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Fludara Side Effects

Generic Name: fludarabine

Note: This document contains side effect information about fludarabine. Some of the dosage forms listed on this page may not apply to the brand name Fludara.

In Summary

Common side effects of Fludara include: central nervous system toxicity, angina pectoris, infection, pneumonia, upper respiratory tract infection, urinary tract infection, asthenia, cough, diarrhea, dyspnea, edema, fatigue, fever, gastrointestinal hemorrhage, myalgia, nausea, pain, paresthesia, skin rash, visual disturbance, vomiting, anorexia, chills, and diaphoresis. Other side effects include: pneumonitis, dysuria, hearing loss, hemoptysis, hyperglycemia, pharyngitis, sinusitis, stomatitis, and malaise. See below for a comprehensive list of adverse effects.

For the Consumer

Applies to fludarabine: oral tablet

Other dosage forms:

Along with its needed effects, fludarabine (the active ingredient contained in Fludara) may cause some unwanted effects. Although not all of these side effects may occur, if they do occur they may need medical attention.

Check with your doctor immediately if any of the following side effects occur while taking fludarabine:

More Common

  • Bloating or swelling of the face, arms, hands, lower legs, or feet
  • body aches or pain
  • burning or stinging of the skin
  • chest pain
  • cough or hoarseness
  • cough producing mucus
  • diarrhea
  • difficult or labored breathing
  • difficulty in breathing
  • ear congestion
  • fever or chills
  • general feeling of discomfort or illness
  • headache
  • joint pain
  • loss of appetite
  • loss of voice
  • lower back or side pain
  • muscle aches and pains
  • nasal congestion
  • nausea
  • painful cold sores or blisters on the lips, nose, eyes, or genitals
  • painful or difficult urination
  • rapid weight gain
  • runny nose
  • shivering
  • shortness of breath
  • sneezing
  • sore throat
  • stuffy nose
  • sweating
  • tightness in the chest
  • tingling of hands or feet
  • trouble sleeping
  • troubled breathing
  • unusual tiredness or weakness
  • unusual weight gain or loss
  • vomiting
  • wheezing

Less Common

  • Bladder pain
  • bloody or cloudy urine
  • difficult, burning, or painful urination
  • frequent urge to urinate
  • pain or tenderness around the eyes and cheekbones

Incidence Not Known

  • Back pain
  • bloody, black, or tarry stools
  • blue lips, fingernails, or skin
  • blurred vision
  • confusion
  • convulsions
  • coughing up blood
  • difficult or fast breathing
  • dizziness
  • drowsiness
  • high fever
  • irregular, fast or slow, or shallow breathing
  • pale skin
  • sores, ulcers, or white spots on the lips or in the mouth
  • swollen glands
  • unexplained bleeding or bruising
  • unusual bleeding or bruising

Some side effects of fludarabine may occur that usually do not need medical attention. These side effects may go away during treatment as your body adjusts to the medicine. Also, your health care professional may be able to tell you about ways to prevent or reduce some of these side effects. Check with your health care professional if any of the following side effects continue or are bothersome or if you have any questions about them:

More Common

Less Common

  • Rash

For Healthcare Professionals

Applies to fludarabine: intravenous powder for injection, intravenous solution, oral tablet


In general, the most common dose-limiting toxicities have been myelosuppression (60%), fever and chills (11% to 60%, sometimes without infection), infection (33%, including serious opportunistic infections), and nausea and vomiting (36%).

General side effects including pain (up to 19%), flu syndrome (up to 8%), and decreased weight (up to 6%) have been reported.[Ref]


Hematologic toxicity has been reported to have occurred in the majority of patients. It presents as either neutropenia, thrombocytopenia, anemia, or a combination. Fifty-nine percent of patients develop an absolute neutrophil count of less than 500/mm3, 60% develop a hemoglobin concentration decrease by at least 2 g percent, and 55% develop a platelet count decrease by 50%. Several instances of trilineage bone marrow hypoplasia or aplasia resulting in sometimes fatal pancytopenia have been reported. Rarely, bone marrow fibrosis or clinically significant hemolytic anemia have been associated with the use of fludarabine (the active ingredient contained in Fludara) A single case of pure red cell aplasia has been reported.[Ref]

Myelosuppression may be severe, cumulative, and may affect multiple cell lines.[Ref]


Instances of life-threatening and sometimes fatal autoimmune hemolytic anemia have been reported after one or more cycles of treatment in patients with or without a previous history of autoimmune hemolytic anemia or a positive Coombs test and who may or may not be in remission for their disease. Steroids may be effective in controlling these hemolytic episodes. The majority of affected patients developed a recurrence upon rechallenge.

