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Clofarabine: Drug information

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

For abbreviations, symbols, and age group definitions used in Lexicomp (show table)
Brand Names: US
  • Clolar
Brand Names: Canada
  • Clolar
Pharmacologic Category
  • Antineoplastic Agent, Antimetabolite;
  • Antineoplastic Agent, Antimetabolite (Purine Analog)
Dosing: Adult

Note: Calculate BSA prior to each cycle, utilizing actual body weight.

Premedications: Clofarabine is associated with a moderate emetic potential; antiemetics are recommended to prevent nausea and vomiting (ASCO [Hesketh 2020]; MASCC/ESMO [Roila 2016]). Consider prophylactic corticosteroids (hydrocortisone 100 mg/m2 on days 1 to 3) to prevent signs/symptoms of capillary leak syndrome or systemic inflammatory response syndrome (SIRS). Provide supportive care, such as IV fluids and antihyperuricemic treatment, and alkalinize urine (to reduce the risk of tumor lysis syndrome/hyperuricemia).

Acute lymphoblastic leukemia, relapsed/refractory

Acute lymphoblastic leukemia, relapsed/refractory:

Acute lymphoblastic leukemia, relapsed/refractory: Adults ≤21 years of age: IV: 52 mg/m2/day days 1 through 5; repeat every ~2 to 6 weeks; subsequent cycles should begin no sooner than 14 days from day 1 of the previous cycle (subsequent cycles may be administered when ANC ≥750/mm3).

Off-label dosing: CLOVE regimen: IV: 20 to 30 mg/m2 once daily on days 1 through 5 (in combination with cyclophosphamide and etoposide) as a bridging regimen to hematopoietic stem cell transplant in patients with relapsed or very high risk disease (Gossai 2014).

Acute lymphoblastic leukemia, relapsed/refractory (off-label population):

Induction: IV: 40 mg/m2 once daily for 5 days; may repeat induction cycle once in 3 to 6 weeks if needed (depending on marrow response and recovery) (Kantarjian 2003).

Consolidation: IV: 30 mg/m2 once daily for 5 days (or last tolerated induction dose, whichever is lower); repeat every 4 weeks for up to a maximum of 6 consolidation cycles (Kantarjian 2003).

Acute myeloid leukemia, refractory

Acute myeloid leukemia, refractory (off-label use): Adults <70 years of age:

Induction: IV: 25 mg/m2/day for 5 days (in combination with cytarabine and filgrastim) may repeat one time after 21 days if needed (Becker 2011).

Consolidation: IV: 20 mg/m2/day for 5 days (in combination with cytarabine and filgrastim) for 1 or 2 cycles (Becker 2011).

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

Clofarabine undergoes renal elimination and exposure is increased as creatinine clearance decreases (Bonate 2011). Minimize the concomitant use of nephrotoxic medications during clofarabine treatment.

Renal impairment at baseline:

CrCl >60 mL/minute: No dosage adjustment necessary.

CrCl 30 to 60 mL/minute: Reduce dose to 50% of the usual dose.

CrCl <30 mL/minute: There are no dosage adjustments provided in the manufacturer's labeling. Use is not recommended (Krens 2019).

Dialysis: There are no dosage adjustments provided in the manufacturer's labeling. Use is not recommended (Krens 2019).

Renal toxicity during treatment: Serum creatinine increase ≥ grade 3: Discontinue clofarabine; may reinitiate with a 25% dose reduction after patient is stable and organ function recovers to baseline.

Dosing: Hepatic Impairment: Adult

Hepatic impairment at baseline: There are no dosage adjustments provided in the manufacturer's labeling. Avoid the concomitant use of medications that may cause hepatotoxicity.

Mild or moderate impairment: No need for dosage adjustment is expected (Krens 2019).

Severe impairment: Use is not recommended (Krens 2019).

