CODOX-M chemotherapy is used to treat high-grade lymphomas such as Burkitt lymphoma and some diffuse large B-cell lymphomas.
CODOX-M chemotherapy is used to treat high-grade lymphomas, such as Burkitt lymphoma and some diffuse large B-cell lymphomas. It is best to read this information with our general information about chemotherapy and the type of cancer you have.
CODOX-M is named after the initials of the chemotherapy drugs used:
- C – cyclophosphamide and cytarabine
- O – vincristine, also known as oncovin
- DOX – doxorubicin
- M – methotrexate.
Some people will also have a targeted therapy drug called rituximab with each cycle. The combination is then called R-CODOX-M.
Sometimes, a chemotherapy treatment called IVAC is given between each cycle of CODOX-M. Your doctor, specialist nurse, or pharmacist will give you more information. They will also talk to you about the possible side effects before you agree (consent) to have treatment.
CODOX-M is often given during a stay in hospital. Some people may have some or all of the treatment in a chemotherapy day unit. Your doctor or nurse will tell you where you will have treatment. A chemotherapy nurse will give it to you.
During treatment you usually see a cancer doctor, a haematologist, a chemotherapy nurse or a specialist nurse, and a specialist pharmacist. This is who we mean when we mention doctor, nurse, or pharmacist 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 your blood cells are at a safe level to have chemotherapy.
You will see a doctor or nurse before you have chemotherapy. They will ask you how you have been feeling. If your blood results are okay, the pharmacist will prepare your chemotherapy. Your nurse will tell you when your treatment is likely to be ready.
Your nurse usually gives you anti-sickness (anti-emetic) drugs before the chemotherapy. CODOX-M is given:
- through a short, thin tube the nurse puts into a vein in your arm or hand (cannula)
- through a fine tube that goes under the skin of your chest and into a vein close by (central line)
- through a fine tube that is put into a vein in your arm and goes up into a vein in your chest (PICC line)
- through an implantable port (portacath) that is put into a vein and has an opening (port) under the skin on your chest or arm
- as an injection into the fluid around your spinal cord (intrathecally).
Your course of chemotherapy
You usually have CODOX-M as a course of up to 4 cycles over a few months. Each cycle of CODOX-M is usually given over 10 to 15 days.
CODOX-M can be given in different ways. We describe one way you might have it. Your doctor or nurse will be able to give you details about your treatment course.
The days you have the cytarabine and methotrexate may be different. This does not affect how the chemotherapy works.
- On day 1 – the nurse will give you infusions of:
The infusions each last about 5 to 10 minutes.
You will also be given an injection of cytarabine into the fluid around your spinal cord (intrathecal injection).
- On days 2, 3, 4, and 5 – the nurse will repeat the infusion of cyclophosphamide.
- On day 3 – you will be given an injection of cytarabine into the fluid around your spinal cord.
- On day 8 – the nurse will give you an infusion of vincristine.
- On day 10 – the nurse will give you two infusions of methotrexate. The first is given over 1 hour. The second is given over 23 hours.
- On day 15 – you will be given an injection of methotrexate into the fluid around your spinal cord.
Before having methotrexate, you will be given extra fluids through a drip to protect your kidneys. You may be asked for a urine sample. This is to check how well your kidneys are working.
A drug called leucovorin (folinic acid) is given 36 hours after starting methotrexate treatment. This helps to reduce the side effects of methotrexate. Folinic acid can be given into your cannula or line while you are attached to a drip. You have it regularly with fluids until the methotrexate is out of your system. Folinic acid is sometimes given as tablets. Your blood may be tested to check how much methotrexate is in your blood.
CODOX-M reduces the number of cells in your blood, which makes you more at risk of infection and bleeding. Doctors test your blood regularly during treatment to measure the numbers of these cells (blood count). Your doctor or nurse will tell you when your blood will be tested.
About side effects
We explain the most common side effects of this treatment here. We also include some less common side effects. You may get some of the side effects we mention, but you are unlikely to get all of them.
You may also have some side effects that we have not listed here. Always tell your doctor, nurse or pharmacist about any side effects you have.
Your doctor can give you drugs to help control some side effects. It is important to take them exactly as your nurse or pharmacist explains. This means they will be more likely to work for you. Your nurse will give you advice about managing your side effects. After your treatment is over, most side effects start to improve.