An increased incidence of infections with pathogens not commonly associated with chronic lymphocytic leukemia have been associated with the use of fludarabine (the active ingredient contained in Fludara) especially when given with corticosteroids. These have included Listeria, Pneumocystis carinii pneumonia, disseminated varicella-zoster, cytomegalovirus, and unusual fungal pathogens. Fludarabine can significantly decrease the quantity of T-helper cells.[Ref]

Immunologic side effects have been reported secondary to neutropenia which predisposes patients to infection. Pneumonia has been reported in 16% to 22% of treated patients from major clinical trials. Other, less common, infections include minor bacterial and/or fungal infections of the oropharynx, upper respiratory tract, urinary tract, and soft tissue, as well as herpes zoster infections. The risk of sepsis or life-threatening infection appears greatest during the first three courses of chemotherapy with fludarabine in patients with extensive disease.[Ref]


Gastrointestinal side effects including nausea, vomiting, and/or diarrhea have been reported in up to 36% of patients. Anorexia, stomatitis, esophagitis, mucositis, constipation, taste disturbances, abdominal pain, and gastrointestinal bleeding have been reported in less than 30% of patients.[Ref]

Nervous system

Central and peripheral nervous system toxicities have been reported, including weakness/fatigue (asthenia) (up to 31%), headache (up to 9%), hearing disturbances (6%), paresthesias (4%), confusion (1%), visual disturbances (3%), and coma (less than 1%). In postmarketing experience, cases of progressive multifocal leukoencephalopathy have been reported. Rare cases of disabling, severe, but reversible neurologic toxicity have been reported.[Ref]

Most cases of progressive multifocal leukoencephalopathy had a fatal outcome. Many of these cases were confounded by prior and/or concurrent chemotherapy. The time to onset has ranged from a few weeks to approximately one year after initiating treatment.

The early trials of fludarabine given at high doses in the treatment of acute leukemia (up to 125 mg/m2 per day for up to 7 days) revealed evidence of severe CNS toxicity. Progressive optic neuritis, cortical blindness, seizures, and paralysis developed in some patients up to 2 months after therapy ended. Use of lower doses for low-grade lymphoid malignancy has not generally been associated with these severe side effects. However, progressive headaches, paresthesias, hemiparesis, and progressive and fatal neurologic dysfunction have rarely been associated with recommended doses.[Ref]


Respiratory side effects have been reported including severe cases of pulmonary toxicity which resulted in adult respiratory distress syndrome, respiratory distress, pulmonary hemorrhage, pulmonary fibrosis, respiratory failure, and death. Cough (10% to 44%), upper respiratory tract infection or pneumonia (up to 22%), dyspnea (1% to 22%), rhinitis (up to 11%), increased cough (up to 6%), bronchitis (up to 5%), and sinusitis (up to 5%) have also been reported. Diffuse interstitial pneumonitis has been reported rarely.[Ref]

Rare cases of diffuse alveolar damage have been associated with tumor lysis syndrome and the use of fludarabine.

In a clinical investigation using fludarabine injection in combination with pentostatin for the treatment of refractory chronic lymphocytic leukemia in adults, there was an unacceptably high incidence of fatal pulmonary toxicity.[Ref]


Cardiovascular side effects including peripheral edema (8%) and chest pain (up to 5%) have been reported. A single case of pericardial effusion has been associated with the use of fludarabine (the active ingredient contained in Fludara) [Ref]


Genitourinary side effects including dysuria, hematuria, or proteinuria have been reported in 1% to 4% of patients. Rare cases of hemorrhagic cystitis have also been reported.[Ref]


A single case of acute renal failure secondary to mesangiocapillary glomerulonephritis has been associated with the use of fludarabine (the active ingredient contained in Fludara) in a 60-year-old man who had refractory chronic lymphocytic leukemia (CLL). This lesion has rarely been associated with CLL itself.[Ref]

