R-ICE is a chemotherapy treatment that is used to treat lymphoma.
This information should ideally be read with our general information about chemotherapy and the type of cancer you have.
The drugs used in R-ICEBack to top
R-ICE is named after the initials of the drugs used:
Rituximab is not a chemotherapy drug. It belongs to a group of drugs called monoclonal antibodies.
You will have R-ICE during a short stay in hospital. A chemotherapy nurse will give it to you. During treatment, you usually see a cancer doctor, a blood specialist (haematologist), 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 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 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.
Your nurse will give you paracetamol tablets before you start your treatment. Then they will give you anti-sickness drugs and an anti-histamine as an injection into a vein or as tablets. Your treatment will be given through one of the following:
- a fine tube that goes under the skin of your chest and into a vein close by (central line)
- a fine tube that is put into a vein in your arm and goes up into a vein in your chest (PICC line).
The nurse will give you the drugs as four separate drips (infusions). They usually run each drip through a pump, which gives you the treatment over a set time. Because there are lots of drugs and fluids given in R-ICE, you may have two drips running at the same time.
Ifosfamide can irritate the bladder lining and cause bleeding. To help prevent this, you will have infusions of a drug called mesna (Uromitexan ®). Occasionally, mesna is given as tablets. There is more information about bladder irritation in the common side effects section of this information.
When the chemotherapy is being given
Some people might have the following side effects while they are having the chemotherapy:
Rituximab may cause an allergic reaction while it’s being given. This is more common with the first treatment, so you have it slowly over a few hours. The nurse will give you drugs to help prevent or reduce this. If you have a reaction, they will treat it quickly. Occasionally other drugs are given as part of the R-ICE treatment, which may cause an allergic reaction.
Signs of a reaction can include:
- flu-like symptoms (headaches, high temperature or chills)
- feeling sick
- a rash
- feeling itchy
- pain in your back, tummy or chest
- feeling unwell.
Tell your nurse straight away if you have any of these symptoms. Rarely, a reaction can happen a few hours after treatment. If you develop any of these symptoms, let your nurse know straight away.
The drug leaks outside the vein
If this happens when you’re having treatment, it can damage the tissue around the vein. This is called extravasation. Tell the nurse straight away if you have any stinging, pain, redness or swelling around the vein. Extravasation is rare, but if it happens, it’s important that it’s dealt with quickly.
Low blood pressure
Some people's blood pressure falls while they are having rituximab. If you usually take medicine to lower your blood pressure, your doctor may ask you not to take it for 12 hours before having rituximab. The nurse will check your blood pressure regularly.
If you get any of these symptoms after you get home, contact the doctor or nurse straight away on the number they gave you.
Your course of R-ICE
You will have chemotherapy as a course of several sessions (cycles) of treatment over a few months. A cycle of R-ICE usually takes 21 days, but it may also be given over 28 days. Your doctor or nurse will tell you which cycle you will have.
Two days before your first cycle of R-ICE, you will be given rituximab through a drip (infusion).
You then have R-ICE as follows:
- On day one, your nurse gives you rituximab as an infusion. They also give you a one-hour infusion of etoposide.
- On day two, your nurse gives you a one-hour infusion of etoposide and a one-hour infusion of carboplatin. They also give you an infusion of mesna over about 15 minutes, then a 24-hour infusion of ifosfamide and mesna.
- On day three, your nurse gives you a one-hour infusion of etoposide. And when the 24-hour infusion of ifosfamide and mesna from day two has finished, they give you a 12-hour infusion of mesna.
After this, you have a rest period with no chemotherapy for 18 or 25 days, before beginning your next cycle of R-ICE. From your second cycle onwards, you will only have rituximab on day one. Usually, 2–4 cycles of treatment are given over 2–4 months. This makes up a course of treatment.
Before you go home, the nurse or pharmacist will give you tablets to take. These will include anti-sickness tablets, and tablets to help prevent infections. Take all your tablets exactly as explained.
While you are having R-ICE treatment, you will have injections of a drug called G-CSF (granulocyte-colony stimulating factor). This is a type of protein that stimulates the bone marrow to make white blood cells. This helps reduce infection. You may have the injections at the hospital, or you may have them at home. They are given under the skin (subcutaneously). You usually begin the injections on the sixth day of each cycle of R-ICE. Your doctor or nurse will tell you how many days you will have them for. Your nurse will teach you to give them to yourself, or it may be possible to arrange for your GP practice nurse to do them.
Possible side effects of R-ICEBack to top
We explain the most common side effects of R-ICE 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.
Serious and life-threatening side effects
Sometimes cancer drugs can result in very serious side effects, which rarely may be life-threatening. Your cancer doctor or nurse can explain the risk of these side effects to you.
Contact the hospital
Your nurse will give you telephone numbers for the hospital. You can call them if you feel unwell or need advice at any time of the day or night. Save these numbers in your phone or keep them somewhere safe.
More information about this drug
We’re not able to list every side effect for this treatment here, particularly the rarer ones. For more detailed information, you can visit the electronic Medicines Compendium (eMC).
