[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Pharmacology](https://durgical.com/en/pharmacology/) › [Alkylating agents](https://durgical.com/en/pharmacology/classes/alkylating-agents/) › Ifosfamide

# Ifosfamide

## Alkylating agents?

Alkylating agents

## High alert?

An error with this medicine can cause serious harm: double checks and protocols are used.

A cyclophosphamide relative that is always given with mesna. Its metabolites can cause bladder bleeding, kidney damage and confusion (encephalopathy).

Updated Nov 1, 2026

## Quick facts

**Group**
[Alkylating agents](https://durgical.com/en/pharmacology/classes/alkylating-agents/)

**Target**
DNA (guanine N7), cross-linked by ifosfamide mustard

**Key effects**
Nausea and vomiting · Hair loss · Blood in the urine

**Monitor**
Urinalysis for blood before each dose

**ATC**
L01AA06

No doses: the clinician sets them by the current guideline.

On this page

- The basics Mechanism of action
- Indications
- Adverse effects
- Pharmacokinetics
- Memory aid

- Clinical What the labels mean

- Safety Contraindications
- Key interactions
- What is monitored
- Administration and safety
- Pregnancy and breastfeeding
- Nursing care

- Study Test yourself

- Connections Connections

## Mechanism of action

Like cyclophosphamide, ifosfamide is a prodrug activated by liver CYP enzymes (mainly CYP3A4) to 4-hydroxyifosfamide, which releases ifosfamide mustard (the DNA cross-linker) and acrolein (toxic to the bladder). A side pathway removes a chloroethyl group and releases chloroacetaldehyde, which is toxic to the brain and kidney tubules; this is why ifosfamide causes more encephalopathy and kidney damage than cyclophosphamide.

- Liver CYP3A4 activates ifosfamide
- Ifosfamide mustard cross-links DNA
- Acrolein reaches the bladder; mesna neutralises it
- Chloroacetaldehyde can injure brain and kidney

## Indications

- Third-line combination chemotherapy for germ cell testicular cancer (licensed use). [Testicular cancer →](https://durgical.com/en/conditions/testicular-cancer/)

## Adverse effects

### Common

- Nausea and vomiting
- Hair loss
- Myelosuppression and infections
- Blood in the urine

### Serious (rare, important)

- Encephalopathy: confusion, somnolence, hallucinations, seizures, coma; can be fatal
- Kidney damage, including Fanconi syndrome (loss of phosphate, glucose and amino acids in urine) and renal failure
- Haemorrhagic cystitis
- Heart toxicity (arrhythmias, cardiomyopathy), pneumonitis, veno-occlusive liver disease, second cancers

## Contraindications

- Known hypersensitivity to ifosfamide
- Urinary outflow obstruction

## Key interactions

**CYP3A4 inducers**
More activation and more chloroacetaldehyde: higher risk of neurotoxicity and nephrotoxicity.

**CYP3A4 inhibitors**
Less activation, possibly less anticancer effect.

**Other cardiotoxic drugs or chest radiotherapy**
Higher risk of heart toxicity.

## What is monitored

- Urinalysis for blood before each dose
- Kidney function, serum electrolytes (phosphate, potassium, bicarbonate) and urine chemistry
- Mental status during and after each infusion
- Complete blood count

## Administration and safety

- Always given with mesna, timed to cover the whole period when metabolites reach the bladder.
- Generous hydration before and during treatment.
- Hazardous drug: chemotherapy handling precautions.

## Pregnancy and breastfeeding

Can cause fetal harm; effective contraception is needed during and after treatment.

## Nursing care

- Check the mesna schedule against each ifosfamide dose; a missed mesna dose leaves the bladder unprotected.
- Assess orientation and level of consciousness regularly; stop the infusion and report confusion, drowsiness or hallucinations.
- Record intake and output; test urine for blood.
- Teaching: report red urine, confusion in a family member, fever or bleeding.

## Pharmacokinetics

**Absorption**
Intravenous infusion.

**Metabolism**
Liver CYP enzymes, producing active mustard, acrolein and chloroacetaldehyde.

**Elimination**
Mostly in the urine as metabolites.

**Half-life**
Increases with age, linked to a larger volume of distribution.

## Memory aid

«IFosfamide: IF mesna is forgotten, the bladder bleeds; IF the brain gets chloroacetaldehyde, it gets confused.»

## Test yourself

Think of the answer, then tap the question to see it.

## Why is ifosfamide always given with mesna?

Its acrolein reaches the bladder and causes haemorrhagic cystitis; mesna binds it in the urine.

## Which ifosfamide metabolite is blamed for encephalopathy and tubular damage?

Chloroacetaldehyde.

## What kidney syndrome causes loss of phosphate, glucose and amino acids in the urine after ifosfamide?

Fanconi syndrome (proximal tubular damage).

[Add to my cards (3)](https://durgical.app/estudiar/?add=/en/pharmacology/ifosfamide/)

[More Pharmacology questions →](https://durgical.com/en/practice/?f=pharmacology)

## What the labels mean

**High alert**
An error with this medicine can cause serious harm: double checks and protocols are used.

## Connections

## Related drugs 2

- [Cyclophosphamide](https://durgical.com/en/pharmacology/cyclophosphamide/)
- [Mesna](https://durgical.com/en/pharmacology/mesna/)

## Related conditions 1

- [Testicular cancer](https://durgical.com/en/conditions/testicular-cancer/)

[← Back to the class: Alkylating agents](https://durgical.com/en/pharmacology/classes/alkylating-agents/)

Educational content on how drugs work; not a prescribing guide and no substitute for a health professional's advice. No doses are given.

Sources: [DailyMed - IFOSFAMIDE injection, solution](https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=ee600728-df69-4e61-9c94-5ef3801b80ad) (DailyMed (U.S. National Library of Medicine), 2026); [Ifosfamide Injection: MedlinePlus Drug Information](https://medlineplus.gov/druginfo/meds/a695023.html) (MedlinePlus (U.S. National Library of Medicine), 2026); [ATCDDD - ATC/DDD Index](https://atcddd.fhi.no/atc_ddd_index/?code=L01AA06) (WHO Collaborating Centre for Drug Statistics Methodology, 2026); [eEML - Electronic Essential Medicines List](https://list.essentialmeds.org/) (World Health Organization, 2025).

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Representative model, for educational purposes only.

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Source: https://durgical.com/en/pharmacology/ifosfamide/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/pharmacology/ifosfamide/