Hepatotoxicity during treatment:

Hepatic enzymes and/or bilirubin increase ≥ grade 3: Discontinue clofarabine; may reinitiate with a 25% dose reduction after patient is stable and organ function recovers to baseline.

Dosing: Obesity: Adult

American Society of Clinical Oncology guidelines for appropriate systemic therapy dosing in adults with cancer with a BMI ≥30 kg/m2: Utilize patient's actual body weight (full 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 kidney impairment) are sufficiently resolved, AND if performance status has markedly improved or is considered adequate (ASCO [Griggs 2021]).

American Society for Blood and Marrow Transplantation practice guideline committee position statement on chemotherapy dosing in obesity: Utilize actual body weight (full weight) for calculation of BSA in clofarabine dosing for hematopoietic stem cell transplant conditioning regimens (ASBMT [Bubalo 2014]).

Dosing: Adjustment for Toxicity: Adult

Hematologic toxicity: ANC <500/mm3 lasting ≥4 weeks: Reduce dose by 25% for next cycle.

Nonhematologic toxicity:

Clinically significant infection: Withhold clofarabine until infection is under control, then restart at full dose.

Grade 3 toxicity excluding infection, nausea and vomiting controlled by antiemetics, or transient elevations in transaminases and bilirubin: Withhold clofarabine; may reinitiate with a 25% dose reduction with resolution or return to baseline.

Grade 4 toxicity (noninfectious): Discontinue clofarabine.

Capillary leak syndrome or systemic inflammatory response syndrome (SIRS) early signs/symptoms (eg, hypotension, tachycardia, tachypnea, pulmonary edema): Discontinue clofarabine; institute supportive measures. Consider supportive treatment with diuretics, corticosteroids, and/or albumin as clinically appropriate. May consider reinitiating clofarabine with a 25% dose reduction after patient is stable and organ function recovers to baseline.

Dermatologic toxicity: Exfoliative or bullous rash, or suspected Stevens-Johnson syndrome or toxic epidermal necrolysis: Discontinue clofarabine.

Hypotension (during the 5 days of infusion): Discontinue clofarabine. If hypotension is transient and resolves and patient is stabilized, may consider reinitiating with 25% dosage reduction (Clolar Canadian product monograph).

Dosing: Pediatric

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

Dosing and frequency may vary by protocol and/or treatment phase; refer to specific protocol.

Note: Consider prophylactic corticosteroids (hydrocortisone 100 mg/m2 on days 1 to 3) to prevent signs/symptoms of capillary leak syndrome or systemic inflammatory response syndrome (SIRS). Provide IV hydration, antihyperuricemic therapy, and alkalinize the urine to reduce the risk of tumor lysis syndrome/hyperuricemia. Calculate BSA prior to each cycle utilizing actual body weight. Clofarabine is associated with a moderate emetic potential; antiemetics are recommended to prevent nausea and vomiting (POGO [Dupuis 2011]).

Acute lymphocytic leukemia, relapsed/refractory

Acute lymphocytic leukemia (ALL), relapsed/refractory:

Monotherapy: Children and Adolescents: IV infusion: 52 mg/m2/day once daily for days 1 to 5 of each cycle; repeat cycle every 2 to 6 weeks following recovery or return to baseline organ function; subsequent cycles should begin no sooner than 14 days from the start of the previous cycle and when ANC ≥750/mm3

Combination therapy: Limited data available: IV Infusion:

Infants: Dosing regimens variable with very limited data available:

Weight-directed dosing: 1.33 mg/kg/day for 5 days in combination with cyclophosphamide and etoposide (O’Connor 2011)

BSA-directed dosing: 40 mg/m2/day for 5 days in combination with cyclophosphamide and etoposide (Inaba 2012); and with topotecan, vinorelbine, thiotepa (TVTC regimen), and dexamethasone in a Phase I trial (Steinherz 2010)

Children and Adolescents: Usual dose: 40 mg/m2/day for 5 days in combination with cyclophosphamide and etoposide has been most frequently studied (Hijiya 2011; Hijiya 2012; Inaba 2012; Locatelli 2009; O’Connor 2011); and with topotecan, vinorelbine, thiotepa (TVTC regimen), and dexamethasone in a Phase I trial (Steinherz 2010). In one trial, the protocol included 5 days of clofarabine therapy during induction and 4 days of therapy for consolidation; this study was also amended to exclude patients with prior hematopoietic stem cell transplantation due to a high incidence of veno-occlusive disease (Hijiya 2011).

