 days) for platelets. Severe myelosuppression (trilineage bone marrow hypoplasia/aplasia) has been reported (rare) with a duration of significant cytopenias ranging from 2 months to 1 year. First-line combination therapy is associated with prolonged cytopenias, with anemia lasting up to 7 months, neutropenia up to 9 months, and thrombocytopenia up to 10 months; increased age is predictive for prolonged cytopenias (Gill 2010).

• Infection: Serious and sometimes fatal infections, including opportunistic infections and reactivations of latent viral infections such as VZV (herpes zoster) and Epstein-Barr virus have been reported with fludarabine. Use with caution in patients with documented infection, fever, immunodeficiency, or with a history of opportunistic infection.

• Neurotoxicity: Higher than recommended doses (up to 96 mg/m2/day for 5 to 7 days) are associated with severe neurologic toxicity (delayed blindness, coma, death); similar neurotoxicity (agitation, coma, confusion, seizure) has been reported (rare) with standard chronic lymphocytic leukemia (CLL) doses (25 mg/m2/day for 5 days). Symptoms of neurotoxicity due to high doses appeared from 21 to 60 days following the last fludarabine dose, although neurotoxicity has been reported as early as 7 days and up to 225 days. Although administration of up to 15 courses of treatment have been used, the possible neurotoxic effects of chronic administration are unknown. Fatigue, weakness, visual disturbances, confusion, and seizures may occur; caution patients about performing tasks which require mental alertness (eg, operating machinery or driving).

• Progressive multifocal leukoencephalopathy: Progressive multifocal leukoencephalopathy (usually fatal) due to JC virus has been reported; most cases were in patients who had received prior and/or other concurrent chemotherapy. Onset may be a few weeks or may be delayed up to 1 year.

• Transfusion-associated graft-versus-host disease: Graft-versus-host disease (GVHD) has been observed following transfusion of non-irradiated blood in patients treated with fludarabine; fatal outcome has been observed. Patients receiving fludarabine should only receive irradiated blood products due to the potential for transfusion-related GVHD.

• Tumor lysis syndrome: May cause tumor lysis syndrome; risk is increased in patients with large tumor burden prior to treatment.

Concurrent drug therapy issues:

• Pentostatin: The use of fludarabine in combination with pentostatin is not recommended. When fludarabine has been used in combination with pentostatin for the treatment of refractory CLL, an unacceptably high incidence of fatal pulmonary toxicity has occurred.

Other warnings/precautions:

• Live vaccines: Avoid vaccination with live vaccines during and after fludarabine treatment.

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution, Intravenous, as phosphate:

Generic: 50 mg/2 mL (2 mL)

Solution, Intravenous, as phosphate [preservative free]:

Generic: 25 mg/mL (2 mL); 50 mg/2 mL (2 mL)

Solution Reconstituted, Intravenous, as phosphate [preservative free]:

Generic: 50 mg (1 ea)

Generic Equivalent Available: US

Yes

Pricing: US

Solution (Fludarabine Phosphate Intravenous)

25 mg/mL (per mL): $237.50

Solution (reconstituted) (Fludarabine Phosphate Intravenous)

50 mg (per each): $113.40

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution, Intravenous, as phosphate:

Generic: 25 mg/mL (2 mL)

Solution Reconstituted, Intravenous, as phosphate:

Generic: 50 mg (1 ea, 2 mL)

Tablet, Oral:

Fludara: 10 mg

Administration: Adult

IV: The manufacturer recommends administering over ~30 minutes (for the treatment of CLL). Continuous infusions and IV bolus over 15 minutes have been used for some off-label protocols (refer to individual studies for infusion rate details).

Oral: Tablet [Canadian product] may be administered with or without food; should be swallowed whole with water; do not chew, break, or crush.

Administration: Pediatric

Parenteral: Consult specific protocols; IV infusion rates may vary by pediatric protocol.

Intermittent IV infusion: Infuse over 30 minutes; a shorter infusion has been used in some protocols (Avramis 1998)

Continuous IV infusion with loading dose (bolus):

Loading dose: Administer over 15 minutes (Ref)

Continuous IV infusion: Administer at a constant rate of 10 mL/hour

Hazardous Drugs Handling Considerations

Hazardous agent (NIOSH 2016 [group 1]).

