This information is about a chemotherapy treatment for myeloma called CTD.
You will see your hospital doctor regularly while you have this treatment so they can monitor the effects of the chemotherapy.
The drugs that are used
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CTD is named after the initials of the drugs used. These are:
How treatment is given
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You can usually have CTD treatment at home because the drugs are taken as tablets or capsules. Before you start treatment, you’ll need to have a blood test. You will also be seen by a doctor, specialist nurse or pharmacist.
If the results of your blood test are normal, the pharmacy will get your chemotherapy drugs ready. This can sometimes take a couple of hours.
Cyclophosphamide is available as pink or white tablets that you should take before meals.
Thalidomide is a white tablet or capsule. You should take it an hour after food, preferably in the late evening.
Dexamethasone is a white tablet that you should take after a meal or with a glass of milk, as it can irritate the lining of the stomach. Steroid tablets can make some people feel very alert, so it's usually best to take them in the morning.
You should swallow the tablets or capsules whole, with plenty of water.
How often treatment is given
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Your doctor may use the word 'regimen' (eg the CTD regimen) when talking about your chemotherapy. This means the plan or schedule of your particular chemotherapy treatment.
There are two different ways of giving CTD chemotherapy. One regimen is repeated every 21 days (three weeks), the other every 28 days (four weeks).
Your doctor, nurse or pharmacist will give you detailed instructions about how many tablets to take and when to take them. It’s important to follow the instructions you are given very carefully.
The following schedules are a guidleine and may vary from time to time.
21-day schedule (three-week cycle)
Cyclophosphamide is taken once a day on days 1, 8 and 15.
Thalidomide is taken once a day for the whole three-week cycle. Your specialist may gradually increase the dose of thalidomide depending on the side effects you experience.
Dexamethasone is usually taken once a day on days 1-4 and days 12-15.
After 21 days, you will have completed one cycle of your treatment. The treatment will then be repeated, which begins the next cycle of your chemotherapy. Your specialist will decide how many cycles of CTD chemotherapy you are given.
28-day schedule (four-week cycle)
Cyclophophamide is taken once a day on days 1, 8, 15 and 22.
Thalidomide is taken once a day for the whole four-week cycle. Your specialist may gradually increase the dose of the thalidomide depending on the side effects you experience.
Dexamethasone is taken once a day on days 1-4 and days 15-18.
After 28 days, you will have completed one cycle of your treatment. The treatment will then be repeated, which begins the next cycle of your chemotherapy. Your specialist will decide how many cycles of CTD chemotherapy you'll be given.
Each person's reaction to chemotherapy is different. Some people have very few side effects while others may experience more. The side effects described here won't affect everyone who has this treatment.
We have outlined the most common side effects but haven't included those that are rare and unlikely to affect you. If you notice any effects that aren't listed here, discuss them with your doctor, chemotherapy nurse or pharmacist.
Risk of infection
CTD can reduce the number of white blood cells, which help fight infection. White blood cells are produced by the bone marrow. If the number of your white blood cells is low you will be more prone to infections. A low white blood cell count is called neutropenia. This begins seven days after treatment and your resistance to infection is usually at its lowest 10-14 days after chemotherapy. The number of your white blood cells will then increase steadily and usually return to normal before your next cycle of chemotherapy is due.
Contact your doctor or the hospital straight away if:
your temperature goes above 38°C (100.4°F)
you suddenly feel unwell, even with a normal temperature.
You will have a blood test before having more chemotherapy to check the number of white blood cells. Occasionally, your treatment may need to be delayed if your number of blood cells (blood count) is still low.
Bruising and bleeding
Cyclophosphamide can reduce the production of platelets, which help the blood to clot. Tell your doctor if you have any unexplained bruising or bleeding, such as nosebleeds, bleeding gums, blood spots or rashes on the skin. You can have a platelet transfusion if your platelet count is low.
This can reduce the number of red blood cells, which carry oxygen around the body. A low red blood cell count is called anaemia. This may make you feel tired and breathless. Tell your doctor or nurse if you have these symptoms. You may need to have a blood transfusion if the number of red blood cells becomes too low.
Feeling sick (nausea) and being sick (vomiting)
Your doctor can prescribe very effective anti-sickness (anti-emetic) drugs to prevent, or greatly reduce, nausea and vomiting. If the sickness isn't controlled, or if it continues, tell your doctor; they can prescribe other anti-sickness drugs that may be more effective. Some anti-sickness drugs may cause constipation. Let your doctor or nurse know if this is a problem.
Risk of developing a blood clot
As thalidomide increases your risk of developing a blood clot, you will be given drugs to help prevent blood clots from forming during CTD treatment. The most commonly used drugs are warfarin or aspirin, which are taken as tablets or a preparation of low molecular weight heparin, which is taken as a daily injection.