Acute myeloid leukemia, relapsed/refractory

Acute myeloid leukemia (AML), relapsed/refractory: Limited data available: Children and Adolescents: IV infusion:

Monotherapy: 52 mg/m2/day once daily for days 1 to 5 of each cycle; repeat cycle every 2 to 6 weeks for up to 12 cycles following recovery or return to baseline organ function; subsequent cycles should begin no sooner than 14 days from the start of the previous cycle and when ANC ≥750/mm3; the trial did not have minimum exclusion age (patient age ≤21 years at time of diagnosis); the youngest patient was 2 years of age (Jeha 2009)

Combination therapy: 40 mg/m2/day once daily for days 1 to 5 of each cycle in combination with cyclophosphamide and etoposide (Inaba 2012)

Langerhans cell histiocytosis, refractory

Langerhans cell histiocytosis, refractory: Limited data available: Children and Adolescents: IV: 25 mg/m2/day days 1 through 5; repeat every 28 days for 2 to 8 cycles (Simko 2014).

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: Children and Adolescents:

Hematologic toxicity: ANC <500/mm3 lasting ≥4 weeks: Reduce clofarabine dose by 25% for next cycle

Nonhematologic toxicity:

Clinically significant infection: Withhold treatment until infection is under control, then restart clofarabine at full dose

Grade 3 toxicity, excluding infection, nausea, and vomiting, and transient elevations in transaminases and bilirubin: Withhold treatment; may reinitiate clofarabine with a 25% dose reduction with resolution or return to baseline

Grade ≥3 increase in creatinine or bilirubin: Discontinue clofarabine; may reinitiate with 25% dosage reduction when creatinine or bilirubin return to baseline and patient is stable; administer antihyperuricemic therapy for elevated uric acid

Grade 4 toxicity (noninfectious): Discontinue clofarabine treatment

Capillary leak or systemic inflammatory response syndrome (SIRS) early signs/symptoms (eg, hypotension, tachycardia, tachypnea, pulmonary edema): Discontinue clofarabine; institute supportive measures. May consider reinitiating with a 25% dose-reduction after patient is stable and after organ function recovers to baseline.

Dermatologic toxicity: Exfoliative or bullous rash, or suspected Stevens-Johnson syndrome or toxic epidermal necrolysis: Discontinue clofarabine.

Hypotension (during the 5 days of infusion): Discontinue clofarabine. If hypotension is transient and resolves (without pharmacologic intervention), some have suggested that may reinitiate with 25% dosage reduction (Clolar Canadian product monograph).

Dosing: Kidney Impairment: Pediatric

Children and Adolescents: Clofarabine undergoes renal elimination and exposure is increased as creatinine clearance decreases (Bonate 2011).

Baseline renal impairment:

CrCl >60 mL/minute: No dosage adjustment recommended

CrCl 30 to 60 mL/minute: Reduce dose by 50%

CrCl <30 mL/minute: There are no dosage adjustments provided in the manufacturer's labeling; use with caution (insufficient evidence)

Renal toxicity during therapy: Grade 3 or higher increase in serum creatinine: Discontinue clofarabine; may reinitiate with a 25% dose reduction after patient is stable and organ function recovers to baseline

Dosing: Hepatic Impairment: Pediatric

Children and Adolescents:

Baseline hepatic impairment: There are no dosage adjustments provided in the manufacturer's labeling (has not been studied)

Hepatotoxicity during therapy: Grade 3 or higher increase in bilirubin: Discontinue clofarabine; may reinitiate with a 25% dose reduction after patient is stable and organ function recovers to baseline.

