Version July 2025
Dosage guidance:
Safety: 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).
Dosing: Calculate BSA prior to each cycle, utilizing actual body weight.
Clinical considerations: Clofarabine is associated with a moderate emetic potential; antiemetics are recommended to prevent nausea and vomiting (Ref).
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 (Ref).
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) (Ref).
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 (Ref).
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 (Ref).
Consolidation: IV: 20 mg/m2/day for 5 days (in combination with cytarabine and filgrastim) for 1 or 2 cycles (Ref).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
Clofarabine undergoes renal elimination and exposure is increased as creatinine clearance decreases (Ref). 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 (Ref).
Dialysis: There are no dosage adjustments provided in the manufacturer's labeling. Use is not recommended (Ref).
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.
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 (Ref).
Severe impairment: Use is not recommended (Ref).
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.
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 (Ref).
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 (Ref).
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 (Ref).
(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 (Ref).
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 (Ref)
BSA-directed dosing: 40 mg/m2/day for 5 days in combination with cyclophosphamide and etoposide (Ref); and with topotecan, vinorelbine, thiotepa (TVTC regimen), and dexamethasone in a Phase I trial (Ref)
Children and Adolescents: Usual dose: 40 mg/m2/day for 5 days in combination with cyclophosphamide and etoposide has been most frequently studied (Ref); and with topotecan, vinorelbine, thiotepa (TVTC regimen), and dexamethasone in a Phase I trial (Ref). 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 (Ref).
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 (Ref)
Combination therapy: 40 mg/m2/day once daily for days 1 to 5 of each cycle in combination with cyclophosphamide and etoposide (Ref)
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 (Ref).
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 (Ref).
Children and Adolescents: Clofarabine undergoes renal elimination and exposure is increased as creatinine clearance decreases (Ref).
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
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.
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)
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)
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.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Solution, Intravenous:
Generic: 1 mg/mL (20 mL)
Solution, Intravenous [preservative free]:
Clolar: 1 mg/mL (20 mL [DSC])
Generic: 1 mg/mL (20 mL)
Yes
Solution (Clofarabine Intravenous)
1 mg/mL (per mL): $48.00 - $176.08
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Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution, Intravenous:
Clolar: 1 mg/mL (20 mL)
Clofarabine is associated with a moderate emetic potential; antiemetics are recommended to prevent nausea and vomiting (Ref).
IV infusion: Infuse over 2 hours for relapsed/refractory ALL. May be infused over 1 hour for some off-label protocols (Ref). 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.
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 (Ref). 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 (Ref).
Hazardous agent (NIOSH 2024 [table 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 2023; NIOSH 2024; USP-NF 2020).
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).
Acute lymphoblastic leukemia, relapsed or refractory (adults); Acute myeloid leukemia, refractory (patients <70 years of age)
Clofarabine may be confused with cladribine, clevidipine, cytarabine, nelarabine
The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drug classes (chemotherapeutic agent, parenteral and oral) which have a heightened risk of causing significant patient harm when used in error (High-Alert Medications in Acute Care, Community/Ambulatory Care, and Long-Term Care Settings).
Substrate of OAT1/3, OCT1, OCT2;
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 drug interactions program by clicking on the “Launch drug interactions program” link above.
5-Aminosalicylic Acid Derivatives: May increase myelosuppressive effects of Myelosuppressive Agents. Risk C: Monitor
Abrocitinib: May increase immunosuppressive effects of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid
Alfuzosin: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Amifostine: Blood Pressure Lowering Agents may increase hypotensive effects 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 increase hypotensive effects of Hypotension-Associated Agents. Risk C: Monitor
Antipsychotic Agents (Second Generation [Atypical]): Blood Pressure Lowering Agents may increase hypotensive effects of Antipsychotic Agents (Second Generation [Atypical]). Risk C: Monitor
Antithymocyte Globulin (Equine): Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of Antithymocyte Globulin (Equine). Specifically, these effects may be unmasked if the dose of cytotoxic chemotherapy is reduced. Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Antithymocyte Globulin (Equine). Specifically, infections may occur with greater severity and/or atypical presentations. Risk C: Monitor
Antithyroid Agents: Myelosuppressive Agents may increase neutropenic effects of Antithyroid Agents. Risk C: Monitor
Arginine: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Arimoclomol: May increase serum concentration of OCT2 Substrates (Clinically Relevant with Inhibitors). Risk C: Monitor
Barbiturates: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Baricitinib: Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Baricitinib. Risk X: Avoid
