DHAP and R-DHAP chemotherapy
This information is about two similar chemotherapy treatments for lymphoma called DHAP and R‑DHAP. Your hospital doctor or nurse will explain to you which one you'll be having.
The drugs that are used
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DHAP is named after the drugs used, which are:
R-DHAP also includes the monoclonal antibody drug rituximab (Mabthera®).
Rituximab belongs to a group of drugs known as monoclonal antibodies. It's used to treat several different kinds of B-cell non-Hodgkin lymphoma.
Monoclonal antibodies recognise and lock on to specific proteins on the surface of cancer cells. This helps the body's immune system to recognise the cancer cells and destroy them. Monoclonal antibodies are sometimes called targeted therapies because they target cancer cells.
Rituximab locks on to a protein called CD20, which is found on the surface of white blood cells called B-lymphocytes or B-cells. This triggers the body’s immune system to attack the cells and destroy them.
As well as being found on the surface of normal B-cells, CD20 is also present on most of the abnormal B-cells, which occur in many types of non‑Hodgkin lymphoma and on some of the abnormal B-cells found in CLL.
Rituximab destroys both abnormal (malignant) and normal B-cells. However, the body can replace normal B-cells that are damaged so their numbers recover once treatment is over.
How treatment is given
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DHAP or R-DHAP treatment is usually given during a short stay in hospital.
You'll need to have a blood test before you start treatment, either on the same day or a few days beforehand. You will also be seen by a doctor, specialist nurse or pharmacist. If the results of your blood test are normal, the pharmacy will prepare your chemotherapy drugs. This may take a couple of hours.
DHAP may be given in one of the following ways:
as a drip (infusion) through a fine tube (cannula) inserted into a vein (intravenously), usually in the back of your hand
through a fine plastic tube inserted under the skin into a vein near your collarbone (central line)
into a fine tube inserted into a vein in the crook of your arm (PICC line).
Your doctor or nurse will explain more about this to you.
You'll be given some anti-sickness (anti-emetic) drugs. These are usually given by injection through the cannula, central line or PICC line, which is connected to a drip (infusion). Some anti-sickness medicines are given as tablets.
The steroid and chemotherapy drugs are then given separately.
If you're being treated with R-DHAP, the rituximab (a colourless fluid in a drip bag) is given as an infusion into your cannula or line. The first dose of rituximab is given slowly over a few hours, as some people can have an allergic reaction to it. You'll be given medication to help reduce the chances of an allergic reaction.
If you do have an allergic reaction, the drip can be stopped and started again more slowly when the symptoms have reduced. You should be able to have your second and subsequent doses of rituximab more quickly.
While having DHAP or R-DHAP you'll also be given plenty of fluid through your drip to help keep your kidneys working normally. This is sometimes known as hydration. You may also be given a drug called mannitol, which is given as an infusion with the cisplatin. Mannitol increases the amount of urine that your kidneys produce.
How often treatment is given
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Your doctor may use the word 'regimen' (eg the DHAP regimen) when talking about your chemotherapy. This means the whole plan or schedule of your particular chemotherapy treatment. The treatment is planned over four days.
If you're having rituximab as part of R-DHAP, you will usually have this first.
The other drugs are given as follows:
Dexamethasone is given as tablets on days 1–4.
Cisplatin (a colourless fluid) is given as an infusion usually over 24 hours. Cisplatin is given on day one.
Cytarabine (a colourless fluid) is given as an infusion over about 2–3 hours. Cytarabine is given on day two and you will have two doses, usually 12 hours apart.
Dexamethasone tablets are usually taken in the morning with food or a glass of milk. Dexamethasone can sometimes be given to you as an infusion instead of tablets.