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Adverse reactions reported in pediatric patients and include off-label use in the treatment of AML.

>10%:

Cardiovascular: Edema (12%), flushing (19%), hypertension (13%), hypotension (29%), septic shock (≤17%), tachycardia (35%)

Dermatologic: Erythema of skin (11%), palmar-plantar erythrodysesthesia (16%), pruritus (43%), skin rash (38%)

Gastrointestinal: Abdominal pain (35%), anorexia (30%), diarrhea (56%; grade 3: 12%), gingival hemorrhage (17%), mucosal swelling (16%), nausea (73%; grades 3/4: 1% to 14%), oral candidiasis (11%), vomiting (78%; grades 3/4: 1% to 8%)

Genitourinary: Hematuria (13%)

Hematologic & oncologic: Anemia (83%; grades ≥3: 75%), febrile neutropenia (55%; grades 3/4: 3% to 51%), leukopenia (88%; grades ≥3: 88%), lymphocytopenia (82%; grades ≥3: 82%), neutropenia (10% to 64%; grades ≥3: 3% to 64%), petechia (26%; grade 3: 6%), thrombocytopenia (81%; grades ≥3: 80%)

Hepatic: Increased serum alanine aminotransferase (81%), increased serum aspartate aminotransferase (74%), increased serum bilirubin (45%)

Infection: Infection (83%; including bacterial infection, fungal infection, and viral infection), sepsis (≤17%)

Nervous system: Anxiety (21%), chills (34%), fatigue (34%), headache (43%), pain (15%)

Neuromuscular & skeletal: Limb pain (30%), myalgia (14%)

Renal: Increased serum creatinine (50%)

Respiratory: Dyspnea (13%), epistaxis (27%), pleural effusion (12%)

Miscellaneous: Fever (39%)

1% to 10%:

Cardiovascular: Capillary leak syndrome (4%), pericardial effusion (8%)

Dermatologic: Cellulitis (8%), pruritic rash (8%)

Gastrointestinal: Clostridioides difficile colitis (7%), gastroenteritis (adenovirus: <5%), neutropenic typhlitis (<5%), oral mucosal petechiae (5%), pancreatitis (<5%), rectal pain (8%), stomatitis (7%; grade 3: 1%), upper abdominal pain (8%)

Hematologic & oncologic: Tumor lysis syndrome (6%; grade 3: 6%)

Hepatic: Hepatic sinusoidal obstruction syndrome (formerly known as hepatic venoocclusive disease: 2%), hyperbilirubinemia (<5%), jaundice (8%)

Hypersensitivity: Hypersensitivity reaction (<5%)

Infection: Bacteremia (9%), candidiasis (7%), herpes simplex infection (10%), herpes zoster (7%), influenza (<5%), systemic inflammatory response syndrome (2%)

Nervous system: Agitation (5%), asthenia (10%), drowsiness (10%), irritability (10%), lethargy (10%), mental status changes (<5%)

Neuromuscular & skeletal: Arthralgia (9%), back pain (10%), ostealgia (10%)

Renal: Acute kidney injury (grades 3/4: 2% to 3%)

Respiratory: Pneumonia (10%), pulmonary edema (<5%), respiratory distress (10%), respiratory syncytial virus infection (<5%), sinusitis (<5%), tachypnea (9%), upper respiratory tract infection (5%)

Frequency not defined:

Gastrointestinal: Enterocolitis (including neutropenic enterocolitis)

Hepatic: Hepatic failure, hepatitis

Postmarketing:

Cardiovascular: Increased right ventricular pressure (Jeha 2006), left systolic heart failure (Jeha 2006)

Dermatologic: Stevens-Johnson syndrome, toxic epidermal necrolysis

Endocrine & metabolic: Hypokalemia (Jeha 2006), hyponatremia, hypophosphatemia (Jeha 2006).