BCG Products: Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of BCG Products. Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of BCG Products. Specifically, the risk of vaccine-associated infection may be increased. Risk X: Avoid
Benperidol: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Blood Pressure Lowering Agents: May increase hypotensive effects of Hypotension-Associated Agents. Risk C: Monitor
Brimonidine (Topical): May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Brincidofovir: Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Brincidofovir. Risk C: Monitor
Brivudine: May increase adverse/toxic effects of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid
Bromperidol: May decrease hypotensive effects of Blood Pressure Lowering Agents. Blood Pressure Lowering Agents may increase hypotensive effects of Bromperidol. Risk X: Avoid
Chikungunya Vaccine (Live): Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of Chikungunya Vaccine (Live). Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Chikungunya Vaccine (Live). Risk X: Avoid
Chloramphenicol (Ophthalmic): May increase adverse/toxic effects of Myelosuppressive Agents. Risk C: Monitor
Chloramphenicol (Systemic): Myelosuppressive Agents may increase myelosuppressive effects of Chloramphenicol (Systemic). Risk X: Avoid
Cladribine: Agents that Undergo Intracellular Phosphorylation may decrease therapeutic effects of Cladribine. Risk X: Avoid
Cladribine: Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Cladribine. Risk X: Avoid
CloZAPine: Myelosuppressive Agents may increase adverse/toxic effects of CloZAPine. Specifically, the risk for neutropenia may be increased. Risk C: Monitor
Coccidioides immitis Skin Test: Coadministration of Immunosuppressants (Cytotoxic Chemotherapy) and Coccidioides immitis Skin Test may alter diagnostic results. 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 (Inactivated Virus): Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of COVID-19 Vaccine (Inactivated Virus). Risk C: Monitor
COVID-19 Vaccine (mRNA): Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects 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 decrease therapeutic effects of COVID-19 Vaccine (Subunit). Risk C: Monitor
Deferiprone: Myelosuppressive Agents may increase neutropenic effects 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 decrease therapeutic effects of Dengue Tetravalent Vaccine (Live). Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of Dengue Tetravalent Vaccine (Live). Specifically, the risk of vaccine-associated infection may be increased. Risk X: Avoid
Denosumab: May increase immunosuppressive effects 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 increase immunosuppressive effects of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid
Diazoxide: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
DULoxetine: Blood Pressure Lowering Agents may increase hypotensive effects of DULoxetine. Risk C: Monitor
Etrasimod: May increase immunosuppressive effects of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid
Fedratinib: May increase serum concentration of OCT2 Substrates (Clinically Relevant with Inhibitors). Risk C: Monitor
Fexinidazole: Myelosuppressive Agents may increase myelosuppressive effects of Fexinidazole. Risk X: Avoid
Filgotinib: May increase immunosuppressive effects of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid
Gilteritinib: May increase serum concentration of OCT1 Substrates (Clinically Relevant with Inhibitors). Risk C: Monitor
Givinostat: May increase serum concentration of OCT2 Substrates (Clinically Relevant with Inhibitors). Risk C: Monitor
Herbal Products with Blood Pressure Lowering Effects: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Hypotension-Associated Agents: Blood Pressure Lowering Agents may increase hypotensive effects of Hypotension-Associated Agents. Risk C: Monitor
Iloperidone: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Inebilizumab: Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Inebilizumab. Risk C: Monitor
Influenza Virus Vaccines: Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects 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 increase immunosuppressive effects 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 decrease therapeutic effects 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 increase hypotensive effects of Levodopa-Foslevodopa. Risk C: Monitor
Linezolid: May increase myelosuppressive effects of Myelosuppressive Agents. Risk C: Monitor
Lipegfilgrastim: Antineoplastic Agents may decrease therapeutic effects 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 increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Metergoline: May decrease antihypertensive effects of Blood Pressure Lowering Agents. Blood Pressure Lowering Agents may increase orthostatic hypotensive effects of Metergoline. Risk C: Monitor
Molsidomine: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Mumps- Rubella- or Varicella-Containing Live Vaccines: Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Mumps- Rubella- or Varicella-Containing Live Vaccines. Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of Mumps- Rubella- or Varicella-Containing Live Vaccines. Specifically, the risk of vaccine-associated infection may be increased. Risk X: Avoid
Nadofaragene Firadenovec: Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of Nadofaragene Firadenovec. Specifically, the risk of disseminated adenovirus infection may be increased. Risk X: Avoid
Naftopidil: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Natalizumab: Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Natalizumab. Risk X: Avoid
Nicergoline: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Nicorandil: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Nitisinone: May increase serum concentration of OAT1/3 Substrates (Clinically Relevant). Risk C: Monitor
Nitroprusside: Blood Pressure Lowering Agents may increase hypotensive effects of Nitroprusside. Risk C: Monitor