If you're taking dexamethasone tablets, you can go home when the chemotherapy infusions and hydration have finished. You will be given some dexamethasone tablets to take at home over the next two days (days three and four of your treatment). It's important to take these as directed. If you have been having dexamethasone infusions, you will need to stay in hospital for the infusions to be given on the third and fourth days. Before going home you will be given some steroid eye drops to take for the next 5–7 days that can help to prevent sore eyes.
Before going home the nurse will remove your cannula. If you have a central or PICC line it will usually stay in place, ready for your next cycle of chemotherapy. You will be shown how to look after the line.
You'll be given a supply of anti-sickness drugs to take home with you. It's important to take these as directed, even if you aren't feeling sick. This is because some anti-sickness drugs are much better at preventing sickness than at stopping it once it starts.
You'll then have a rest period with no chemotherapy, which completes one cycle of your chemotherapy treatment. Each cycle lasts 21 or 28 days.
You'll begin your next cycle of treatment after the rest period, which will be either three or four weeks after your first infusion.
Each person’s reaction to chemotherapy is different. Some people have very few side effects while others have more.
The side effects described here won't affect everyone who is having DHAP or R‑DHAP chemotherapy.
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
DHAP and R-DHAP 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'll be more prone to infections. A low white blood cell count is called neutropenia.
Neutropenia 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'll 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.
You may be given injections of G-CSF to help prevent the number of white blood cells getting too low. G-CSF is a type of protein that can stimulate the bone marrow to produce white blood cells. G-CSF is given as an injection under the skin (subcutaneously).
You may also be given antibiotics (called prophylactic antibiotics) to help prevent infections.
Bruising or bleeding
DHAP and R-DHAP 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.
DHAP and R-DHAP 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)
This may begin soon after the treatment is given. 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 can cause constipation. Let your doctor or nurse know if this is a problem.
Your kidneys may be affected
Cisplatin can affect your kidneys. This doesn't usually cause any symptoms and the effect is generally mild. Rarely, it may cause permanent damage to the kidneys unless the treatment is stopped.
Before each treatment, your kidneys will be checked by a blood test. You’ll be given fluid through a drip (infusion) before and after the treatment to keep your kidneys working normally. You may be asked to measure and record what you drink and the amount of urine you pass. It’s important to tell your nurse or doctor if you pass less urine than usual.
If necessary, you may be given medicine to help you pass urine. You may be asked to drink extra fluid before and after treatment. It's important to do this, so let your doctor know if this is a problem, for example, if you are feeling sick.
Some people have an allergic reaction to rituximab while it’s being given. Signs of this include flu-like symptoms (headache, high temperature or chills), feeling sick, skin rashes and itching, breathlessness, or pain in your back, tummy or chest.
It‘s most common with the first infusion, so the first dose is given slowly over a number of hours. You’ll also be given medicines before the treatment to help prevent or reduce any reaction. You’ll be monitored closely during your infusion but it's important to tell your nurse or doctor if you feel unwell or have any of the above symptoms. If you do have a reaction, it can be treated quickly.
Sometimes a reaction can happen a few hours after treatment. If you develop these symptoms or feel unwell, let your doctor or nurse know straight away.
Low blood pressure
This may happen during the infusion of rituximab, so your blood pressure will be checked regularly.
If you usually take drugs to lower your blood pressure your doctor may advise you to take these at least 12 hours before you have rituximab. It’s important not to do this without discussing it with your doctor first.
Your mouth may become sore or you may notice small ulcers during this treatment. Drinking plenty of fluids, and cleaning your teeth regularly and gently with a soft toothbrush, can help to reduce the risk of this happening. Some people may find sucking on ice soothing. You will be given mouthwashes to help keep your mouth clean and prevent infection. Your nurse will show you how to use these. Let your doctor know if you develop any problems, as you may need to have painkillers or antibiotics if your mouth becomes sore and infected.
Feeling tired is a common side effect of chemotherapy, especially towards the end of treatment and for some weeks after it’s over.