Use appropriate precautions for receiving, handling, storage, preparation, dispensing, transporting, administration, and disposal. Follow NIOSH and USP 800 recommendations and institution-specific policies/procedures for appropriate containment strategy (NIOSH 2016; USP-NF 2020).

Use: Labeled Indications

Chronic lymphocytic leukemia (refractory or progressive): Treatment of B-cell chronic lymphocytic leukemia (CLL) in adults who have not responded to or have progressed during treatment with at least one standard regimen containing an alkylating agent.

Use: Off-Label: Adult

Acute myeloid leukemia (newly diagnosed); Acute myeloid leukemia (refractory or high/poor risk); Hematopoietic cell transplant (allogeneic) myeloablative conditioning regimen (older adults); Hematopoietic cell transplant (allogeneic) nonmyeloablative conditioning regimen; Hematopoietic cell transplant (allogeneic) reduced-intensity conditioning regimen; Lymphodepleting therapy prior to chimeric antigen receptor T-cell immunotherapy; T-cell large granular lymphocytic leukemia, relapsed/refractory; T-cell prolymphocytic leukemia; Waldenström macroglobulinemia

Medication Safety Issues
Sound-alike/look-alike issues:

Fludarabine may be confused with cladribine, floxuridine, flucytosine, Flumadine

Fludara may be confused with FUDR

High alert medication:

This medication is in a class the Institute for Safe Medication Practices (ISMP) includes among its list of drug classes which have a heightened risk of causing significant patient harm when used in error.

Metabolism/Transport Effects

None known.

Drug Interactions

Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.

5-Aminosalicylic Acid Derivatives: May enhance the myelosuppressive effect of Myelosuppressive Agents. Risk C: Monitor therapy

Abrocitinib: May enhance the immunosuppressive effect of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid combination

Antithymocyte Globulin (Equine): Immunosuppressants (Cytotoxic Chemotherapy) may enhance the adverse/toxic effect of Antithymocyte Globulin (Equine). Specifically, these effects may be unmasked if the dose of cytotoxic chemotherapy is reduced. Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Antithymocyte Globulin (Equine). Specifically, infections may occur with greater severity and/or atypical presentations. Risk C: Monitor therapy

Baricitinib: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Baricitinib. Risk X: Avoid combination

BCG (Intravesical): Myelosuppressive Agents may diminish the therapeutic effect of BCG (Intravesical). Risk X: Avoid combination

BCG Products: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the adverse/toxic effect of BCG Products. Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of BCG Products. Risk X: Avoid combination

Brincidofovir: Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Brincidofovir. Risk C: Monitor therapy

Brivudine: May enhance the adverse/toxic effect of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid combination

Chikungunya Vaccine (Live): Immunosuppressants (Cytotoxic Chemotherapy) may enhance the adverse/toxic effect of Chikungunya Vaccine (Live). Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Chikungunya Vaccine (Live). Risk X: Avoid combination

Chloramphenicol (Ophthalmic): May enhance the adverse/toxic effect of Myelosuppressive Agents. Risk C: Monitor therapy

Chloramphenicol (Systemic): Myelosuppressive Agents may enhance the myelosuppressive effect of Chloramphenicol (Systemic). Risk X: Avoid combination

Cladribine: May enhance the myelosuppressive effect of Myelosuppressive Agents. Risk X: Avoid combination

Cladribine: Agents that Undergo Intracellular Phosphorylation may diminish the therapeutic effect of Cladribine. Risk X: Avoid combination

Cladribine: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Cladribine. Risk X: Avoid combination

CloZAPine: Myelosuppressive Agents may enhance the adverse/toxic effect of CloZAPine. Specifically, the risk for neutropenia may be increased. Risk C: Monitor therapy

Coccidioides immitis Skin Test: Immunosuppressants (Cytotoxic Chemotherapy) may diminish the diagnostic effect of Coccidioides immitis Skin Test. Management: Consider discontinuing cytotoxic chemotherapy several weeks prior to coccidioides immitis skin antigen testing to increase the likelihood of accurate diagnostic results. Risk D: Consider therapy modification

COVID-19 Vaccine (Adenovirus Vector): Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of COVID-19 Vaccine (Adenovirus Vector). Management: Administer a 2nd dose using an mRNA COVID-19 vaccine (at least 4 weeks after the primary vaccine dose) and a bivalent booster dose (at least 2 months after the additional mRNA dose or any other boosters). Risk D: Consider therapy modification

