FLUDARABINE

Posology The recommended dose is 25 mg fludarabine phosphate/m² body surface area given daily for 5 consecutive days every 28 days by intravenous route. Each vial is to be made up in 2 ml water for injection. 6). The required dose (calculated on the basis of the patient's body surface area) of the reconstituted solution is drawn up into a syringe.

9%). 9%) and infused over approximately 30 minutes. The duration of treatment depends on the treatment success and the tolerability of the drug. In CLL patients, Fludarabine should be administered up to the achievement of best response (complete or partial remission, usually 6 cycles) and then the drug should be discontinued.

Patients with renal impairment Doses should be adjusted for patients with reduced kidney function. 4). 3). Patients with hepatic impairment No data are available concerning the use of Fludarabine in patients with hepatic impairment. In this group of patients, Fludarabine should be used with caution.

Paediatric population The safety and efficacy of Fludarabine in children below the age of 18 years have not been established. Therefore, Fludarabine is not recommended for use in children. Older people Since there are limited data for the use of Fludarabine in older people (> 75 years), caution should be exercised with the administration of Fludarabine in these patients.

4). Method of administration Fludarabine should be administered under the supervision of a qualified physician experienced in the use of antineoplastic therapy. It is strongly recommended that Fludarabine should be only administered intravenously.

No cases have been reported in which paravenously administered Fludarabine led to severe local adverse reactions. However, unintentional paravenous administration must be avoided. 6.

Summary of safety profile Based on the experience with the use of Fludarabine, the most common adverse events include myelosuppression (neutropenia, thrombocytopenia and anaemia), infection including pneumonia, cough, fever, fatigue, weakness, nausea, vomiting and diarrhoea.

Other commonly reported events include chills, oedema, malaise, peripheral neuropathy, visual disturbance, anorexia, mucositis, stomatitis and skin rash. Serious opportunistic infections have occurred in patients treated with Fludarabine.

Fatalities as a consequence of serious adverse events have been reported. Tabulated list of adverse reactions The table below reports adverse events by MedDRA system organ classes (MedDRA SOCs). The frequencies are based on clinical trial data regardless of the causal relationship with Fludarabine.

The rare adverse reactions were mainly identified from the post-marketing experience. g. progressive multifocal leucoencephalo pathy, Herpes zoster virus, Epstein-Barr- virus), Pneumonia Lympho- proliferative disorder (EBV- associated) Neoplasms benign, malignant and unspecified (incl cysts and polyps) Myelodysplastic syndrome and acute myeloid leukaemia (mainly associated with prior, conco- mitant or sub- sequent treatment with alkylating agents, topo- isomerase inhibitors or irradiation) Blood and lymphatic system disorders Neutropenia, anaemia, thrombocyto- penia Myelo- suppression System Organ Class MedDRA Very Common ≥1/10 Common ≥ 1/100 to <1/10 Uncommon ≥ 1/1000 to <1/100 Rare ≥1/10,000 to <1/1000 Immune system disorders Autoimmune disorder (including autoimmune haemolytic anaemia, Evans syndrome, thrombocyto- penic purpura, acquired haemophilia, pemphigus) Metabolism and nutrition disorders Anorexia Tumour lysis syndrome (including renal failure, metabolic acidosis, hyperkalaemia hypocalcemia, hyperuricemia, haematuria, urate crystalluria, hyper- phosphatemia) Nervous system disorders Neuropathy peripheral Confusion Coma, seizures, agitation Eye disorders Visual disturbance Blindness, optic neuritis, optic neuropathy Cardiac disorders Heart failure, arrhythmia Respiratory, thoracic and mediastinal disorders Cough Pulmonary toxicity (including pulmonary fibrosis, pneumonitis, dyspnoea) System Organ Class MedDRA Very Common ≥1/10 Common ≥ 1/100 to <1/10 Uncommon ≥ 1/1000 to <1/100 Rare ≥1/10,000 to <1/1000 Gastro- intestinal disorders Vomiting, diarrhoea, nausea Stomatitis Gastro- intestinal haemorrhage, pancreatic enzymes abnormal Hepatobiliary disorders Hepatic enzyme abnormal Skin and subcutaneous tissue disorders Rash Skin cancer, necrolysis epidermal toxic (Lyell type) , Stevens-Johnson syndrome General disorders and administration site conditions Fever, fatigue, weakness Oedema, mucositis, chills, malaise The most appropriate MedDRA term to describe a certain adverse event is listed.

Synonyms or related conditions are not listed, but should be taken into account as well. 0. Within each frequency grouping, undesirable effects are presented in order of decreasing seriousness. 4) • Respiratory, thoracic and mediastinal disorders - Pulmonary haemorrhage • Renal and urinary disorder - Haemorrhagic cystitis Reporting of suspected adverse reactions Reporting suspected adverse reactions after authorisation of the medicinal product is important.