Hematologic & oncologic: Major hemorrhage (including cerebral hemorrhage, gastrointestinal hemorrhage, and pulmonary hemorrhage)

Hepatic: Hepatomegaly (Jeha 2006)

Nervous system: Drug fever (Irie 2022), hallucination (Jeha 2006)

Contraindications

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

Canadian labeling: Hypersensitivity to clofarabine or any component of the formulation; symptomatic CNS involvement; history of serious heart, liver, kidney, or pancreas disease; severe hepatic impairment (AST and/or ALT >5 x ULN, and/or bilirubin >3 x ULN); severe renal impairment (CrCl <30 mL/minute)

Warnings/Precautions

Concerns related to adverse effects:

• Bone marrow suppression: Dose-dependent, reversible myelosuppression (neutropenia, thrombocytopenia, and anemia) is common; may be severe and prolonged. Patients may be at increased risk for infection due to neutropenia.

• Capillary leak syndrome/systemic inflammatory response syndrome: Clofarabine may cause a cytokine release syndrome (eg, tachypnea, tachycardia, hypotension, pulmonary edema), which may progress to systemic inflammatory response syndrome with capillary leak syndrome and organ dysfunction; may be fatal.

• Dermatologic reactions: Serious and fatal cases of Stevens-Johnson syndrome and toxic epidermal necrolysis have been reported.

• GI toxicity: Serious and fatal enterocolitis (including neutropenic colitis, cecitis, and C. difficile colitis) has been reported, usually occurring within 30 days of treatment, and when used in combination with other chemotherapy. Enterocolitis may lead to necrosis, perforation, hemorrhage, or sepsis complications.

• Hemorrhage: Serious and fatal hemorrhages (including cerebral, GI, and pulmonary hemorrhage) have occurred, usually associated with thrombocytopenia.

• Hepatotoxicity: Transaminases and bilirubin may be increased during treatment (including grade 3 and 4 events); severe and fatal hepatitis and hepatic failure have been reported. Transaminase elevations generally occur within 10 days of administration and resolve to ≤ grade 2 within 15 days. The risk for hepatotoxicity, including hepatic sinusoidal obstruction syndrome (SOS; formerly called veno-occlusive disease), is increased in patients who have previously undergone a hematopoietic stem cell transplant.

• Infection: Clofarabine increases the risk for infections, including opportunistic infection or severe or fatal sepsis. Fungal, bacterial, and viral infections have occurred.

• Renal toxicity: Elevated creatinine, acute renal failure, and hematuria were observed in clinical studies. Infection, sepsis, or tumor lysis syndrome may cause an increased risk of renal toxicity in patients receiving clofarabine.

• Tumor lysis syndrome/hyperuricemia: Tumor lysis syndrome may occur as a consequence of leukemia treatment, including treatment with clofarabine, usually occurring in the first treatment cycle. Tumor lysis syndrome may lead to life-threatening acute renal failure; adequate hydration and prophylactic antihyperuricemic therapy will reduce the risk/effects of tumor lysis syndrome.

Dosage Forms: US

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

Solution, Intravenous:

Generic: 1 mg/mL (20 mL)

Solution, Intravenous [preservative free]:

Clolar: 1 mg/mL (20 mL)

Generic: 1 mg/mL (20 mL)

Generic Equivalent Available: US

Yes

Pricing: US

Solution (Clofarabine Intravenous)

1 mg/mL (per mL): $48.00 - $176.08

Solution (Clolar Intravenous)

1 mg/mL (per mL): $213.87

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:

Clolar: 1 mg/mL (20 mL)

Administration: Adult

Clofarabine is associated with a moderate emetic potential; antiemetics are recommended to prevent nausea and vomiting (ASCO [Hesketh 2020]; MASCC/ESMO [Roila 2016]).

