FMD

FMD is the name of a combination of chemotherapy drugs used to treat non Hodgkin’s lymphoma. It is made up of the drugs

• F = Fludarabine
• M = Mitoxantrone
• D = Dexamethasone, which is a steroid

Mitoxantrone is a blue liquid and fludarabine is a clear liquid. Fludarabine also comes as a 10mg pink tablet. You have fludarabine through your drip and as tablets as part of FMD treatment. You take the dexamethasone as white tablets. Your doctor will tell you the dose you need to take.

You have mitoxantrone and some of the doses of fludarabine into your bloodstream (intravenously). You can have them through a thin, short tube (a cannula) put into a vein in your arm each time you have treatment. Or you may have them 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 FMD chemotherapy as cycles of treatment. Depending on your needs, you may have up to 6 cycles. Each cycle of treatment lasts 4 weeks.

You have each cycle in the following way

• On the first day you have fludarabine and mitoxantrone either as an injection into your cannula or central line, or as a drip (infusion). You also start taking the dexamethasone tablets
• On the second and third day you have fludarabine as an injection or tablets and continue taking the dexamethasone
• You take dexamethasone tablets on the fourth and fifth day

Then you have no treatment for just over 3 weeks. This completes one cycle. You then start your next cycle.

The side effects of a combination of drugs are usually a mixture of those of each drug. The combination may increase or decrease your chance of getting each side effect or it may change the severity. The side effects associated with FMD are listed below. You can use the underlined links to find out more about each one. For general information, see our side effects of cancer drugs 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 happens in 4 out of 10 people (40%) – 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. You will have regular blood tests to see how well your bone marrow is working.

Other common side effects include

• Fatigue that may continue after treatment has finished – most people find their energy levels are back to normal within 6 months to a year
• A high temperature in up to 6 out of 10 people (60%)
• Feeling or being sick is usually well controlled with anti sickness drugs
• Fludarabine may cause changes in your immune system that permanently affect the production of blood cells – these include autoimmune haemolytic anaemia, thrombocytopenia and thrombocytopenic purpura
• Urine may become a blue-green colour for one or two days after treatment – this is normal and nothing to worry about
• Changes to your blood sugar levels due to steroids – you will have regular blood tests and may also need to check your urine for sugar
• These drugs may have a harmful effect on a developing baby – do talk to your doctor or nurse about contraception before having treatment if there is any chance that you or your partner could become pregnant

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

• Diarrhoea – drink plenty of fluid and tell your doctor or nurse if it becomes severe or continues for more than 3 days
• Mouth sores and ulcers
• Hair thinning
• Liver changes that are very mild and 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 it is working
• Loss of fertility – you may not be able to get pregnant or father a child after treatment with this drug. It is important to talk to your doctor before starting treatment if having a baby is important to you
• Women may stop having periods (amenorrhoea) but this may only be temporary

Fewer than 1 in 100 people have these.

• In a very small number of people who have mitoxantrone, the whites of their eyes have a slight blue tint, but this is temporary
• Numbness or tingling in your hands or feet – it usually improves a few months after the treatment ends
• Effects on the brain and spinal cord causing eyesight problems, drowsiness, agitation, fits (seizures) or confusion – tell your doctor or nurse if you have any of these effects
• A cough or difficulty breathing
• A skin rash
• 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 to flush out the uric acid. Your doctors may also give you a drug called allopurinol
• There is a small risk that you may get a second cancer some years after FMD treatment

You will not get all of these side effects. Any that you have may be mild. 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)
• The way you take the drug (tablets or drip)
• Other drugs you are having

Talk to your doctor, pharmacist or nurse about all your side effects so they can help you manage them. Your nurse will give you a contact number. You can ring them if you have any questions or problems. They can give you advice or reassure you. If in doubt, call 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.

You should not have immunisations with live vaccines while you are having this treatment 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.

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.