What is FLAG-Ida?

FLAG-Ida is used to treat acute myeloid leukaemia (AML). It is sometimes used to treat acute lymphoblastic leukaemia (ALL). It is best to read this information with our general information about chemotherapy and the type of leukaemia you have.

Your doctor will talk to you about this treatment and its possible side effects before you agree (consent) to have treatment. 

The term FLAG-Ida comes from the letters in the names of the drugs used:

G-CSF is not a chemotherapy drug. It is given to make the chemotherapy drugs work better and to help your body make healthy white blood cells. 

How FLAG-Ida is given

You will be given FLAG-Ida during a stay in hospital. A chemotherapy nurse will give it to you. 
During treatment, you usually see a specialist doctor (haematologist), a chemotherapy nurse or a specialist nurse, and a specialist pharmacist. This is who we mean when we mention doctor, nurse or pharmacist in this information.

Before or on the day of treatment, a nurse or person trained to take blood (phlebotomist) will take a blood sample from you. This is to check that your blood cells are at a safe level to have chemotherapy.

You will see a doctor or nurse before you have chemotherapy. They will ask you how you have been feeling. If your blood results are okay, the pharmacist will prepare your chemotherapy. Your nurse will tell you when your treatment is likely to be ready.

Your nurse usually gives you anti-sickness (anti-emetic) drugs before the chemotherapy. The chemotherapy drugs fludarabine, cytarabine and idarubicin can be given through:

  • a short thin tube that the nurse puts into a vein in your arm or hand (cannula)
  • a fine tube that goes under the skin of your chest and into a vein close by (central line)
  • a fine tube that is put into a vein in your arm and goes up into a vein in your chest (PICC line).

You have G-CSF as an injection under the skin (subcutaneously).

Your course of chemotherapy

You have FLAG-Ida while you are in hospital. The treatment severely reduces the levels of your blood cells, which makes you more at risk of infection and bleeding. You stay in hospital until your blood cells have recovered. Doctors test your blood regularly to measure the numbers of these cells (blood count).

Some people may be able to go home for a few days straight after they have had all their chemotherapy. This is because your blood count takes a few days to reduce. They come back to hospital when their blood count starts to go down.

Flag-IDA is usually given over 7 days. On days 1 to 7 you will have an injection of G-CSF under the skin.

On days 2 to 6 your nurse will give you fludarabine and cytarabine. They are both given as a drip (infusion).

On days 4 to 6 they will also give you idarubicin. You have this as an injection through your line with a drip to flush it. Or it can be given as a drip.

After this you stay in hospital until your blood count recovers. This can take about 3 to 4 weeks. You may need to start taking daily injections of G-CSF again. This is to help your body make more healthy white blood cells.

Some people may have another treatment with FLAG-Ida when their blood count has recovered. Your nurse or doctor will discuss your treatment plan with you.

About side effects

We explain the most common side effects of this treatment here. We also include some less common side effects. You may get some of the side effects we mention, but you are unlikely to get all of them.

You may also have some side effects that we have not listed here. Always tell your doctor, nurse or pharmacist about any side effects you have.

Your doctor can give you drugs to help control some side effects. It is important to take them exactly as your nurse or pharmacist explains. This means they will be more likely to work for you. Your nurse will give you advice about managing your side effects. After your treatment is over, most side effects start to improve.

Serious and life-threatening side effects

Some cancer treatments can cause severe side effects. Rarely, these may be life-threatening. Your cancer doctor or nurse can explain the risk of these side effects to you.

Contact the hospital

Your nurse will give you telephone numbers for the hospital. If you feel unwell or need advice, you can call them at any time of the day or night. Save these numbers in your phone or keep them somewhere safe.

More information

We cannot list every side effect for this treatment. There are some rare side effects that are not listed. You can visit the electronic Medicines Compendium (eMC) to download a Patient Information Leaflet (PIL) for these drugs. The leaflet lists all known side effects.

Side effects while treatment is being given

Allergic reaction

Some people have an allergic reaction while having this treatment. Signs of a reaction can include:

  • feeling hot or flushed
  • a skin rash
  • itching
  • shivering
  • feeling dizzy
  • a headache
  • feeling breathless
  • swelling of your face or mouth
  • pain in your back, tummy or chest.

Your nurse will check you for signs of a reaction during your treatment. If you feel unwell or have any of these signs, tell them straight away. If you do have a reaction, it can be treated quickly.

Sometimes a reaction can happen a few hours after treatment. If you get any signs or feel unwell after you get home, contact the hospital straight away.

Pain along the vein

Idarubicin and cytarabine can cause pain at the place where the injection is given or along the vein. If you feel pain, tell your nurse or doctor straight away so that they can check the site. They may give the drug more slowly or flush it through with more fluid to reduce pain.