IV infusion: Infuse over 2 hours for relapsed/refractory ALL. May be infused over 1 hour for some off-label protocols (Becker 2011; Kantarjian 2003). Continuous IV fluids are encouraged to decrease adverse events and tumor lysis effects. Hypotension may be a sign of capillary leak syndrome or systemic inflammatory response syndrome. Do not administer any other medications through the same intravenous line.

Administration: Pediatric

Parenteral: IV infusion: Administer by IV infusion over 2 hours per the manufacturer's labeling and in most trials; a few trials have infused over 1 hour (Federl 2005; Jeha 2004; Kantarian 2003). An inline filter is not needed for administration. Do not administer with any other medications through the same intravenous line.

Clofarabine is associated with a moderate emetic potential; antiemetics are recommended to prevent nausea and vomiting (POGO [Dupuis 2011]).

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

Acute lymphoblastic leukemia, relapsed or refractory: Treatment of relapsed or refractory acute lymphoblastic leukemia in patients 1 to 21 years of age (after at least 2 prior regimens).

Use: Off-Label: Adult

Acute lymphoblastic leukemia, relapsed or refractory (adults); Acute myeloid leukemia, refractory (patients <70 years of age)

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

Clofarabine may be confused with cladribine, clevidipine, cytarabine, nelarabine

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

Substrate of OAT1/3, OCT1, OCT2

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

Alfuzosin: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Amifostine: Blood Pressure Lowering Agents may enhance the hypotensive effect of Amifostine. Management: When used at chemotherapy doses, hold blood pressure lowering medications for 24 hours before amifostine administration. If blood pressure lowering therapy cannot be held, do not administer amifostine. Use caution with radiotherapy doses of amifostine. Risk D: Consider therapy modification

Amisulpride (Oral): May enhance the hypotensive effect of Hypotension-Associated Agents. Risk C: Monitor therapy

Antipsychotic Agents (Second Generation [Atypical]): Blood Pressure Lowering Agents may enhance the hypotensive effect of Antipsychotic Agents (Second Generation [Atypical]). Risk C: Monitor therapy

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

Arginine: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Barbiturates: May enhance the hypotensive effect of Blood Pressure Lowering Agents. 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

Benperidol: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Blood Pressure Lowering Agents: May enhance the hypotensive effect of Hypotension-Associated Agents. Risk C: Monitor therapy

Brimonidine (Topical): May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

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

Bromperidol: May diminish the hypotensive effect of Blood Pressure Lowering Agents. Blood Pressure Lowering Agents may enhance the hypotensive effect of Bromperidol. 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

Diazoxide: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

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

DULoxetine: Blood Pressure Lowering Agents may enhance the hypotensive effect of DULoxetine. Risk C: Monitor therapy

Erdafitinib: May increase the serum concentration of OCT2 Substrates (Clinically Relevant with Inhibitors). Management: Consider alternatives to this combination when possible. If combined, monitor for increased effects/toxicities of OCT2 substrates and consider OCT2 substrate dose reductions when appropriate. Risk D: Consider therapy modification

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

Gilteritinib: May increase the serum concentration of OCT1 Substrates (Clinically Relevant with Inhibitors). Risk C: Monitor therapy

Herbal Products with Blood Pressure Lowering Effects: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Hypotension-Associated Agents: Blood Pressure Lowering Agents may enhance the hypotensive effect of Hypotension-Associated Agents. Risk C: Monitor therapy

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

Levodopa-Foslevodopa: Blood Pressure Lowering Agents may enhance the hypotensive effect of Levodopa-Foslevodopa. Risk C: Monitor therapy

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

Lormetazepam: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Molsidomine: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

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

Naftopidil: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

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

Nicergoline: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Nicorandil: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Nitroprusside: Blood Pressure Lowering Agents may enhance the hypotensive effect of Nitroprusside. Risk C: Monitor therapy

OAT1/3 Inhibitors: May increase the serum concentration of Clofarabine. Risk C: Monitor therapy

