This information is about a chemotherapy treatment for non-Hodgkin lymphoma called R-CHOP.
The drugs that are used
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R-CHOP is named after the initials of the drugs used, which are:
Rituximab belongs to a group of drugs called monoclonal antibodies. These are used to try to destroy some types of cancer cells while causing little harm to normal cells. They are designed to recognise certain proteins that are found on the surface of some cancer cells. The monoclonal antibody recognises the protein and locks onto it like a key in a lock. This then triggers the body’s immune system to attack the cancer cells and can sometimes cause the cells to destroy themselves.
Rituximab is used to treat several different types of B-cell lymphoma. It locks onto a protein called CD20, which is found on the surface of one of the main types of normal white blood cells (B-cell lymphocytes). It is also present on the surface of most of the abnormal B-cell lymphocytes that occur in some types of non-Hodgkin lymphoma. Rituximab acts by attacking both abnormal (malignant) and normal B-cell lymphocytes. The body can quickly replace any normal white blood cells that are damaged.
How treatment is given
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R-CHOP can usually be given to you as a day patient. However, the first treatment may take longer so you may need to stay in hospital overnight, or come back the next day.
Before you start treatment, you'll need to have a blood test on the same day or a few days beforehand. You'll 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. All of this may take a couple of hours.
The nurse will put a thin, flexible tube (cannula) into a vein in your hand or arm. You may find this uncomfortable or a little painful, but it shouldn't take long. Some people have their chemotherapy given through a thin, plastic tube that is inserted under the skin and into a vein near their collarbone (central line), or passed through a vein in the crook or their arm (PICC line). Your doctor or nurse will explain more about this to you.
You'll be given anti-sickness (anti-emetic) drugs. These are usually given by injection through the cannula or into your line, but they can also be given as tablets.
The first dose of rituximab is given slowly into the vein as a drip (infusion) over a few hours, as some people can have an allergic reaction to it. If you have a reaction, the infusion can be stopped and started again more slowly when the symptoms have reduced. You may need to stay in hospital overnight for the first treatment so that you can be monitored. You should be able to have your second and subsequent doses of rituximab more quickly and all your treatment as an outpatient. However, it may take about four hours for all the drugs to be given.
R-CHOP treatment is given by a combination of injections into the tubing of a drip (infusion) and by drips. The prednisolone is taken as tablets. The first dose of prednisolone is usually taken before the rituximab and you may be given it to take at home.
The drugs to be given into the vein are usually given in the following order:
Rituximab (a colourless fluid) is given in a drip bag.
Doxorubicin (a red fluid) is given as an injection into the drip tubing.
Vincristine (a colourless fluid) is given as a short infusion.
Cyclophosphamide (a colourless fluid) is usually given as an infusion but may be given as an injection into the tubing.
When all the drugs have been given the nurse will remove your cannula and you can go home. If you have a central or PICC line, it will usually stay in place ready for the next cycle of your chemotherapy.
You'll be shown how to look after the line. Before you go home you'll be given a course of prednisolone tablets. It's important to take all the tablets as prescribed by your doctor.
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 stopping it once it starts.
How often treatment is given
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Your doctor may use the word 'regimen' (eg the R-CHOP regimen) when talking about your chemotherapy. This refers to the whole plan or schedule of your particular chemotherapy treatment.
On the first day of your treatment you'll be given rituximab, doxorubicin, vincristine and cyclophosphamide. On the same day you'll begin a five-day course of prednisolone tablets. When you've finished the tablets, you'll have a rest period with no treatment for the next 16 days. This completes what's called a cycle of treatment. Each cycle takes 21 days.
After the rest period the same treatment will be repeated again, which begins your next cycle of chemotherapy. Usually 6–8 cycles are given over a period of 3–4 months. This makes up a course of treatment.
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 is having 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 do notice any effects that aren't listed here, discuss them with your doctor, chemotherapy nurse or pharmacist.
Some people have an allergic reaction to rituximab while it’s being given. Signs of this include flu-like symptoms (such as headaches, 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 after you get home, contact the hospital straight away for advice.
Low blood pressure
This may happen during the infusion of rituximab, so your blood pressure will be regularly checked.
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.
You may have a sudden feeling of warmth and some reddening in your face. This can happen for a short period of time while the drug is being given.
Risk of infection
R-CHOP can reduce the number of white blood cells, which help to 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 38ºC (100.4ºF)
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 the number of your blood cells (blood count) is still low.
