CTD chemotherapy is a treatment used to treat myeloma.
This information should ideally be read with our general information about chemotherapy and myeloma.
CTD comes from the initials of the drugs used:
Before you start treatment with thalidomide, your doctor will talk to you about contraception. This is because thalidomide can cause birth defects in children. You may find it helpful to see our information below on contraception and CTD.
You have CTD treatment at home as all the drugs are taken as tablets or capsules. During your treatment, you usually see a cancer doctor, a chemotherapy nurse or a specialist nurse. This is who we mean when we mention doctor or nurse in this information.
Before or on the first day of treatment, a nurse or person trained to take blood (phlebotomist) will take a blood sample from you. This is to check that it is okay for you to have chemotherapy.
You will also see a doctor or nurse before you have chemotherapy. They will ask you about how you have been. If your blood results are alright on the day of your treatment, the pharmacist will prepare your chemotherapy. Your nurse will tell you when your treatment is likely to be ready.
Taking your chemotherapy tablets
Before you leave hospital, the nurse or pharmacist will give you chemotherapy tablets to take when you are at home. Always take your tablets exactly as explained. This is important to make sure they work as well as possible for you.
You should swallow the tablets or capsules whole with plenty of water. You should also:
Take cyclophosphamide before meals.
Take thalidomide an hour after food, preferably late evening.
Take dexamethasone after a meal or with milk as it can irritate the lining of the stomach.
If you are sick just after taking the tablets, contact the hospital. You may need to take another dose. If you forget to take a tablet, do not take a double dose. Keep to your regular schedule and let your doctor or nurse know.
Other things to remember about your tablets:
Keep them in the original package at room temperature away from heat and direct sunlight.
Keep them safe and out of the reach of children.
Return any remaining tablets to the pharmacist if your treatment is stopped.
The nurse or pharmacist will also give you anti-sickness drugs to take at home. Take all your tablets exactly as instructed.
Your course of CTD
You have chemotherapy as a course of several sessions (or cycles) of treatment over a few months. Each cycle of CTD lasts either 21 days (three weeks) or 28 days (four weeks). Your doctor or nurse will tell you which of these cycles you are going to have.
You take cyclophosphamide on days one, eight and 15.
You take thalidomide once a day for the whole three-week cycle. Your doctor may gradually increase the dose depending on the side effects you have.
You take dexamethasone on days 1–4 and on days 12–15.
At the end of the 21 days, you start your second cycle of CTD. This is exactly the same as the first cycle. Your doctor or nurse will tell you the number of cycles you are likely to have.
You take cyclophophamide on days one, eight, 15 and 22.
You take thalidomide once a day for the whole four-week cycle. Your doctor may gradually increase the dose depending on the side effects you have.
You take dexamethasone on days 1–4 and on days 15–18.
At the end of the 28 days, you start your second cycle of CTD. This is exactly the same as the first cycle. Your doctor or nurse will tell you the number of cycles you are likely to have.
Possible side effects of CTD
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We explain the most common side effects of CTD here. But we don’t include all the rare ones that are unlikely to affect you.
You may get some of the side effects we mention, but you are very unlikely to get all of them. Always tell your doctor or nurse about the side effects you have. Your doctor can prescribe drugs to help control some of these.
It is very important to take the drugs exactly as your nurse or pharmacist has explained. This means they will be more likely to work better for you.
Your nurse will give you advice about managing your side effects. After your treatment is over, the side effects will start to improve.
Contact the hospital
Yur nurse will give you telephone numbers for the hospital. You can call them if you feel unwell or need advice any time of day or night. Save these numbers in your phone or keep them somewhere safe.
Risk of infection
CTD can reduce the number of white blood cells in your blood. This will make you more likely to get an infection. When the number of white blood cells is low, it’s called neutropenia.
Contact the hospital straight away on the contact number you’ve been given if:
your temperature goes over 37.5°C (99.5 °F) or over 38°C (100.4 °F), depending on the advice given by your chemotherapy team
you suddenly feel unwell, even with a normal temperature
you have symptoms of an infection – this can include feeling shaky, a sore throat, a cough, diarrhoea or needing to pass urine a lot.
The number of white blood cells usually increases steadily and returns to normal before your next treatment. You will have a blood test before having more chemotherapy. If your white blood cells are still low, your doctor may delay your treatment for a short time.