If you have a daily injection of a heparin preparation, you can be taught how to give this to yourself or your doctors can arrange for a district nurse to visit you at home.
If you’re taking warfarin tablets, you’ll need to have regular blood tests. Depending on the results of your blood tests, your doctor may vary the dose of your warfarin.
You should let your hospital or doctor know immediately if you develop pain, swelling or redness in one of your calves, or if you suddenly become breathless or have chest pain during your treatment. This could be a sign of a blood clot, which needs urgent treatment.
Irritation of the stomach lining
Dexamethasone can irritate the lining of the stomach and may cause a stomach ulcer or make one worse. You should take the tablets with a meal or a drink of milk to reduce this side effect. Tell your doctor if you have indigestion, or pain or discomfort in the tummy (abdomen). You may be prescribed medication to reduce irritation of the stomach.
Behavioural changes and mood swings
Occasionally steroids can cause mood swings, difficulty sleeping and anxiety or irritability. Let your doctor know if there are any changes in your behaviour that are worrying you. Difficulty with sleeping may be helped by taking the steroids in the early part of the day, but discuss this with your doctor first.
It’s important to avoid getting pregnant or fathering a child while you’re taking thalidomide, as it causes severe abnormalities in developing babies.
Before starting thalidomide, women are asked to have a pregnancy test to check that they aren’t pregnant. You’ll also be advised to use a very effective form of contraception and given advice on the types of contraception recommended.
Men taking thalidomide are advised to use a condom during sex if their female partner is not already using effective contraception or is pregnant. Your doctor will tell you more about this.
Men and women are asked to use contraception for four weeks before starting treatment and for four weeks after treatment has finished.
Because thalidomide causes birth defects, you will usually have to take part in a risk-management programme. You’ll need to sign a consent form and may have to be registered with the company that makes the drug.
Your specialist can only prescribe four weeks of thalidomide at a time. So you’ll need to go to the hospital to get it prescribed and to sign a new consent form every month.
If a woman suspects that she may have become pregnant while taking thalidomide, or if she has had heterosexual intercourse without using an effective method of contraception, she should stop taking the thalidomide and inform her doctor straight away.
Numbness or tingling in hands or feet
This is due to the effect of thalidomide on the nerve endings and is known as peripheral neuropathy. You may also notice that you have difficulty with fiddly tasks such as doing up buttons. If you notice any of these side effects, tell your doctor straight away.
You'll usually be advised to stop taking the thalidomide or the dose may be reduced. This is necessary to prevent the symptoms from getting worse.
These symptoms may be permanent, or they may improve slowly with time.
Appetite changes and weight gain
You may notice that you feel hungrier than usual while taking steroids, and this can make you want to eat more. If you’re concerned about gaining weight, you can speak to your doctor, specialist nurse or dietitian. You might also find our section on weight management useful.
You may notice that food tastes different. Normal taste usually comes back after treatment finishes. A dietitian or specialist nurse at your hospital can give you advice about ways of coping with this side effect.
You may get constipated. This can usually be helped by drinking plenty of fluids, eating more fibre and doing some gentle exercise. You may need to take medicine (laxative) to help. Your doctor can prescribe these or you can buy them at a pharmacy.
It’s not unusual for people to feel drowsy or sleepy when taking thalidomide. Tell your doctor if this is a problem for you. It may help to take the tablets in the evening. You may find that the drowsiness improves as you continue to take the drug. It’s important not to drive or operate machinery if you’re feeling sleepy.
Raised blood sugar
This may happen if you’re having high-dose or ongoing treatment with dexamethasone (a steroid). During your treatment with steroids, your blood sugar levels may be checked with regular blood tests. You may also be asked to test your urine for sugar. A nurse will show you how to do this.
Tell your doctors if you get very thirsty or if you’re passing more urine than usual. This can be a sign that your blood sugar level is rising.
Hair may fall out completely or just thin. This usually starts 2-4 weeks after the first dose of cyclophosphamide, although it may occur earlier. You may also have thinning and loss of eyelashes, eyebrows and other body hair. This is temporary and your hair will start to grow again once treatment has finished. Your hair may grow back straighter, curlier, finer or a slightly different colour than it was before treatment. Your nurse can give you advice about coping with hair loss.
Sore mouth and ulcers
Your mouth may become sore or dry, or you may notice small ulcers during this treatment. Some people find that sucking on ice may be soothing. Drinking plenty of fluids, and cleaning your teeth regularly and gently with a soft toothbrush, can help reduce the risk of this happening. Tell your nurse or doctor if you have any of these problems, as they can prescribe mouthwashes and medicines to prevent or clear mouth infections. You may find our section on mouth care during chemotherapy helpful.