Obinutuzumab: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Management: Consider temporarily withholding blood pressure lowering medications beginning 12 hours prior to obinutuzumab infusion and continuing until 1 hour after the end of the infusion. Risk D: Consider therapy modification

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

OCT2 Inhibitors: May increase the serum concentration of Clofarabine. 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

Pacritinib: May increase the serum concentration of OCT1 Substrates (Clinically Relevant with Inhibitors). Risk X: Avoid combination

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

Pentoxifylline: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Pholcodine: Blood Pressure Lowering Agents may enhance the hypotensive effect of Pholcodine. Risk C: Monitor therapy

Phosphodiesterase 5 Inhibitors: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

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

Pretomanid: May increase the serum concentration of OAT1/3 Substrates (Clinically Relevant). Risk C: Monitor therapy

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

Prostacyclin Analogues: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Quinagolide: May enhance the hypotensive effect of Blood Pressure Lowering 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

Silodosin: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

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

Tafenoquine: May increase the serum concentration of OCT2 Substrates (Clinically Relevant with Inhibitors). Management: Avoid use of OCT2 substrates with tafenoquine, and if the combination cannot be avoided, monitor closely for evidence of toxicity of the OCT2 substrate and consider a reduced dose of the OCT2 substrate according to that substrate's labeling. Risk D: Consider therapy modification

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

Taurursodiol: May increase the serum concentration of OAT1/3 Substrates (Clinically Relevant). 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

Vaborbactam: May increase the serum concentration of OAT1/3 Substrates (Clinically Relevant). Risk C: Monitor therapy

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

Evaluate pregnancy status prior to use in patients who may become pregnant. Patients who may become pregnant should use effective contraception during therapy and for at least 6 months after the last clofarabine dose. Patients with partners who may become pregnant should use effective contraception during therapy and for at least 3 months after the last dose of clofarabine.

A long-term observational research study is collecting information about the diagnosis and treatment of cancer during pregnancy. For additional information about the pregnancy and cancer registry or to become a participant, contact Cooper Health (1-877-635-4499).

Pregnancy Considerations

Based on the mechanism of action and data from animal reproduction studies, in utero exposure to clofarabine may cause fetal harm.

Breastfeeding Considerations

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

Due to the potential for serious adverse reactions in the breastfed infant, breastfeeding is not recommended by the manufacturer during treatment and for at least 2 weeks after the last dose of clofarabine.

Monitoring Parameters

CBC with differential and platelets (regularly during treatment); liver and kidney function (during the 5 days of clofarabine administration); coagulation parameters. Monitor BP, cardiac function, and respiratory status during infusion. Monitor for signs and symptoms of tumor lysis syndrome, infection, hepatic sinusoidal obstruction syndrome, dermatologic toxicity, enterocolitis, hemorrhage, cytokine release syndrome (tachypnea, tachycardia, hypotension, pulmonary edema), and capillary leak syndrome/systemic inflammatory response syndrome (rapid onset respiratory distress, hypotension, pleural/pericardial effusion, and multiorgan failure); monitor hydration status.

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

Clofarabine, a purine (deoxyadenosine) nucleoside analog, is metabolized to clofarabine 5'-triphosphate. Clofarabine 5'-triphosphate decreases cell replication and repair as well as causing cell death. To decrease cell replication and repair, clofarabine 5'-triphosphate competes with deoxyadenosine triphosphate for the enzymes ribonucleotide reductase and DNA polymerase. Cell replication is decreased when clofarabine 5'-triphosphate inhibits ribonucleotide reductase from reacting with deoxyadenosine triphosphate to produce deoxynucleotide triphosphate which is needed for DNA synthesis. Cell replication is also decreased when clofarabine 5'-triphosphate competes with DNA polymerase for incorporation into the DNA chain; when done during the repair process, cell repair is affected. To cause cell death, clofarabine 5'-triphosphate alters the mitochondrial membrane by releasing proteins, an inducing factor and cytochrome C.