Common side effects of R-ICEBack to top
Risk of infection
R-ICE reduces 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. Your nurse will give you injections of a drug called G-CSF under the skin. It encourages the bone marrow (where blood cells are made) to make more white blood cells.
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 – these 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 number of white blood cells is still low, your doctor may delay your treatment for a short time.
Bruising and bleeding
R-ICE can reduce 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)
R-ICE 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 (known as a blood transfusion).
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.
Ifosfamide may irritate your bladder and cause discomfort when you pass urine. Make sure you drink at least two litres (three and a half pints) of fluids during the 24 hours after 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.
You will be given fluids through a drip (infusion) and a drug called mesna (Uromitexan ®) as an infusion and/or tablets. This helps prevent bladder irritation.
Tell your nurse or doctor straight away if you feel any discomfort or stinging when you pass urine, or if you notice any blood in your urine.
You usually lose all the hair on your head. Your eyelashes, eyebrows and other body hair may also thin or fall out. 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 until your hair grows back. Your nurse can give you advice about coping with hair loss.
Your doctor can prescribe drugs to control diarrhoea. Let them know if it is severe or if it doesn’t get better. Make sure you drink at least two litres (three and a half pints) of fluids every day if you have diarrhoea.
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 or dentures every morning, evening, 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.
You may get a bitter or metallic taste in your mouth or find that food tastes different. This should go away when your treatment finishes. Try using herbs and spices (unless you have a sore mouth or ulcers) or strong-flavoured sauces to give your food more flavour. Sucking boiled sweets can sometimes help get rid of a bitter or metallic taste. Your nurse can give you more advice.
Chemotherapy may affect your skin. 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.
Feeling very tired is a common side effect. It’s often worse towards the end of treatment and for some weeks after it’s finished. Try to pace yourself and get as much rest as you need. It helps to balance this with some gentle exercise, such as short walks. If you feel sleepy, don’t drive or operate machinery.
Loss of appetite
You may lose your appetite during your treatment. If you can’t face big meals, try to eat small, frequent meals or snacks instead of three meals a day. Don’t worry if you don’t eat much for a day or two.
If your appetite doesn’t improve after a few days, let your nurse or dietitian know. They can give you advice on getting more calories and protein in your diet. They may give you food supplements or meal replacement drinks to try. Your doctor can prescribe some of these and you can buy them from chemists.
Less common side effects of R-ICEBack to top
Changes in the way the heart works
Some of the drugs used in R-ICE can affect the way the heart works. You may have tests to see how well your heart is working before, during and sometimes after treatment.
If you have any of these symptoms at any time during or after treatment, tell a doctor straight away:
- pain or tightness in your chest
- changes to your heartbeat.
These symptoms can be caused by other conditions, but it’s important to get them checked by a doctor.
Changes in the way the kidneys and liver work
R-ICE can affect how your kidneys and liver work. This is usually mild and goes back to normal after treatment. You will have blood tests before chemotherapy to check how well your kidneys and liver are working.
Effects on the nervous system
Ifosfamide can affect the nervous system. You may feel very drowsy or confused, or you may have hallucinations. You may feel dizzy or unsteady. Rarely, this treatment can cause fits (seizures). You may be given medication to prevent this. Tell your doctor or nurse straight away if you notice any of these symptoms. They may make some changes to your treatment if they become a problem for you.
It’s important not to drive or operate machinery if you have these side effects.
Tumour lysis syndrome (TLS)
R-ICE may cause the cancer cells to break down very quickly. This releases uric acid (a waste product) into the blood. The kidneys usually get rid of uric acid, but they may not be able to cope with large amounts. This can cause chemical imbalances in the blood that affect the kidneys and the heart. This is called tumour lysis syndrome (TLS).
To reduce the risk of TLS, your doctor may give you a drug called rasburicase. You will have this as a drip. You will also be given fluid through your drip to help protect your kidneys. You may only need rasburicase with the first treatment. After that, you may have tablets called allopurinol (Zyloric ®) instead.
Rarely, ifosfamide can increase the risk of developing a second cancer, usually leukaemia, years later. But the benefits of treatment usually far outweigh this risk. Your doctor can talk to you about this.
It is 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 R-ICEBack to top
Blood clot risk
Cancer increases the chance of a blood clot (thrombosis) and chemotherapy can add to this. A clot can cause symptoms such as:
- pain, redness and swelling in a leg
- 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.
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. Etoposide and ifosfamide may affect the way some drugs work. Tell your doctor about any medicines you are taking, including over-the-counter drugs, complementary therapies and herbal drugs.
R-ICE can affect your fertility (being able to get pregnant or father a child). If you are worried about this, you can talk to your doctor before treatment starts.
Your doctor will advise you not to become pregnant or father a child during treatment. This is because the drugs may harm a developing baby. It’s important to use contraception during and for a few months after chemotherapy. You can talk to your doctor or nurse about this.
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 your semen or vaginal fluid.
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.
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.
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. 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 page has been compiled using information from a number of reliable sources, including the electronic Medicines Compendium (eMC; medicines.org.uk). If you’d like further information on the sources we use, please feel free to contact us.
This information was reviewed by a medical professional.
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