COVID-19 Vaccine (Inactivated Virus): Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of COVID-19 Vaccine (Inactivated Virus). Risk C: Monitor therapy

COVID-19 Vaccine (mRNA): Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of COVID-19 Vaccine (mRNA). Management: Give a 3-dose primary series for all patients aged 6 months and older taking immunosuppressive medications or therapies. Booster doses are recommended for certain age groups. See CDC guidance for details. Risk D: Consider therapy modification

COVID-19 Vaccine (Subunit): Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of COVID-19 Vaccine (Subunit). Risk C: Monitor therapy

COVID-19 Vaccine (Virus-like Particles): Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of COVID-19 Vaccine (Virus-like Particles). Risk C: Monitor therapy

Deferiprone: Myelosuppressive Agents may enhance the neutropenic effect of Deferiprone. Management: Avoid the concomitant use of deferiprone and myelosuppressive agents whenever possible. If this combination cannot be avoided, monitor the absolute neutrophil count more closely. Risk D: Consider therapy modification

Dengue Tetravalent Vaccine (Live): Immunosuppressants (Cytotoxic Chemotherapy) may enhance the adverse/toxic effect of Dengue Tetravalent Vaccine (Live). Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Dengue Tetravalent Vaccine (Live). Risk X: Avoid combination

Denosumab: May enhance the immunosuppressive effect of Immunosuppressants (Cytotoxic Chemotherapy). Management: Consider the risk of serious infections versus the potential benefits of coadministration of denosumab and cytotoxic chemotherapy. If combined, monitor patients for signs/symptoms of serious infections. Risk D: Consider therapy modification

Deucravacitinib: May enhance the immunosuppressive effect of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid combination

Dipyrone: May enhance the adverse/toxic effect of Myelosuppressive Agents. Specifically, the risk for agranulocytosis and pancytopenia may be increased Risk X: Avoid combination

Etrasimod: May enhance the immunosuppressive effect of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid combination

Fexinidazole: Myelosuppressive Agents may enhance the myelosuppressive effect of Fexinidazole. Risk X: Avoid combination

Filgotinib: May enhance the immunosuppressive effect of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid combination

Inebilizumab: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Inebilizumab. Risk C: Monitor therapy

Influenza Virus Vaccines: Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Influenza Virus Vaccines. Management: Administer influenza vaccines at least 2 weeks prior to initiating chemotherapy if possible. If vaccination occurs less than 2 weeks prior to or during chemotherapy, revaccinate at least 3 months after therapy discontinued if immune competence restored. Risk D: Consider therapy modification

Leflunomide: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Leflunomide. Management: Increase the frequency of chronic monitoring of platelet, white blood cell count, and hemoglobin or hematocrit to monthly, instead of every 6 to 8 weeks, if leflunomide is coadministered with immunosuppressive agents, such as cytotoxic chemotherapy. Risk D: Consider therapy modification

Lenograstim: Antineoplastic Agents may diminish the therapeutic effect of Lenograstim. Management: Avoid the use of lenograstim 24 hours before until 24 hours after the completion of myelosuppressive cytotoxic chemotherapy. Risk D: Consider therapy modification

Lipegfilgrastim: Antineoplastic Agents may diminish the therapeutic effect of Lipegfilgrastim. Management: Avoid concomitant use of lipegfilgrastim and myelosuppressive cytotoxic chemotherapy. Lipegfilgrastim should be administered at least 24 hours after the completion of myelosuppressive cytotoxic chemotherapy. Risk D: Consider therapy modification

Mumps- Rubella- or Varicella-Containing Live Vaccines: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the adverse/toxic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Risk X: Avoid combination

Nadofaragene Firadenovec: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the adverse/toxic effect of Nadofaragene Firadenovec. Specifically, the risk of disseminated adenovirus infection may be increased. Risk X: Avoid combination

Natalizumab: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Natalizumab. Risk X: Avoid combination

Ocrelizumab: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Ocrelizumab. Risk C: Monitor therapy

Ofatumumab: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Ofatumumab. Risk C: Monitor therapy

Olaparib: Myelosuppressive Agents may enhance the myelosuppressive effect of Olaparib. Risk C: Monitor therapy

Palifermin: May enhance the adverse/toxic effect of Antineoplastic Agents. Specifically, the duration and severity of oral mucositis may be increased. Management: Do not administer palifermin within 24 hours before, during infusion of, or within 24 hours after administration of myelotoxic chemotherapy. Risk D: Consider therapy modification