Pharmacokinetics (Adult Data Unless Noted)

Distribution: Vd: Decreased with increasing age, based on pharmacokinetic simulations: 5.8 L/kg (3 years old); 3.1 L/kg (30 years old); 2.7 L/kg (82 years old) (Bonate 2011); Children and Adolescents 2 to 19 years: 172 L/m2

Protein binding: 47%, primarily to albumin

Metabolism: Intracellulary by deoxycytidine kinase and mono- and diphosphokinases to active metabolite clofarabine 5′-triphosphate; limited hepatic metabolism (0.2%)

Half-life elimination: Children and Adolescents 2 to 19 years: 5.2 hours; Children and Adults: 7 hours; may be prolonged in in the elderly and in patients with renal impairment (Bonate, 2011)

Excretion: Urine (49% to 60%, as unchanged drug)

Pharmacokinetics: Additional Considerations (Adult Data Unless Noted)

Altered kidney function: Clofarabine undergoes renal elimination and exposure is increased as creatinine clearance decreases (Bonate 2011). In patients with CrCl 60 to <90 mL/minute, the AUC was increased by 60% and in patients with CrCl 30 to <60 mL/minute, the AUC was increased by 140%.

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

  • (AR) Argentina: Cistadine | Clobinea | Clofazic | Cloficris | Clolar | Luvuden;
  • (AT) Austria: Evoltra;
  • (BE) Belgium: Evoltra;
  • (BG) Bulgaria: Clofarabin alvogen | Evoltra;
  • (CL) Chile: Clofazic;
  • (CO) Colombia: Clofazic | Cloficris | Clolar | Farabine | Hb clovotabin | Metisa | Reluka;
  • (CZ) Czech Republic: Evoltra;
  • (DE) Germany: Clofarabin aqvida | Clofarabin ratiopharm | Clofarabin tillomed | Clofarabine tillomed;
  • (EC) Ecuador: Clofazic;
  • (EE) Estonia: Clofarabin tillomed;
  • (EG) Egypt: Evoltra;
  • (ES) Spain: Clofarabina accord | Clofarabina aristo | Clofarabina teva | Clofarabina tillom | Evoltra;
  • (FI) Finland: Clofarabine avans | Evoltra;
  • (FR) France: Clofarabine mylan | Clofarabine tillomed | Evoltra | Ivozall;
  • (GR) Greece: Evoltra;
  • (HK) Hong Kong: Evoltra;
  • (HU) Hungary: Clofarabine accord | Clofarabine vivanta | Evoltra;
  • (IE) Ireland: Evoltra;
  • (IN) India: Farabine;
  • (IT) Italy: Clofarabina teva | Clofarabina Tillomed | Evoltra;
  • (JO) Jordan: Evoltra;
  • (JP) Japan: Evoltra;
  • (KR) Korea, Republic of: Evoltra;
  • (LB) Lebanon: Evoltra;
  • (LT) Lithuania: Ivozall;
  • (LV) Latvia: Evoltra;
  • (MX) Mexico: Clofazic | Clolar;
  • (MY) Malaysia: Evoltra | Nuclofar;
  • (NL) Netherlands: Clofarabine accord | Clofarabine mylan;
  • (NZ) New Zealand: Evoltra;
  • (PE) Peru: Clofazic;
  • (PL) Poland: Clofarabine norame | Evoltra;
  • (PR) Puerto Rico: Clolar;
  • (PT) Portugal: Evoltra;
  • (PY) Paraguay: Clofarabina lkm;
  • (RO) Romania: Evoltra;
  • (RU) Russian Federation: Evoltra;
  • (SE) Sweden: Clofarabine avans | Evoltra;
  • (SG) Singapore: Evoltra;
  • (SI) Slovenia: Evoltra | Klofarabin makpharm;
  • (SK) Slovakia: Evoltra;
  • (TH) Thailand: Evoltra;
  • (TR) Turkey: Evoltu | Evorabin;
  • (TW) Taiwan: Evoltra
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