Treatment Name: FCR (Fludara­bine + Cyclophospha­mide + Rituximab)
FCR (Fludara­bine + Cyclophospha­mide + Rituximab) is a Chemotherapy Regimen for Chronic Lymphocytic Leukemia (CLL)
How does FCR work?
Each of the medications in FCR are designed to kill or slow the growth of leukemia cells.
F - Fludarabine
C - Cyclophosphamide (Cytoxan)
R - Rituximab (Rituxan)
Goals of therapy:
FCR is given to alleviate symptoms of CLL such as enlarged lymph nodes, enlarged liver or spleen, or symptoms of abnormal bone marrow function, such as frequent infection. FCR may not cure CLL, but frequently leads to long-term remission (3 or more years without signs or symptoms of CLL).
- Fludarabine intravenous infusion (I.V.) over 30 minutes on Days 1, 2, and 3
- Cyclophosphamide I.V. over 30 minutes on Days 1, 2, and 3
- Rituximab I.V. on Day 1. The time of infusion varies depending on tolerability.
Estimated total infusion time for this treatment:
- Up to 6 hours for Cycle 1, Day 1; as short as 3 hours for the first day of next cycles if well tolerated
- Infusion times are based on clinical studies, but may vary depending on doctor preference or patient tolerability. Pre-medications and intravenous (I.V.) fluids, such as hydration, may add more time
Click here for common starting doses
FCR is repeated every 28 days. This is known as one Cycle. Each cycle may be repeated up to 6 times, depending upon the stage of the disease. Duration of therapy may last up to 6 months, depending upon response, tolerability, and number of cycles prescribed.
FCR is usually given in an outpatient infusion center, allowing the person to go home afterwards. On occasion, FCR may be given in the hospital if someone is too sick to go home after treatment. Often, the first day of treatment can take upwards of 6 hours.
In a multi-drug regimen, each medication has unique side effects. When these medicines are given together, drug-related side effects reported in clinical studies give the best estimate of what to expect. In clinical studies the most commonly reported side effects with FCR are shown here. Side effects sometimes have percentage ranges [example: low white blood cells 34 – 42%] because they differed between clinical studies:
On average, 17 - 26% of patients discontinue FCR due to unacceptable side effects.
The exact incidence of hair loss or neutropenic fever after FCR chemotherapy were not reported in the original studies, but may occur
How often is monitoring needed?
Labs (blood tests) may be checked before treatment and periodically throughout treatment. Pre-treatment labs often include: Hepatitis B screening, Human Immunodeficiency Virus (HIV) screening, Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), uric acid, lactate dehydrogenase (LDH), plus any others your doctor may order.
How often is imaging needed?
Imaging may be checked before treatment, which commonly include a computerized tomography (CT) scan. There may be other scans if necessary.
How might blood test results/imaging affect treatment?
Depending upon the results, your doctor may advise to continue chemotherapy as planned, or delay or switch therapy if it is not working.
- Pre-medications may be given before rituximab to help avoid infusion related reactions, these include: diphenhydramine (Benadryl®), acetaminophen (Tylenol®), and hydrocortisone (Solu-Cortef®)
- The first dose of rituximab is often the most difficult, or takes the longest to infuse. It may lead to fever, shaking, and chills even if “pre-medications” are given to help prevent these side effects. Side effects generally go away when the rituximab is stopped. It may be restarted at a slower rate. Most patients are able to receive the entire dose, although it may take longer. If rituximab is well tolerated, it may be infused over 90 minutes
- Allopurinol may be prescribed for the first cycle of chemotherapy to help prevent tumor lysis syndrome
- An antiviral agent such as acyclovir (Zovirax®), valacyclovir (Valtrex®), or famciclovir (Famvir®) may be used to prevent reactivation of herpes simplex virus (HSV) or varicella zoster virus (VZV)
- Typically, filgrastim (Neupogen®) or pegfilgrastim (Neulasta®) is given after chemotherapy to stimulate production of white blood cells and avoid periods of low white blood cell count (neutropenia) and infections
- A pharmacist should ALWAYS review your medication list to ensure that drug interactions are prevented or managed appropriately
- Clinical trials may exist for Lymphoma. Ask your doctor if any studies are currently enrolling in your area. If not, go to clinicaltrials.gov to search for other centers offering study medications
Patient Assistance & Co-payment Coverage
Patients under the age of 65 years, or those with private insurance plans:
If you have insurance and are looking for patient assistance or copay assistance for FCR (Fludara­bine + Cyclophospha­mide + Rituximab), we have provided links that may help.
Visit our Patient Assistance page and click the links to various patient assistance programs for help paying for FCR (Fludara­bine + Cyclophospha­mide + Rituximab). Depending upon your income, they may be able to help cover the cost of:
- Cyclophosphamide IV
For Branded medications (may be available for generic medications too), check with the manufacturer to determine if a co-pay card is offered and if it could reduce your monthly copay.
- If you are uninsured, check with the manufacturer to determine if you are eligible to receive medication at no cost.
Medicare and Medicaid patients (Patients 65 years or older):
The clinic providing treatment will likely pre-authorize medications and immune therapies such as FCR (Fludara­bine + Cyclophospha­mide + Rituximab) and are the best source to help you understand drug cost.
- Ask to speak with a patient assistance technician or financial counselor at the clinic or hospital administering this therapy.
What is Emotional Wellness?
Emotional wellness is having a positive outlook balanced with a realistic understanding of current life events. This requires both an awareness and acceptance of your emotions. It is with this knowledge that you can develop a plan to take the necessary actions to positively impact your life.
Emotional wellness uses an ongoing process to continually reflect on the stressors of life in a constructive manner to move forward and create happiness.
Because emotional wellness is deeply connected with physical, social, and spiritual wellness, pursuing it often becomes particularly difficult in times of major illness. Despite this difficulty, working toward emotional wellness has been connected to improved treatment outcomes and a higher likelihood of achieving goals of therapy.
Learn more about pursuing emotional wellness while receiving treatment with FCR (Fludara­bine + Cyclophospha­mide + Rituximab)