Idarubicin leaks outside the vein

If this happens it can damage the tissue around the vein. This is called extravasation. Extravasation is not common but if it happens it is important that it is dealt with quickly. Tell your nurse straight away if you have any stinging, pain, redness or swelling around the vein.

If you get any of these symptoms after you get home, contact the doctor or nurse straight away on the number they gave you.

Common side effects

Risk of infection

This treatment can reduce the number of white blood cells in your blood. These cells fight infection. If the number of white blood cells is low, you are more likely to get an infection. A low white blood cell count is called neutropenia.

Your doctor may give you antibiotics and other drugs to try to stop you getting an infection. These are called prophylactic medicines. 

If you have an infection, it is important to treat it as soon as possible. If you are not in hospital, contact them straight away on the 24-hour contact number you have if:

  • your temperature goes over 37.5°C (99.5°F)
  • you suddenly feel unwell, even with a normal temperature
  • you have symptoms of an infection.

Symptoms of an infection include:

  • feeling shivery
  • a sore throat
  • a cough
  • diarrhoea
  • needing to pass urine more often.

It is important to follow any specific advice your cancer treatment team gives you.

You will have regular blood tests during and after your treatment. The number of white blood cells will usually return to normal before your next treatment. You may have ongoing daily injections of G-CSF to help your body to make more white blood cells. 

Bruising and bleeding

This treatment can reduce the number of platelets in your blood. Platelets are cells that help the blood to clot. 

Tell your doctor if you have any bruising or bleeding that you cannot explain. This includes:

  • nosebleeds
  • bleeding gums
  • tiny red or purple spots on the skin that may look like a rash.

Some people may need a drip to give them extra platelets. This is called a platelet transfusion.

Anaemia (low number of red blood cells)

This treatment can reduce the number of red blood cells in your blood. These cells carry oxygen around the body. If the number of red blood cells is low, you may be tired and breathless. Tell your doctor or nurse if you feel like this. If you are very anaemic, you may need a drip to give you extra red blood cells. This is called a blood transfusion.

Feeling sick

You may feel sick in the first few days after this treatment. Your doctor will give you anti-sickness drugs to help prevent or control sickness. Take the drugs exactly as your nurse or pharmacist tells you. It is easier to prevent sickness than to treat it after it has started.

If you feel sick, take small sips of fluids and eat small amounts often. If you continue to feel sick, or if you vomit more than once in 24-hours, contact the hospital as soon as possible. They will give you advice and may change the anti-sickness drug to one that works better for you.

Sore mouth

You may get a sore mouth or mouth ulcers. This can make you more likely to get a mouth infection.

Use a soft toothbrush to clean your teeth or dentures in the morning, at night and after meals.

If your mouth is sore:

  • tell your nurse or doctor – they can give you a mouthwash or medicines to help
  • try to drink plenty of fluids
  • avoid alcohol, tobacco, and foods that irritate your mouth.

Diarrhoea

If you have diarrhoea, contact the hospital for advice. Try to drink at least 2 litres (3½ pints) of fluids every day. It can help to avoid alcohol, caffeine, milk products, high-fat foods and high-fibre foods.

Feeling tired

This treatment will make you feel very tired and you will need a lot of rest. You will get tired easily for some months after treatment too. Gentle exercise, like short walks, can give you more energy. The tiredness will gradually get better.

Tummy pain and bleeding from the bowel

Idarubicin can irritate the lining of the stomach. This may cause a stomach ulcer. Tell your doctor if you have pain in your tummy or if you have indigestion. Your doctor may prescribe drugs to help reduce stomach irritation.

Idarubicin may also cause bleeding from the bowel. Tell your doctor straight away if you notice blood when you have a bowel movement or if your stool is darker.

Eye problems

This treatment may make your eyes feel sore, red and itchy (conjunctivitis). Your doctor will prescribe eye drops to help prevent this. It is important to use these as you are told to.

This treatment may also make your eyes more sensitive to light and cause blurry vision. If you have pain or notice any change in your vision, always tell your doctor or nurse. It is important not to drive or operate machinery if your vision is affected.

Hair loss

Most people will lose all the hair from their head. This usually starts happening about 10 to 14 days into your first FLAG-Ida treatment. You may also lose your eyelashes, eyebrows or other body hair. Your hair will usually grow back after treatment ends.

Your nurse can talk to you about ways to cope with hair loss. There are ways to cover up hair loss if you want to. It is important to cover your head to protect your scalp when you are out in the sun.

Red or pink urine

Your urine may be a pink-red colour for the first few times you pee after having idarubicin. This is due to the colour of the drug. It is not harmful.

Headaches

This treatment may cause headaches. If this happens, tell your doctor or nurse. They can give you painkillers.

Bone pain

G-CSF may cause discomfort or a dull ache in the bones of your pelvis, back, arms or legs. Your doctor can prescribe pain relief if needed.