Renal side effects including hemolytic uremic syndrome and acute renal failure have rarely been associated with the use of fludarabine.[Ref]


Hypersensitivity reactions--usually skin rashes-- to fludarabine (the active ingredient contained in Fludara) are relatively rare. Corticosteroid-responsive acute interstitial pulmonary infiltrates have been reported. Extremely rare cases of anaphylaxis have been reported.[Ref]


TLS may result in serious metabolic problems, including hyperuricemia, hyperphosphatemia, hypocalcemia, metabolic acidosis, hyperkalemia, hematuria, urate crystalluria, renal failure, and even death. (Allopurinol before and during therapy is recommended.) The onset of this syndrome may be heralded by flank pain and hematuria.[Ref]

Metabolic side effects including tumor lysis syndrome (TLS) has been reported to have occurred in approximately 1% of patients. A single case of diffuse alveolar damage has been associated with TLS and the use of fludarabine.[Ref]


Most dermatologic problems are related to allergic reactions to fludarabine (the active ingredient contained in Fludara) [Ref]

Dermatologic side effects including increased sweating (up to 14%), diaphoresis (up to 8%), skin disorder (up to 6%), and rash (up to 5%) have been reported. Alopecia has been reported only rarely.[Ref]


Oncologic side effects have been reported in animal studies. Fludarabine phosphate was clastogenic in vitro to Chinese hamster ovary cells (chromosome aberrations in the presence of metabolic activation and induce sister chromatid exchanges both with and without metabolic activation). In addition, fludarabine (the active ingredient contained in Fludara) phosphate was clastogenic in vivo (mouse micronucleus assay).[Ref]


Hepatic side effects including increased lactic dehydrogenase (up to 6%) have been reported.


Musculoskeletal side effects including back pain (up to 9%) have been reported.


1. Ross SR, McTavish D, Faulds D "Fludarabine. A review of its pharmacological properties and therapeutic potential in malignancy." Drugs 45 (1993): 737-59

2. Keating MJ, Estey E, O'Brien S, Kantarjian H, Robertson LE, Plunkett W "Clinical experience with fludarabine in leukaemia." Drugs 47 Suppl 6 (1994): 39-49

3. Feldman EJ, Keating MJ "Fludarabine in the treatment of lymphoproliferative malignancies." Cancer Invest 11 (1993): 314-8

4. "Product Information. Fludara (fludarabine)." Berlex, Richmond, CA.

5. Schilling PJ, Vadhan-Raj S "Concurrent cytomegalovirus and pneumocystis pneumonia after fludarabine therapy for chronic lymphocytic leukemia." N Engl J Med 323 (1990): 833-4

6. Maclean R, Meiklejohn D, Soutar R "Fludarabine-related autoimmune haemolytic anaemia in patients with chronic lymphocytic leukaemia." Br J Haematol 92 (1996): 768-9

7. Kavanagh JJ, Krakoff IH, Bodey GP "Phase I study of fludarabine (2-fluoro-ara-AMP)." Eur J Cancer Clin Oncol 21 (1985): 1009-11

8. Hocepied AMLJ, Falkson CI, Falkson G "A phase II trial of fludarabine in patients with previously treated chronic lymphocytic leukaemia." S Afr Med J 86 (1996): 549-50

9. Sanders C, Perez EA, Lawrence HJ "Opportunistic infections in patients with chronic lymphocytic leukemia following treatment with fludarabine." Am J Hematol 39 (1992): 314-5

10. Leenders A, Sonneveld P, de Marie S "Cryptococcal meningitis following fludarabine treatment for chronic lymphocytic leukemia." Eur J Clin Microbiol Infect Dis 14 (1995): 826-8

11. Cohn J, Fraifeld M, Desai A, Zaeri N "Hemolytic uremic syndrome (HUS) and severe pulmonary toxicity associated with fludarabine treatment for non-Hodgkin's lymphoma (NHL) (Meeting abstract)." Proc Annu Meet Am Soc Clin Oncol 13 (1994): a13161994

12. Bastion Y, Coiffier B, Tigaud JD, Espinouse D, Bryon PA "Pneumocystis pneumonia in a patient treated with fludarabine for chronic lymphocytic leukemia." Eur J Cancer 27 (1991): 671

