Clofarabine (Evoltra)

Clofarabine is a new chemotherapy drug. It is pronounced clo-fara-been. It is also called Evoltra.

Clofarabine is a treatment for children and young people between the ages of 1 and 21 years with acute lymphoblastic leukaemia. It is only licensed for people whose leukaemia has come back after at least two other treatments.

Researchers are also looking at it as a treatment for older people with acute myeloid leukaemia who can’t have high dose treatment with a stem cell transplant. And for people with myelodysplastic syndrome.

Clofarabine is a type of chemotherapy drug known as an anti metabolite. Anti metabolites stop cells making DNA, which is the genetic material of the cell. Cancer cells need to make and repair DNA so that they can grow and multiply.

You have clofarabine into your bloodstream (intravenously). You can have it through a thin, short tube (a cannula) put into a vein in your arm each time you have treatment. Or you may have it through a central line, a portacath or a PICC line. These are long, plastic tubes that give the drugs directly into a large vein in your chest. You have the tube put in just before your course of treatment starts and it stays in place as long as you need it.

You usually have chemotherapy as a course of several cycles of treatment. There is detailed information about the way doctors plan chemotherapy in the planning chemotherapy section. How many cycles of treatment you have depends on your treatment plan and how well the treatment works.

You have clofarabine as a drip for 2 hours each day for 5 days. You also have extra fluids through the drip to help stop the build up of uric acid. Uric acid can build up in the body when cancer cells are broken down. After the 5 days of treatment you have a break from treatment of 2 to 6 weeks. This makes up a treatment cycle. Once your level of blood cells goes back to normal you have the next cycle of treatment.

The side effects associated with clofarabine are listed below. You can use the links to find out more about each effect. For general information, see our cancer drug side effects section.

More than 10 in every 100 people have one or more of the side effects listed below.

Temporary drop in the number of blood cells made by the bone marrow, causing

• Increased risk of getting an infection from a drop in white blood cells – it is harder to fight infections and you can become very ill. You may have headaches, aching muscles, a cough, sore throat, pain passing urine or feel cold and shivery
• Tiredness and breathlessness due to a drop in red blood cells (anaemia) – you may need a blood transfusion
• Bruising more easily due to a drop in platelets – you may have nosebleeds, bleeding gums after brushing your teeth, or lots of tiny red spots or bruises on your arms or legs (known as petechia)

Some of these side effects can be life threatening, particularly infections. You should contact your doctor if you have any of these effects. Your doctor will check your blood counts regularly to see how well your bone marrow is working.

Other common side effects include

• Feeling or being sick in about 6 out of 10 people (60%) but this is usually well controlled with anti sickness drugs
• Headaches in about 1 out of 4 people (25%)
• Skin changes in 1 out of 5 people (20%) – the changes may include a rash, redness, itching and dryness
• A high temperature in 1 out of 5 people (20%)
• Diarrhoea in about 2 out of 10 people – drink plenty of fluid and tell your doctor if diarrhoea becomes severe, or continues for more than 3 days
• Some people develop soreness, redness and peeling on the palms of the hands and soles of the feet (plantar palmar syndrome), which may cause tingling, numbness, pain and dryness
• Tiredness (fatigue) and feeling weak during and after treatment – most people find their energy levels are back to normal within 6 months to a year
• Mood changes – you may feel anxious and restless
• Flushing
• A sore mouth
• Loss of appetite
• Liver changes that are unlikely to cause symptoms – the liver will almost certainly go back to normal when treatment is finished, but you will have regular blood tests to check how well your liver is working
• Heart changes which can cause changes to your blood pressure, a faster heart beat, and a build up of fluid around the heart – your doctor will check your heart before and after your treatment
• High uric acid levels in your blood due to cancer cells being broken down by the body – you will have regular blood tests and will be asked to drink plenty of fluids. Your doctors may also give you a drug called allopurinol
• This drug may have a harmful effect on a developing baby – do talk to your doctor about contraception before having treatment if there is any chance that you or your partner could become pregnant
• Loss of fertility – we don’t know exactly how this drug affects fertility so do talk with your doctor before starting treatment if having a baby is important to you

Between 1 and 10 in every 100 people have one or more of these.

• Kidney changes that are unlikely to cause symptoms – the kidneys will almost certainly go back to normal when treatment is finished, but you will have regular blood tests to check how well your kidneys are working
• Pain in your joints, muscles, bone, neck, back and stomach
• You may have some hearing loss
• Swelling of your ankles and legs due to a build up of fluid (oedema)
• Some people have an allergic reaction while having clofarabine treatment, usually during the first or second treatment – let your treatment team know immediately if you feel hot or have any skin rashes, itching, dizziness, headaches, shivering, breathlessness, anxiety, flushing of the face, or a sudden need to pass urine
• Capillary leak syndrome – a condition where fluid leaks out of the small blood vessels, causing low blood pressure and a build up of fluid. It can become a serious problem. The first symptoms are usually similar to a head cold. Tell your doctor immediately if you feel faint, sick, and have swollen ankles or legs

A very small number of people having clofaribine have developed Stevens Johnson syndrome, which is a painful inflammation of the eyes, eyelids and skin. It is not clear whether the Stevens Johnson syndrome is due to the drug.

You won’t get all these side effects. A side effect may get worse through your course of treatment. Or you may have more side effects as the course goes on. This depends on

• How many times you've had a drug before
• Your general health
• How much of the drug you have (the dose)
• Other drugs you are having

Talk to your doctor, pharmacist or nurse about all your side effects so they can help you manage them.

Tell your doctor about any other medicines you are taking, including vitamins, herbal supplements, and other over the counter remedies – some drugs can react together.

Clofarabine is a relatively new drug in cancer treatment. This means that the information about side effects is based on only a few trials. And there is no information available at the moment about possible longer term effects that it may cause. Tell your doctor if you notice anything that is not normal for you.

You should not have immunisations with live vaccines while you are having chemotherapy or for at least 6 months afterwards. In the UK, these include rubella, mumps, measles (usually given together as MMR), BCG and yellow fever. You can have other vaccines, but they may not give you as much protection as usual until your immune system has fully recovered from your chemotherapy.

It is safe for you to be in contact with other people who've had live vaccines as injections. There can be problems with oral vaccines, but not many people in the UK have oral vaccines now. So there is usually no problem in being with any baby or child who has recently had any vaccination in the UK. You might need to make sure that you aren't in contact with anyone who has had oral polio, cholera or typhoid vaccination recently, particularly if you live abroad.