Less common side effects

Effects on the heart

Chemotherapy can affect the way the heart works. You may have tests to see how well your heart is working. These may be done before, during and sometimes after treatment. If the treatment is causing heart problems, your doctor can change the type of chemotherapy you are having.

Contact a doctor straight away if you:

  • have pain or tightness in your chest
  • feel breathless or dizzy
  • feel your heart is beating too fast or too slowly.

Other conditions can cause these symptoms, but it is important to get them checked by a doctor.

Skin changes

Chemotherapy may affect your skin. Your doctor or nurse can tell you what to expect. If your skin feels dry, try using an unperfumed moisturising cream every day. These drugs can cause a rash, which may be itchy.

Sometimes your skin colour may change slightly during treatment. People with lighter skin may notice their skin looks more tanned. People with darker skin may develop patches of lighter skin.

Your skin may also be more sensitive in the sun. So use suncream and take care if you are out in the sun.

Always tell your doctor or nurse about any skin changes. They can give you advice and may give you creams or medicines to help. Any changes to your skin are usually temporary and improve when treatment finishes.

Effects on the nervous system

Fludarabine and cytarabine can affect the nervous system. You may:

  • feel anxious or restless
  • have problems sleeping
  • experience mood changes
  • feel drowsy or confused.

Rarely, fludarabine and cytarabine can cause seizures (fits).

Tell your doctor or nurse straight away if you notice any of these symptoms.

Numb or tingling hands or feet (peripheral neuropathy)

Fludarabine may affect the nerves, which can cause numb, tingling or painful hands or feet. You may find it hard to fasten buttons or do other fiddly tasks.

Tell your doctor if you have these symptoms. They sometimes need to lower the dose of the drug or delay treatment for a short time. The symptoms usually improve slowly after treatment finishes, but for some people they may never go away. Talk to your doctor if you are worried about this.

Raised levels of uric acid (tumour lysis syndrome)

This treatment may cause the cancer cells to break down quickly. This releases uric acid (a waste product) into the blood. The kidneys usually get rid of uric acid but may not be able to cope with large amounts. Too much uric acid can cause swelling and pain in the joints, which is called gout.

Your doctor may give you tablets called allopurinol (Zyloric®) to help prevent this. Drinking at least 2 litres (3½ pints) of fluid a day will also help. You will have regular blood tests to check the uric acid levels.

Other information

Blood transfusions after FLAG-Ida

If you need a blood transfusion after this treatment, any blood or platelets you are given should first be treated with radiation (irradiated). This lowers the risk of the donated blood cells reacting against your own. It will not damage the blood or make you radioactive.

Your doctor will record in your medical notes that you should only be given irradiated blood products. They will also give you a card to carry in case you need treatment at another hospital. Keep this card with you at all times and always remind your hospital team that any blood or platelets you need must be irradiated.

Vaccinations

Your doctor or nurse may talk to you about vaccinations. These help reduce your risk of getting infections.

Doctors usually recommend that you have a flu jab, which is an inactivated vaccination. People with weak immune systems can have this type of vaccination.

If your immune system is weak, you need to avoid live vaccinations such as shingles. Your cancer doctor or GP can tell you more about live vaccinations.

Other medicines

Some medicines can affect how this treatment works or be harmful when you are having it. Always tell your cancer doctor about any drugs you are taking or planning to take, such as:

  • medicines you have been prescribed
  • medicines you buy in a shop or chemist
  • vitamins, herbal drugs and complementary therapies.

Tell other doctors, pharmacists or dentists who prescribe or give you medicines that you are having this cancer treatment.

You can visit the electronic Medicines Compendium (eMC) for more detailed information about your treatment.

Fertility

Some cancer drugs can affect whether you can get pregnant or make someone pregnant. If you are worried about this, it is important to talk with your doctor before you start treatment.

Contraception

Your doctor will advise you not to get pregnant or make someone pregnant while having this treatment. The drugs may harm a developing baby. It is important to use contraception during your treatment and for a while after treatment finishes. Your doctor, nurse or pharmacist can tell you more about this.

Sex

If you have sex in the first few days after chemotherapy, you need to use a condom. This is to protect your partner in case there is any chemotherapy in semen or vaginal fluids.

Breastfeeding

Women are advised not to breastfeed while having this treatment. This is because the drugs could be passed to the baby through breast milk.

Blood clot risk

Cancer and some cancer treatments can increase the risk of a blood clot. Symptoms of a blood clot include:

  • pain, redness or swelling in a leg or arm
  • breathlessness
  • chest pain.

If you have any of these symptoms, contact a doctor straight away.

A blood clot is serious, but can be treated with drugs that thin the blood. Your doctor or nurse can give you more information.

Medical and dental treatment

If you need medical treatment for any reason other than cancer, always tell the doctors and nurses that you are having cancer treatment. Give them the contact details for your cancer doctor so they can ask for advice.

If you think you need dental treatment, talk to your cancer doctor or nurse. Always tell your dentist you are having cancer treatment.

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