It allows continued monitoring of the benefit/risk balance of the medicinal product. uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

Myelosuppression Severe bone marrow suppression, notably anaemia, thrombocytopenia and neutropenia, has been reported in patients treated with Fludarabine. In a Phase I intravenous study in adult solid tumour patients, the median time to nadir counts was 13 days (range, 3-25 days) for granulocytes and 16 days (range, 2-32 days) for platelets.

Most patients had haematological impairment at baseline either as a result of disease or as a result of prior myelosuppressive therapy. Cumulative myelosuppression may be seen. While chemotherapy-induced myelosuppression is often reversible, administration of fludarabine phosphate requires careful haematological monitoring.

Fludarabine phosphate is a potent antineoplastic agent with potentially significant toxic side effects. Patients undergoing therapy should be closely observed for signs of haematologic and non-haematologic toxicity. Periodic assessment of peripheral blood counts is recommended to detect the development of anaemia, neutropenia and thrombocytopenia.

Several instances of trilineage bone marrow hypoplasia or aplasia resulting in pancytopenia, sometimes resulting in death, have been reported in adult patients. The duration of clinically significant cytopenia in the reported cases has ranged from approximately 2 months to approximately 1 year.

These episodes have occurred both in previously treated or untreated patients. As with other cytotoxics, caution should be exercised with fludarabine phosphate, when further haematopoietic stem cell sampling is considered. 8) have been reported to occur during or after treatment with Fludarabine .

The majority of patients experiencing haemolytic anaemia developed a recurrence in the haemolytic process after rechallenge with Fludarabine . Patients treated with Fludarabine should be closely monitored for signs of haemolysis. Discontinuation of therapy with Fludarabine is recommended in case of haemolysis.

Blood transfusion (irradiated, see below) and adrenocorticoid preparations are the most common treatment measures for autoimmune haemolytic anaemia. Neurotoxicity The effect of chronic administration of Fludarabine on the central nervous system is unknown.

However, patients tolerated the recommended dose in some studies for relatively long term treatment times (for up to 26 courses of therapy). Patients should be closely observed for signs of neurologic effects. When used at high doses in dose-ranging studies in patients with acute leukaemia, intravenous Fludarabine was associated with severe neurological effects, including blindness, coma and death.

Symptoms appeared from 21 to 60 days from last dose. This severe central nervous system toxicity occurred in 36 % of patients treated intravenously with doses approximately four times greater (96 mg/m²/day for 5 7 days) than the recommended dose.

8). In post-marketing experience neurotoxicity has been reported to occur earlier or later than in clinical trials. Administration of Fludarabine can be associated with leukoencephalopathy (LE), acute toxic leukoencephalopathy (ATL) or reversible posterior leukoencephalopathy syndrome (RPLS).

These may occur: • at the recommended dose • when Fludarabine is given following, or in combination with, medications known to be associated with LE, ATL or RPLS, • or when Fludarabine is given in patients with other risk factors such as cranial or total body irradiation, Hematopoietic Cell Transplantation, Graft versus Host Disease, renal impairment, or hepatic encephalopathy.

• at doses higher than the recommended dose LE, ATL or RPLS symptoms may include headache, nausea and vomiting, seizures, visual disturbances such as vision loss, altered sensorium, and focal neurological deficits. Additional effects may include optic neuritis, and papillitis, confusion, somnolence, agitation, paraparesis/ quadriparesis, muscle spasticity and incontinence.

LE/ ATL/ RPLS may be irreversible, life-threatening, or fatal. Whenever LE, ATL or RPLS is suspected, fludarabine treatment should be stopped. Patients should be monitored and should undergo brain imaging, preferably utilizing MRI. If the diagnosis is confirmed, fludarabine therapy should be permanently discontinued.

Tumour lysis syndrome Tumour lysis syndrome has been reported in CLL patients with large tumour burdens. Since Fludarabine can induce a response as early as the first week of treatment, precautions should be taken in those patients at risk of developing this complication, and hospitalisation may be recommended for these patients during the first course of treatment.

Transfusion-associated graft-versus-host disease Transfusion-associated graft-versus-host disease (reaction by the transfused immunocompetent lymphocytes to the host) has been observed after transfusion of non-irradiated blood in patients treated with Fludarabine.

Fatal outcome as a consequence of this disease has been reported with a high frequency. Therefore, to minimize the risk of transfusion-associated graft-versus-host disease, patients who require blood transfusion and who are undergoing, or who have received treatment with Fludarabine should receive irradiated blood only.

Skin cancer The worsening or flare up of pre-existing skin cancer lesions as well as new onset of skin cancer have been reported in some patients to occur during or after Fludarabine therapy. Impaired state of health In patients with impaired state of health, Fludarabine should be given with caution and after careful risk/benefit consideration.

This applies especially for patients with severe impairment of bone marrow […]

1. - Renal impairment with creatinine clearance < 30 ml/min. - Decompensated haemolytic anaemia. - Lactation.