Pentostatin: May enhance the adverse/toxic effect of Fludarabine. Specifically, the risk of fatal pulmonary toxicity may be increased. Risk X: Avoid combination

Pidotimod: Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Pidotimod. Risk C: Monitor therapy

Pimecrolimus: May enhance the immunosuppressive effect of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid combination

Pneumococcal Vaccines: Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Pneumococcal Vaccines. Risk C: Monitor therapy

Poliovirus Vaccine (Live/Trivalent/Oral): Immunosuppressants (Cytotoxic Chemotherapy) may enhance the adverse/toxic effect of Poliovirus Vaccine (Live/Trivalent/Oral). Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Poliovirus Vaccine (Live/Trivalent/Oral). Risk X: Avoid combination

Polymethylmethacrylate: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the potential for allergic or hypersensitivity reactions to Polymethylmethacrylate. Management: Use caution when considering use of bovine collagen-containing implants such as the polymethylmethacrylate-based Bellafill brand implant in patients who are receiving immunosuppressants. Consider use of additional skin tests prior to administration. Risk D: Consider therapy modification

Promazine: May enhance the myelosuppressive effect of Myelosuppressive Agents. Risk C: Monitor therapy

Rabies Vaccine: Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Rabies Vaccine. Management: Complete rabies vaccination at least 2 weeks before initiation of immunosuppressant therapy if possible. If combined, check for rabies antibody titers, and if vaccination is for post exposure prophylaxis, administer a 5th dose of the vaccine. Risk D: Consider therapy modification

Ritlecitinib: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Ritlecitinib. Risk X: Avoid combination

Ropeginterferon Alfa-2b: Myelosuppressive Agents may enhance the myelosuppressive effect of Ropeginterferon Alfa-2b. Management: Avoid coadministration of ropeginterferon alfa-2b and other myelosuppressive agents. If this combination cannot be avoided, monitor patients for excessive myelosuppressive effects. Risk D: Consider therapy modification

Ruxolitinib (Topical): Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Ruxolitinib (Topical). Risk X: Avoid combination

Sipuleucel-T: Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Sipuleucel-T. Management: Consider reducing the dose or discontinuing the use of immunosuppressants, such as cytotoxic chemotherapy, prior to initiating sipuleucel-T therapy. Risk D: Consider therapy modification

Sphingosine 1-Phosphate (S1P) Receptor Modulator: May enhance the immunosuppressive effect of Immunosuppressants (Cytotoxic Chemotherapy). Risk C: Monitor therapy

Tacrolimus (Topical): Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Tacrolimus (Topical). Risk X: Avoid combination

Talimogene Laherparepvec: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the adverse/toxic effect of Talimogene Laherparepvec. Specifically, the risk of infection from the live, attenuated herpes simplex virus contained in talimogene laherparepvec may be increased. Risk X: Avoid combination

Tertomotide: Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Tertomotide. Risk X: Avoid combination

Tofacitinib: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Tofacitinib. Risk X: Avoid combination

Typhoid Vaccine: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the adverse/toxic effect of Typhoid Vaccine. Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Typhoid Vaccine. Risk X: Avoid combination

Ublituximab: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Ublituximab. Risk C: Monitor therapy

Upadacitinib: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Upadacitinib. Risk X: Avoid combination

Vaccines (Inactivated/Non-Replicating): Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Vaccines (Inactivated/Non-Replicating). Management: Give inactivated vaccines at least 2 weeks prior to initiation of chemotherapy when possible. Patients vaccinated less than 14 days before initiating or during chemotherapy should be revaccinated at least 3 months after therapy is complete. Risk D: Consider therapy modification

Vaccines (Live): Immunosuppressants (Cytotoxic Chemotherapy) may enhance the adverse/toxic effect of Vaccines (Live). Specifically, the risk of vaccine-associated infection may be increased. Vaccines (Live) may diminish the therapeutic effect of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid combination

Yellow Fever Vaccine: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the adverse/toxic effect of Yellow Fever Vaccine. Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Yellow Fever Vaccine. Risk X: Avoid combination

Reproductive Considerations

Patients who could become pregnant should use effective contraception during therapy and for at least 6 months after the last fludarabine dose.

Fludarabine may damage testicular tissue and spermatozoa. Patients with partners who could become pregnant should use contraception during therapy and for at least 6 months after the last fludarabine dose (duration of effect is uncertain).