Bruising and bleeding
Chemotherapy reduces 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 you can’t explain. This includes nosebleeds, bleeding gums, blood spots or rashes on the skin. Some people may need a drip to give them extra platelets.
Anaemia (low number of red blood cells)
Chemotherapy 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 (blood transfusion).
Blood clot risk
Thalidomide and chemotherapy can increase the chance of a blood clot (thrombosis). You may be given drugs, usually as tablets, to help prevent a blood clot during treatment.
A clot can cause symptoms such as pain, redness and swelling in a leg, breathlessness and chest pain. Contact your doctor straight away if you have any of these symptoms. A blood clot is serious, but your doctor can treat it with drugs that thin the blood. Your doctor or nurse can give you more information.
This may happen in the first few days after chemotherapy. Your doctor will prescribe anti-sickness (anti-emetic) drugs to help prevent or control sickness. Take the drugs exactly as your nurse or pharmacist explains to you. It’s easier to prevent sickness than to treat it after it has started.
If you still feel sick or are vomiting, contact the hospital as soon as possible. They can give you advice and change the anti-sickness drug to one that works better for you.
Tummy pain and/or indigestion
Steroids can irritate the stomach lining. Let your nurse or doctor know if you have pain in your tummy or indigestion. They can prescribe drugs to help reduce stomach irritation. Take your tablets with food to help protect your stomach.
Steroids can make you feel much hungrier than usual and you may gain weight. Your appetite will go back to normal when you stop taking them. If you’re worried about gaining weight, talk to your doctor or nurse.
Raised blood sugar levels
Dexamethasone can raise your blood sugar levels. Your nurse will check your blood regularly for this. They may also test your urine for sugar. Symptoms of raised blood sugar include feeling thirsty, needing to pass urine more often and feeling tired. Tell your doctor or nurse if you have these symptoms.
If you have diabetes, your blood sugar levels may be higher than usual. Your doctor will talk to you about how to manage this. You may need to adjust your insulin or tablet dose.
Mood and behaviour changes
Steroids can affect your mood. You may feel anxious or restless, have mood swings or have problems sleeping. Taking your steroids in the morning may help you sleep better.
Tell your doctor or nurse if you have any of these side effects. They may make some changes to your treatment if the side effects become a problem.
Your mouth may become sore and you may get ulcers. This can make you more likely to get an infection in your mouth. Gently clean your teeth and/or dentures morning and night and after meals. Use a soft-bristled or children’s toothbrush. Your nurse might ask you to rinse your mouth regularly or use mouthwashes. It’s important to follow any advice you are given and to drink plenty of fluids.
Tell your nurse or doctor if you have any problems with your mouth. They can prescribe medicines to prevent or treat mouth infections and reduce any soreness.
Effects on the nervous system
Thalidomide can affect the nervous system. You may feel drowsy or confused. It can help to take your tablets in the evening. Tell your doctor or nurse straight away if you notice any of these symptoms. It’s important not to drive or operate machinery if you notice these effects.
Your hair will thin or you may lose all the hair from your head. This usually starts after your first or second cycle of chemotherapy. It is almost always temporary and your hair will grow back after chemotherapy ends. It is important to cover your head to protect your scalp when you are out in the sun. Your nurse can give you advice about coping with hair loss.
Thalidomide may make you constipated. Drinking at least two litres of fluids (three and a half pints) every day will help. Try to eat more foods that contain fibre (such as fruit, vegetables and wholemeal bread) and take some regular gentle exercise.
Chemotherapy may affect your skin and thalidomide may cause a rash. Your doctor or nurse can tell you what to expect. If your skin feels dry, try using an unperfumed moisturising cream every day.
During treatment and for several months afterwards, you'll be more sensitive to the sun and your skin may burn more easily than usual. You can still go out in the sun, but use a suncream with a sun protection factor (SPF) of at least 30, and cover up with clothing and a hat. Your skin may darken. It will return to its normal colour after you finish treatment.
Always tell your doctor or nurse about any skin changes. They can give you advice and may prescribe creams or medicines to help. Any changes to your skin are usually temporary and improve when treatment finishes.
Your nails may become brittle and break easily. They may get darker or discoloured, and you may get lines or ridges on them. These changes grow out after treatment finishes. Wearing gloves when washing dishes or using detergents will help protect your nails during treatment.