Bruising and bleeding
R-CHOP 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 may need to have a platelet transfusion if your platelet count is low.
R-CHOP 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.
Vincristine and some anti- sickness drugs can cause constipation and tummy (abdominal) pain. You may be prescribed medicine to prevent this. Drinking plenty of fluids, eating a high-fibre diet and doing some exercise may also help. Tell your doctor or nurse if you get constipated or have tummy pain.
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 some gentle exercise, such as short walks, which will help. If tiredness is making you feel sleepy, don’t drive or operate machinery.
This usually starts 3–4 weeks after starting treatment, although it may occur earlier. Hair usually falls out completely. 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 the treatment has finished. Your hair may grow back straighter, curlier, finer, or a slightly different colour than it was before. Your nurse can give you advice about coping with hair loss.
Your mouth may become sore or dry, 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 reduce the risk of this happening. Some people may find sucking on ice soothing. Tell your nurse or doctor if you have any of these problems, as they can prescribe mouthwashes and medicine to prevent or clear mouth infections.
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.
Irritation of the stomach lining
Prednisolone 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.
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.
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. Doxorubicin is red and, as a result, your urine may become a pink-red colour. This is normal and can last up to 48 hours after your treatment. Let your doctor know if you have any discomfort when you pass urine, or if you notice any blood in it.
Numbness or tingling in the hands or feet
This is due to the effect of vincristine 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's 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.
Raised blood sugar
Occasionally prednisolone can cause your blood sugar level to rise. During treatment you may have regular blood tests to check this. Your urine may also be tested for sugar.
Tell your doctors know 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.
Less common side effects
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Prednisolone may affect the salt and water balance in your body. You may notice that your ankles and/or fingers swell. Some people have a bloated feeling in the abdomen. Let your doctor know if this happens. This is usually only a problem with long-term steroid 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.
Sometimes areas of skin that have been treated with radiotherapy may become red and sore. Tell your doctor if this happens.
The colour of your nails may change. They may become darker and white lines may appear on them. These usually grow out over several months once the treatment has finished.
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.
Changes in the way your heart works
This is very rare with standard doses of doxorubicin but may occasionally occur with high-dose treatment. The muscle of the heart may be affected, usually temporarily. Tests to see how well your heart is working may be carried out before the drug is given.
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 the risk of developing a blood clot (thrombosis), and 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’s important to tell your doctor straight away if you notice any of these symptoms. Most clots can be treated with drugs that thin the blood. The doctor or nurse can give you more information.
Some medicines, including those you can buy in a shop or chemist, can be harmful to take when you're having chemotherapy. Tell your doctor about any medicines you're taking, including over-the-counter drugs, complementary therapies and herbal drugs.
Leakage into the tissue around the vein (extravasation)
If this happens when doxorubicin or vincristine is being given, the tissue in that area can be damaged. Tell the doctor or nurse immediately if you notice any stinging or burning around the vein while the drug is being given. This is unlikely to happen if the chemotherapy is given through a central or PICC line.
If the area around the injection site becomes red or swollen at any time, you should tell the doctor or nurse on the ward. If you're at home, ring the clinic or ward and ask to speak to the doctor or nurse.
Your ability to become pregnant or father a child is likely to 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 having this treatment as it may harm the developing baby. It’s important to use effective contraception while taking/having this drug and for at least a few months afterwards. You can discuss this with your doctor or nurse.
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.
Loss of periods in women
Because of the effect of chemotherapy on the ovaries, women may find that their periods become irregular and may eventually stop. In some women this may be temporary, but for others it will be permanent. This will result in menopausal symptoms, such as hot flushes, sweats and vaginal dryness.
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're 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 prednisolone tablets
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It’s important to take your tablets at the right times as directed by your doctor.
Always tell any doctors treating you for non-cancerous conditions that you're taking a course of chemotherapy tablets that should not be stopped or restarted without advice from your cancer specialist.
Keep the tablets in their original packaging, and store them at room temperature away from heat and direct sunlight.
Keep the tablets in a safe place and out of the reach of children.
If your doctor decides to stop the treatment, return any remaining tablets to the pharmacist. Don't flush them down the toilet or throw them away.
If you're sick just after taking the tablets, tell your doctor as you may need to take another dose. Don't take another tablet/capsule without telling your doctor first.
If you forget to take a tablet, don't take a double dose. Let your doctor know and keep to your regular dose schedule.
This section is based on our R-CHOP 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. 2009. 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.