Pregnancy Considerations

Based on the mechanism of action, fludarabine may cause fetal harm if administered during pregnancy.

Breastfeeding Considerations

It is not known if fludarabine is present in breast milk.

Due to the potential for serious adverse reactions in the breastfed infant, a decision should be made to discontinue breastfeeding or fludarabine, considering the importance of treatment to the breastfeeding patient.

Monitoring Parameters

CBC with differential, platelet count, AST, ALT, serum creatinine, serum albumin, uric acid. Assess risk for opportunistic infections (eg, pneumocystis jirovecii pneumonia, herpes virus infection). Monitor for signs/symptoms of hemolysis, infection, neurotoxicity, progressive multifocal leukoencephalopathy (evaluate any neurologic change promptly), and tumor lysis syndrome. Monitor patients with bone marrow impairment or renal impairment closely for excess toxicity.

The American Society of Clinical Oncology hepatitis B virus (HBV) screening and management provisional clinical opinion (ASCO [Hwang 2020]) recommends HBV screening with hepatitis B surface antigen, hepatitis B core antibody, total Ig or IgG, and antibody to hepatitis B surface antigen prior to beginning (or at the beginning of) systemic anticancer therapy; do not delay treatment for screening/results. Detection of chronic or past HBV infection requires a risk assessment to determine antiviral prophylaxis requirements, monitoring, and follow-up.

Mechanism of Action

Fludarabine inhibits DNA synthesis by inhibition of DNA polymerase and ribonucleotide reductase; also inhibits DNA primase and DNA ligase I

Pharmacokinetics (Adult Data Unless Noted)

Distribution: Vss: 11 to 96 L/m2 (Johnson 2000)

Protein binding: 2-fluoro-ara-A: ~19% to 29%

Metabolism: IV: Fludarabine phosphate is rapidly dephosphorylated in the plasma to 2-fluoro-ara-A (active metabolite), which subsequently enters tumor cells and is phosphorylated by deoxycytidine kinase to the active triphosphate derivative (2-fluoro-ara-ATP)

Bioavailability: Oral: 2-fluoro-ara-A: 50% to 65%

Half-life elimination: 2-fluoro-ara-A: Adults: ~20 hours

Time to peak, plasma: Oral: 1 to 2 hours

Excretion: Urine (primarily) (Johnson 2000)

Pharmacokinetics: Additional Considerations (Adult Data Unless Noted)

Altered kidney function: Total body clearance of the principal metabolite (2-fluoro-ara-A) correlates with CrCl. Mean body clearance is 124 mL/minute for patients with moderate renal impairment and 71 mL/minute for patients with severe renal impairment. In 2 patients with a median CrCl of 22 mL/minute/m2, clearance was reduced by 56%.

Brand Names: International
International Brand Names by Country
For country code abbreviations (show table)