OAT1/3 Inhibitors: May increase serum concentration of Clofarabine. Risk C: Monitor
Obinutuzumab: May increase hypotensive effects 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 increase immunosuppressive effects of Ocrelizumab. Risk C: Monitor
OCT2 Inhibitors: May increase serum concentration of Clofarabine. Risk C: Monitor
Ofatumumab: Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Ofatumumab. Risk C: Monitor
Olaparib: Myelosuppressive Agents may increase myelosuppressive effects of Olaparib. Risk C: Monitor
Palifermin: May increase adverse/toxic effects 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 increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Pholcodine: Blood Pressure Lowering Agents may increase hypotensive effects of Pholcodine. Risk C: Monitor
Phosphodiesterase 5 Inhibitors: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Pidotimod: Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Pidotimod. Risk C: Monitor
Pimecrolimus: May increase immunosuppressive effects of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid
Piperacillin: May increase hypokalemic effects of Antineoplastic Agents. Risk C: Monitor
Pneumococcal Vaccines: Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Pneumococcal Vaccines. Risk C: Monitor
Poliovirus Vaccine (Live/Trivalent/Oral): Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Poliovirus Vaccine (Live/Trivalent/Oral). Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of Poliovirus Vaccine (Live/Trivalent/Oral). Specifically, the risk of vaccine-associated infection may be increased. Risk X: Avoid
Polymethylmethacrylate: Immunosuppressants (Cytotoxic Chemotherapy) may increase hypersensitivity effects of 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 serum concentration of OAT1/3 Substrates (Clinically Relevant). Risk C: Monitor
Promazine: May increase myelosuppressive effects of Myelosuppressive Agents. Risk C: Monitor
Prostacyclin Analogues: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Quinagolide: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Rabies Vaccine: Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects 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 increase immunosuppressive effects of Ritlecitinib. Risk X: Avoid
Ropeginterferon Alfa-2b: Myelosuppressive Agents may increase myelosuppressive effects 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 increase immunosuppressive effects of Ruxolitinib (Topical). Risk X: Avoid
Silodosin: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor
Sipuleucel-T: Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects 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 Modulators: May increase immunosuppressive effects of Immunosuppressants (Cytotoxic Chemotherapy). Risk C: Monitor
Tacrolimus (Topical): Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Tacrolimus (Topical). Risk X: Avoid
Tafenoquine: May increase 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 increase adverse/toxic effects 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
Taurursodiol: May increase serum concentration of OAT1/3 Substrates (Clinically Relevant). Risk X: Avoid
Tertomotide: Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Tertomotide. Risk X: Avoid
Tofacitinib: Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Tofacitinib. Risk X: Avoid
Typhoid Vaccine: Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Typhoid Vaccine. Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of Typhoid Vaccine. Specifically, the risk of vaccine-associated infection may be increased. Risk X: Avoid
Ublituximab: Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Ublituximab. Risk C: Monitor
Upadacitinib: Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Upadacitinib. Risk X: Avoid
Vaborbactam: May increase serum concentration of OAT1/3 Substrates (Clinically Relevant). Risk C: Monitor
Vaccines (Live): Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of Vaccines (Live). Specifically, the risk of vaccine-associated infection may be increased. Vaccines (Live) may decrease therapeutic effects of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid
Vaccines (Non-Live/Inactivated/Non-Replicating): Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Vaccines (Non-Live/Inactivated/Non-Replicating). Management: Give non-live/inactivated/non-replicating vaccines at least 2 weeks prior to starting chemotherapy when possible. Patients vaccinated less than 14 days before or during chemotherapy should be revaccinated at least 3 months after therapy is complete. Risk D: Consider Therapy Modification
Vadadustat: May increase serum concentration of OAT1/3 Substrates (Clinically Relevant). Risk C: Monitor
Vimseltinib: May increase serum concentration of OCT2 Substrates (Clinically Relevant with Inhibitors). Management: Avoid concomitant use of vimseltinib and OCT2 substrates when possible. If combined, monitor for increased effects and toxicities of the OCT2 substrate and consider dose adjustments. Risk D: Consider Therapy Modification
Yellow Fever Vaccine: Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Yellow Fever Vaccine. Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of Yellow Fever Vaccine. Specifically, the risk of vaccine-associated infection may be increased. Risk X: Avoid
Zoster Vaccine (Live/Attenuated): Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of Zoster Vaccine (Live/Attenuated). Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Zoster Vaccine (Live/Attenuated). Risk X: Avoid
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).
Based on the mechanism of action and data from animal reproduction studies, in utero exposure to clofarabine may cause fetal harm.
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.
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.
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.
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)
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%.
