# Lymphodepleting chemotherapy before CAR T-cell infusion

Source: https://onco.cc/protocols/car-t-lymphodepletion/  
OnCo record `car-t-lymphodepletion` (Protocol). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

A few days before CAR T cells are given, a short course of chemotherapy, usually fludarabine and cyclophosphamide, lowers your own white cells to make room for the CAR T cells to grow. The team first checks that your CAR T cells are ready and that you have no uncontrolled infection. The doses and timing follow the instructions for your product.

## Summary

EBMT/JACIE 2019: lymphodepletion favours CAR T-cell expansion and persistence; fludarabine-cyclophosphamide is the most widely used regimen, usually over 3 to 5 days before infusion, with admission unless the centre has a safe outpatient pathway. If more than about 3 weeks pass between lymphodepletion and infusion and the white count is above 1.0 x 10^9/L, consider repeating it (SITC 2020: consider after 4 weeks). Infections must be treated and controlled first; SITC 2020 does not give lymphodepletion while a suspected fungal infection is uncontrolled.

The regimen and dose come from each product's label. YESCARTA (axicabtagene ciloleucel, US label revised 07/2026): cyclophosphamide 500 mg/m2 and fludarabine 30 mg/m2 intravenously on days 5, 4 and 3 before infusion. KYMRIAH (tisagenlecleucel, revised 6/2025): for adult DLBCL and follicular lymphoma, fludarabine 25 mg/m2 and cyclophosphamide 250 mg/m2 daily for 3 days, with bendamustine 90 mg/m2 for 2 days as the alternative after grade 4 haemorrhagic cystitis or cyclophosphamide resistance, and lymphodepletion may be omitted if the white count is under 1 x 10^9/L in the week before; for children and young adults with B-ALL, fludarabine 30 mg/m2 for 4 days and cyclophosphamide 500 mg/m2 for 2 days. Both labels: confirm the product is available before starting; no live vaccines for at least 6 weeks before lymphodepletion.

## Fields

- Kind: Protocol
- Last checked: 2026-11-11
- Also known as: lymphodepletion; LD chemotherapy; Flu/Cy; fludarabine and cyclophosphamide conditioning; lymphodepleting conditioning
- Tags: protocol; cell-therapy; car-t

## Connected records

- protocols: [Bridging therapy while CAR T cells are manufactured](https://onco.cc/protocols/car-t-bridging/), [Infection screening, prophylaxis and immunoglobulin replacement around CAR T-cell therapy](https://onco.cc/protocols/car-t-infection-prevention/), [Leukapheresis to collect T cells for CAR T-cell manufacture](https://onco.cc/protocols/car-t-apheresis/), [Prolonged low blood counts after CAR T-cell therapy (ICAHT): grading, work-up and treatment](https://onco.cc/protocols/icaht-prolonged-cytopenia/), [Referral and eligibility assessment for CAR T-cell therapy](https://onco.cc/protocols/car-t-referral-and-eligibility/)
- cancers: [Acute lymphoblastic leukaemia](https://onco.cc/cancers/all-leukemia/), [Diffuse large B-cell lymphoma](https://onco.cc/cancers/dlbcl/), [Follicular lymphoma](https://onco.cc/cancers/follicular-lymphoma/)
- technologies: [CAR-T cell therapy](https://onco.cc/technologies/car-t/)
- drugs: [Axicabtagene ciloleucel](https://onco.cc/drugs/axicabtagene-ciloleucel/), [Bendamustine](https://onco.cc/drugs/bendamustine/), [Cyclophosphamide](https://onco.cc/drugs/cyclophosphamide/), [Fludarabine](https://onco.cc/drugs/fludarabine/), [Tisagenlecleucel](https://onco.cc/drugs/tisagenlecleucel/)
- terms: [Lymphodepletion before CAR-T](https://onco.cc/terms/lymphodepletion/), [The CAR-T pathway in lymphoma: referral, apheresis, bridging and the waiting](https://onco.cc/terms/lymphoma-tx-car-t-pathway/)

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