Less common side effects
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Cyclophosphamide may irritate your bladder. It’s important to drink as much fluid as you can (at least two litres) during the 24 hours following chemotherapy to help prevent this. Let your doctor know if you have any discomfort when you pass urine or if you notice any blood in it.
Treatment with CTD may cause changes in the way your liver works, although it will return to normal when the treatment finishes. You're very unlikely to notice any problems, but your doctor will take regular blood samples to check your liver is working properly
Your nails may become darker or ridged. They usually return to normal within a few months of finishing the treatment.
Rarely, your skin may darken. If it does, it usually goes back to normal a few months after the treatment has finished. During treatment and for several months afterwards, you'll be more sensitive to the sun and your skin may burn more easily than normal. You can still go out in the sun, but should wear a suncream with a high sun protection factor (SPF) and cover up with clothing and a hat. You might find our page on taking care in the sun useful.
Sometimes areas of skin that have been treated with radiotherapy may become red and sore. Tell your doctor if this happens.
Thalidomide can cause a rash or dry skin, which may be itchy. Your doctor can prescribe medicine to help with this.
Dizziness on standing
You may feel dizzy for a few moments if you stand up too suddenly. This is caused by a temporary fall in blood pressure. Move slowly from lying to sitting and then sitting to standing. Tell your doctor if you've ever had problems with your blood pressure and if you’re taking any blood pressure medicine.
Ankle swelling and fluid retention
You may find that your ankles swell, particularly if you have been standing still or sitting down for a time. Putting your feet up when you’re sitting helps reduce this. Talk to your doctor about medicines that may help. If the swelling is uncomfortable, your doctor may be able to prescribe elastic stockings to keep it under control.
Cyclophosphamide may cause some changes to lung tissue. Tell your doctor if you notice any coughing or breathlessness.
Always let your doctor or nurse know about any side effects you have. There are usually ways in which they can be controlled or improved .
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Some other medicines, including those you can buy in a shop or chemist, can be harmful to take when you are having chemotherapy. Tell your doctor about any medicines you are taking, including over-the-counter drugs, complementary therapies and herbal drugs.
Your ability to become pregnant or father a child may be affected by having this treatment. It’s important to discuss fertility with your doctor before starting treatment.
It is not advisable to become pregnant or father a child while taking CTD, as it may harm the developing baby. It is necessary to use effective contraception while taking this drug and for at least a few months afterwards. You can discuss this with your doctor.
It’s not known whether chemotherapy drugs can be present in semen or vaginal fluids. To protect your partner, it’s safest to either avoid sex or use a barrier form of contraception for about 48 hours after chemotherapy.
If you’re admitted to hospital for a reason not related to the cancer, it’s important to tell the doctors and nurses looking after you that you are having chemotherapy treatment. You should tell them the name of your cancer specialist so that they can ask for advice.
It’s a good idea to know who you should contact if you have any problems or troublesome side effects when you’re at home. Your chemotherapy nurse or doctor will give you details of who to contact for advice. This should include ‘out-of hours’ contact details if you need to call someone at evenings, overnight or at the weekend.
Things to remember about your tablets
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It’s important to take your tabletsor capsules at the right times as directed by your doctor.
Take the thalidomide capsules whole with water. Do not open the capsules.
Always tell any doctors treating you for non-cancerous conditions that you're taking a course of chemotherapy tablets that shouldn't be stopped or restarted without advice from your cancer specialist.
Keep the tablets in a safe place, out of the reach of children.
If your doctor decides to stop the treatment, return any remaining tablets to the pharmacist. Do not flush them down the toilet or throw them away.
If you forget to take a tablet, don't take a double dose. Tell your doctor and keep to your regular dose schedule.
If you are sick just after taking the tablet, let your doctor know. You may need to take another dose. Don't take another without telling your doctor first.
When planning overseas travel, check whether the country you are visiting has any special requirements regarding thalidomide. For example, Australia requires you to provide a letter from your doctor explaining why you are taking the drug.
This information is based on our CTD chemotherapy fact sheet, which has been compiled using information from a number of reliable sources including:
British National Formulary. 62nd edition. 2011. British Medical Association and Royal Pharmaceutical Society of Great Britain.
electronic Medicines Compendium. www.medicines.org.uk (accessed October 2011).
Hicks LK, et al. A meta-analysis and systematic review of thalidomide for patients with previously untreated multiple myeloma. 2008. Cancer Treatment Reviews.
Sweetman, et al. Martindale: The Complete Drug Reference. 37th edition. 2011. Pharmaceutical Press.