It’s important to try to pace yourself and get as much rest as you need. Try to balance this with taking some gentle exercise, such as short walks, which will help. If tiredness is making you feel sleepy, don’t drive or operate machinery.
Cytarabine may cause an inflammation of the lining of the eyelids (conjunctiva) that makes your eyes feel sore, red and itchy. You'll be given steroid eye drops to prevent this side effect occurring. It’s important to follow the instructions you are given.
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 will be checked with regular blood tests. If you are still taking dexamethasone when you go home, 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.
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.
Less common side effects
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Constipation or diarrhoea
DHAP and R-DHAP can cause constipation or diarrhoea. Constipation can usually be helped by drinking plenty of fluids, eating more fibre and doing some exercise.
You may need to take medicine to help (laxatives). Your doctor can prescribe these or you can buy them at a pharmacy.
Diarrhoea can usually be easily controlled with medicine but tell your doctor if it’s severe or continues. It's important to drink plenty of fluids if you have diarrhoea.
This is rare with this treatment, but your hair may become thinner. If you lose any hair it will grow back once the treatment has finished. Your nurse can give you advice about coping with hair loss.
Changes in hearing
Cisplatin may cause ringing in the ears (tinnitus) and you may lose the ability to hear some high-pitched sounds. Hearing loss can be more severe with higher doses and longer courses of treatment. Very occasionally, your sense of balance may be affected. Any hearing loss, and balance changes if they occur, may be permanent. However tinnitus usually improves when treatment ends. Tell your doctor if you notice any loss of hearing or tinnitus.
Numbness or tingling in the hands or feet
This is due to the effect of cisplatin on nerves and is known as peripheral neuropathy. You may also notice that you have difficulty doing up buttons or similar fiddly tasks.
Tell your doctor if you notice any numbness or tingling in your hands or feet. It is important to report your symptoms to your doctor as they may be controlled by slightly lowering the dose of the drug.
This side effect usually improves slowly, a few months after the treatment has finished. Sometimes symptoms can persist; talk to your doctor if this happens.
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.
Loss of appetite
Some people lose their appetite while they’re having chemotherapy. This can be mild and may only last a few days. If it doesn’t improve you can ask to see a dietitian or specialist nurse at your hospital. They can give you advice on improving your appetite and keeping to a healthy weight.
Behavioural changes and mood swings
Occasionally, steroids can cause mood swings, difficulty sleeping and perhaps 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.
You may develop an itchy rash. Your doctor can prescribe medicine to help with this. During treatment, and for several months afterwards, you'll be more sensitive to the sun and your skin may burn more easily. 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.
Cytarabine can cause soreness and redness of the palms of the hands and soles of the feet. This is temporary and usually improves once treatment finishes. Let your doctor know if this happens.
It’s important to let your doctor know straight away if you feel unwell or have any severe side effects, even if they’re not mentioned above.
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Risk of developing a blood clot
Cancer can increase your risk of developing a blood clot (thrombosis), and having chemotherapy may increase this risk further. A blood clot may cause symptoms such as pain, redness and swelling in a leg, or breathlessness and chest pain. Blood clots can be very serious, so it is important to tell your doctor straight away if you have any of these symptoms. Most clots can be treated with drugs that thin the blood. Your doctor or nurse can give you more information.
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's not advisable to become pregnant or father a child while taking this treatment, as it may harm the developing baby. It is important to use effective contraception while taking this drug, and for some time 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.
This section is based upon our DHAP and R-DHAP chemotherapy fact sheet, which has been compiled using information from a number of reliable sources including:
Sweetman, et al. Martindale: The Complete Drug Reference. 37th edition. 2011. Pharmaceutical Press.
British National Formulary. 62nd edition. 2011. British Medical Association and Royal Pharmaceutical Society of Great Britain.
electronic Medicines Compendium (eMC). (accessed October 2011).
Perry MC. The Chemotherapy Source Book. 4th edition. 2007. Lippincott Williams and Wilkins.