13. Girmenia C, Mauro FR, Rahimi S "Late listeriosis after fludarabine plus prednisone treatment." Br J Haematol 87 (1994): 407-8

14. Zinzani PL, Tabanelli M, Bendandi M, Tura S "Prolonged bone marrow aplasia of refractory prolymphocytoid variant of B-cell chronic lymphocytic leukemia related to fludarabine treatment." Eur J Haematol 53 (1994): 56-8

15. Leporrier M, Reman O, Troussard X "Pure red-cell aplasia with fludarabine for chronic lymphocytic leukaemia." Lancet 342 (1993): 555

16. Woodcock BE "Cytopenia and fludarabine." Lancet 342 (1993): 1049

17. Chim CS, Liang R, Wong SSY, Yuen KY "Cryptococcal infection associated with fludarabine therapy." Am J Med 108 (2000): 523-4

18. Anaissie EJ, Kontoyiannis DP, O'Brien S, et al. "Infections in patients with chronic lymphocytic leukemia treated with fludarabine." Ann Intern Med 129 (1998): 559-66

19. Zabernigg A, Maier H, Thaler J, Gattringer C "Late-onset fatal neurological toxicity of fludarabine." Lancet 344 (1994): 1780

20. Merkel DE, Griffin NL, Kagan-Hallet K, Von Hoff DD "Central nervous system toxicity with fludarabine." Cancer Treat Rep 70 (1986): 1449-50

21. Johnson PW, Fearnley J, Domizio P, Goldin J, Nagendran K, Gawler J, Rohatiner AZ, Lister TA "Neurological illness following treatment with fludarabine." Br J Cancer 70 (1994): 966-8

22. Cohen RB, Abdallah JM, Gray JR, Foss F "Reversible neurologic toxicity in patients treated with standard-dose fludarabine phosphate for mycosis fungoides and chronic lymphocytic leukemia." Ann Intern Med 118 (1993): 114-6

23. Cervantes F, Salgado C, Montserrat E, Rozman C "Fludarabine for prolymphocytic leukaemia and risk of interstitial pneumonitis." Lancet 336 (1990): 1130

24. Kane GC, McMichael AJ, Patrick H, Erslev AJ "Pulmonary toxicity and acute respiratory failure associated with fludarabine monophosphate." Respir Med 86 (1992): 261-3

25. Crowley JJ, Knight L, Charan N "Lysis pneumonopathy associated with the use of fludarabine phosphate." West J Med 161 (1994): 597-9

26. Hurst PG, Habib MP, Garewal H, Bluestein M, Paquin M, Greenberg BR "Pulmonary toxicity associated with fludarabine monophosphate." Invest New Drugs 5 (1987): 207-10

27. "Multum Information Services, Inc. Expert Review Panel"

28. Nunes R, Passos-Coelho JL, Miranda N, Nave M, Leal Da Costa F, Abecasis M "Reversible acute renal failure following single administration of fludarabine." Bone Marrow Transplant (2004):

29. Montillo M, Tedeschi A, Leoni P "Acute renal failure as a consequence of urine stop flow in a patient with chronic lymphocytic leukemia after treatment with fludarabine." Am J Hematol 50 (1995): 73-4

30. Macheta MP, Parapia LA, Gouldesbrough DR "Renal failure in a patient with chronic lymphocytic leukaemia treated with fludarabine." J Clin Pathol 48 (1995): 181-2

31. List AF, Kummet TD, Adams JD, Chun HG "Tumor lysis syndrome complicating treatment of chronic lymphocytic leukemia with fludarabine phosphate." Am J Med 89 (1990): 388-90

32. Nakhoul F, Green J, Abassi ZA, Carter A "Tumor lysis syndrome induced by fludarabine monophosphate: a case report." Eur J Haematol 56 (1996): 254-5

33. Montalban C, Liano F, Aguilera A "Tumour lysis syndrome after treatment of chronic lymphocytic leukaemia with fludarabine." Postgrad Med J 70 (1994): 651-2

34. Frame JN, Dahut WL, Crowley S "Fludarabine and acute tumor lysis in chronic lymphocytic leukemia." N Engl J Med 327 (1992): 1396-7

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.

Some side effects may not be reported. You may report them to the FDA.