Build up of fluid
Your ankles and legs may swell because of fluid building up. Tell your doctor or nurse if fluid builds up. Talk to your doctor about medicines that may help. If the swelling is uncomfortable, they may prescribe support stockings to help. If your ankles and legs swell, it can help to put your legs up on a foot stool or cushion. The swelling gets better after your treatment ends.
Less common side effects of CTD
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Cyclophosphamide may irritate your bladder and cause discomfort when you pass urine. Drink plenty of fluids – at least two litres (three and a half pints) - especially during the 24 hours following chemotherapy. It is also important to empty your bladder regularly and to try to pass urine as soon as you feel the need to go.
If you are treated with higher doses of cyclophosphamide, you will be given fluids through a drip (infusion). You may also be given a drug called mesna (Uromitexan®) as an infusion and/or tablets. This helps to prevent bladder irritation.
Contact the hospital straight away if you feel any discomfort or stinging when you pass urine or if you notice any blood in your urine.
Changes to the way your liver works
Thalidomide may affect how your liver works. This is usually mild and goes back to normal after treatment. You will have blood tests to check how well your liver is working.
Low blood pressure
Thalidomide can cause a temporary fall in your blood pressure. This can make you feel dizzy for a few moments if you stand up too quickly. Tell your doctor or nurse if you have ever had any problems with your blood pressure. It can help to move slowly from lying to sitting and from sitting to standing.
Effects on the lungs
Cyclophosphamide can cause changes to the lungs. These are more common if you are treated with higher doses of chemotherapy.
Always tell your doctor if you develop wheezing, a cough, a fever or feel breathless. You should also let them know if any existing breathing problems get worse. If necessary, they can arrange for you to have tests to check your lungs.
It’s important to tell your doctor or nurse straight away if you feel ill or have severe side effects. This includes any we don’t mention here.
Other information about CTD
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Contraception and CTD
Thalidomide can cause severe abnormalities in developing babies. Chemotherapy drugs may also harm a developing baby. It’s therefore extremely important not to get pregnant or father a child during, and for a few months after, treatment.
Your doctor or specialist nurse will explain this and give you written information about the risks of thalidomide. They will advise you on the type of contraception to use and for how long to use it.
Due to the possible birth defects that thalidomide can cause, you will have to take part in a pregnancy prevention programme. You will be asked to sign a form stating that you understand the risks of taking thalidomide and agree to use contraception for a set length of time. This is called a consent form. You may also need to register with the company that makes the drug. Your doctor or nurse can tell you more about this.
If you are a woman of childbearing age, you must have a pregnancy test before taking thalidomide to check that you aren’t pregnant. You must then take another test every four weeks until a month after treatment finishes. Women are only prescribed four weeks of thalidomide at a time.
You must also start using effective contraception four weeks before starting treatment. The combined contraceptive pill isn’t recommended because it increases the chance of a blood clot.
Men taking thalidomide are advised to use a condom during sex with a woman of childbearing age or with a woman who is pregnant.
If you have sex within the first couple of days of having chemotherapy you need to use a condom. This is to protect your partner in case there is any chemotherapy in semen or vaginal fluid.
Chemotherapy may affect your fertility (being able to get pregnant or father a child). If you are worried about this, you can talk to your doctor or nurse before treatment starts.
Changes to your periods
Chemotherapy can sometimes stop the ovaries working. You may not get a period every month and they may eventually stop. In some women, this is temporary, but for others it is permanent and they start the menopause.
Women are advised not to breastfeed during treatment and for a few months after. This is in case there is chemotherapy in their breast milk.
Some medicines can interact with chemotherapy or be harmful when you are having chemotherapy. This includes medicines you can buy in a shop or chemist. Tell your doctor about any medicines you are taking, including over-the-counter drugs, complementary therapies and herbal drugs.
Medical and dental treatment
If you need to go into hospital for any reason other than cancer, always tell the doctors and nurses that you are having chemotherapy. Explain you are taking chemotherapy tablets that no one should stop or restart without advice from your cancer doctor. Give them contact details for your cancer doctor.
Talk to your cancer doctor or nurse if you think you need dental treatment. Always tell your dentist you are having chemotherapy.
This section has been compiled using information from a number of reliable sources, including:
electronic Medicines Compendium (eMC). www.medicines.org.uk (accessed July 2013).
Perry MC. The Chemotherapy Source Book. 5th edition. Lippincott Williams and Wilkins. 2012
With thanks to Catherine Loughran, Lead Pharmacist Haematology who reviewed this edition.
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