  • (AE) United Arab Emirates: Fludara;
  • (AR) Argentina: Agule | Fludakebir | Fludara | Fludarabina filaxis | Fludarabina ima | Fludarabina Tuteur | Fludarabina varifarma;
  • (AT) Austria: Fludara | Fludarabin accord | Fludarabinphosphat Actavis | Fludarabinphosphat Hospira | Fludarabinphosphat Pharmachemie | Neoflubin;
  • (AU) Australia: Farine | Fludara | Fludarabine | Fludarabine actavis | Fludarabine an | Fludarabine ebewe | Fludarabine juno;
  • (BE) Belgium: Fludara | Fludarabine accord healthcare | Fludarabine ebewe | Fludarabine fresenius kabi;
  • (BG) Bulgaria: Fludara | Fludarabine accord | Fludarabine actavis;
  • (BR) Brazil: Evoflubina | Fludalibbs | Fludara;
  • (CH) Switzerland: Fludara | Fludarabin accord | Fludarabin ebewe | Fludarabin Labatec | Fludarabin sandoz;
  • (CL) Chile: Fludara | Fludarabina fosfato;
  • (CN) China: Fludara | Fu da long | Rui zhi wan;
  • (CO) Colombia: Aldarabina | Fludara | Fludarabina | Forclina | Ludabina;
  • (CZ) Czech Republic: Fludara | Fludarabin actavis | Fludarabine accord | Fludarabine Teva;
  • (DE) Germany: Bendarabin | Beneflur | Fludara | Fludarabin | Fludarabin accord | Fludarabin actavis | Fludarabin aurobindo | Fludarabin Omnicar | Fludarabinphosphat Hospira | Fludarabinphosphat omnicare;
  • (DO) Dominican Republic: Fludara;
  • (EC) Ecuador: Fludara | Fludarabina | Fludarabina fosfato | Fludarabina kemex;
  • (EE) Estonia: Fludara | Fludarabine actavis | Fludarabine ebewe | Fludarabine Teva;
  • (EG) Egypt: Fludara | Fludarabine;
  • (ES) Spain: Beneflur | Fludarabina Accord | Fludarabina actavis | Fludarabina Ebewe | Fosfato de fludarabina Hospira;
  • (FI) Finland: Fludara | Fludarabin actavis | Fludarabin ebewe | Fludarabine accord;
  • (FR) France: Fludara | Fludarabine accord | Fludarabine actavis | Fludarabine ebewe | Fludarabine Mylan | Fludarabine phosphate hospira | Fludarabine Teva;
  • (GB) United Kingdom: Fludara | Fludarabine | Trav fludarabine;
  • (GR) Greece: Fludara | Fludarabin/ebewe | Fludarabine/specifar;
  • (HK) Hong Kong: Fludalym | Fludara | Fludarabin ebewe;
  • (HR) Croatia: Fludara;
  • (HU) Hungary: Fludara | Fludarabin | Fludarabin accord;
  • (ID) Indonesia: Fludara;
  • (IE) Ireland: Fludara | Fludarabine;
  • (IL) Israel: Fludara;
  • (IN) India: Fludabine | Fludacel | Fludara | Fludocyte;
  • (IT) Italy: Fludara | Fludarabina | Fludarabina Accord | Fludarabina Act | Fludarabina Ebe | Fludarabina Mylan;
  • (JO) Jordan: Fludara;
  • (JP) Japan: Fludara;
  • (KR) Korea, Republic of: Fludara | Fludarabine | Pfizer fludarabin | Samoh fludarabine;
  • (LB) Lebanon: Fludara | Fludarabin;
  • (LT) Lithuania: Fludacel | Fludara | Fludarabin actavis | Fludarabine | Fludarabine accord | Fludarabine actavis | Fludarabine Teva;
  • (LV) Latvia: Fludara;
  • (MX) Mexico: Asoleudox | Fludara;
  • (MY) Malaysia: Fludara | Fludarabine kabi;
  • (NL) Netherlands: Fludara | Fludarabine | Fludarabine sandoz | Fludarabinefosfaat Actavis;
  • (NO) Norway: Fludara | Fludarabin | Fludarabin ebewe | Fludarabine Pharmachemie;
  • (NZ) New Zealand: Fludara | Fludarabine;
  • (PE) Peru: Fludara | Mepredin;
  • (PH) Philippines: Fludara;
  • (PK) Pakistan: Fludara | Neoflubin;
  • (PL) Poland: Fludalym | Fludara | Fludarabin ebewe | Fludarabine accord | Fludarabine actavis | Fludarabine Teva;
  • (PR) Puerto Rico: Fludara | Fludarabine;
  • (PT) Portugal: Fludara | Fludarabina | Fludarabina Accord | Fludarabina Teva;
  • (PY) Paraguay: Darabin;
  • (RO) Romania: Fludara | Fludarabina actavis;
  • (RU) Russian Federation: Darbines | Fludara | Fludarabin | Fludarabin actavis | Fludarabin ebewe | Fludarabin teva | Flugarda | Vero fludarabin;
  • (SA) Saudi Arabia: Fludara | Fludarabine;
  • (SE) Sweden: Fludara | Fludarabin actavis | Fludarabin ebewe | Fludarabin hospira | Fludarabine accord;
  • (SG) Singapore: Fludara;
  • (SI) Slovenia: Fludara | Fludarabin teva;
  • (SK) Slovakia: Fludara | Fludarabin ebewe;
  • (TH) Thailand: Fludara;
  • (TN) Tunisia: Fludara | Fludarabine ebewe;
  • (TR) Turkey: Darabin | Fludalym | Fludara | Flumen;
  • (TW) Taiwan: Fludara;
  • (UA) Ukraine: Fludabin | Fludabine | Fludameda | Fludara | Fludarabin | Fludarabine;
  • (UY) Uruguay: Darabin | Fludarabina fu;
  • (ZA) South Africa: Fludara | Teva Fludarabine
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