Serious and life-threatening side effects
Some cancer treatments can cause severe side effects. Rarely, these 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. If you feel unwell or need advice, you can call them at any time of the day or night. Save these numbers in your phone or keep them somewhere safe.
We cannot list every side effect for this treatment. There are some rare side effects that are not listed. You can visit the electronic Medicines Compendium (eMC) to download a Patient Information Leaflet (PIL) for these drugs. The leaflet lists all known side effects.
Some people have an allergic reaction while having this treatment. Signs of a reaction can include:
- feeling hot or flushed
- a skin rash
- feeling dizzy
- a headache
- feeling breathless
- swelling of your face or mouth
- pain in your back, tummy or chest.
Your nurse will check you for signs of a reaction during your treatment. If you feel unwell or have any of these signs, tell them straight away. If you do have a reaction, it can be treated quickly.
Sometimes a reaction can happen a few hours after treatment. If you get any signs or feel unwell after you get home, contact the hospital straight away.
Pain along the vein
You may get pain at the place where the injection is given or along the vein. If you feel pain, tell your nurse or doctor straight away so that they can check the site. They may give the drug more slowly or flush it through with more fluid to reduce pain.
The drug leaks outside the vein
If the drug leaks outside the vein, it can damage the surrounding tissue. This is called extravasation. Extravasation is not common but if it happens it is important to treat it quickly. Tell your nurse straight away if you have any stinging, pain, redness or swelling around the vein.
If you get any of these symptoms after you get home, contact the doctor or nurse straight away on the contact telephone number they gave you.
Risk of infection
This treatment can reduce the number of white blood cells in your blood. These cells fight infection. If the number of white blood cells is low, you are more likely to get an infection. A low white blood cell count is called neutropenia.
If you have an infection, it is important to treat it as soon as possible. Contact the hospital straight away on the 24-hour contact number you have if:
- your temperature goes over 37.5°C (99.5°F)
- you suddenly feel unwell, even with a normal temperature
- you have symptoms of an infection.
Symptoms of an infection include:
- feeling shivery
- a sore throat
- a cough
- needing to pass urine often.
It is important to follow any specific advice your cancer treatment team gives you.
The number of white blood cells will usually return to normal before your next treatment. You will have a blood test before having more treatment. If your white blood cell count is low, your doctor may delay your treatment for a short time.
G-CSF (granulocyte-colony stimulating factor) is a type of drug called a growth factor. It encourages the body to make more white blood cells.
Your doctor may give you G-CSF:
- if the number of white blood cells is very low
- to stop the number of white blood cells getting low.
You have it as a small injection under the skin.
Bruising and bleeding
This treatment 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 that you cannot explain. This includes:
- bleeding gums
- tiny red or purple spots on the skin that may look like a rash.
Some people may need a drip to give them extra platelets. This is called a platelet transfusion.
Anaemia (low number of red blood cells)
This treatment 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. This is called a blood transfusion.
You may feel sick in the first few days of your treatment. The nurses will give you anti-sickness drugs regularly. If you still feel sick, tell your nurse or doctor. They can change the anti-sickness drug to one that works better for you.
Tell your doctor or nurse straight away if you vomit blood or have vomit that looks like coffee grounds.
Cyclophosphamide may irritate your bladder and cause discomfort when you pass urine (pee). Make sure you drink plenty of fluids during the 24 hours following chemotherapy. Try to drink at least 2 litres (3 ½ pints).
It is also important to empty your bladder regularly and to try to pass urine as soon as you feel the need to go.
Tell your nurse straight away if you feel any discomfort or stinging when you pass urine, or if you notice any blood in it.
Your nurse may ask you for a sample of urine so that they can check it for any blood or infection.
Urine (pee) changing colour
Your hair will get thinner or you may lose all the hair from your head. You may also lose your eyelashes, eyebrows or other body hair. Hair loss usually starts after your first or second treatment.
Your nurse can talk to you about ways to cope with hair loss. There are ways to cover up hair loss if you want to. It is important to cover your head to protect your scalp when you are out in the sun.
Hair loss is almost always temporary and your hair will usually grow back after treatment ends.
This treatment can cause constipation. Here are some tips that may help:
- Drink at least 2 litres (3½ pints) of fluids each day.
- Eat high-fibre foods, such as fruit, vegetables and wholemeal bread.
- Do regular gentle exercise, like going for short walks.
If you have constipation, contact the hospital for advice. Your doctor can give you drugs called laxatives to help.
This treatment may cause severe diarrhoea. Diarrhoea means passing more stools (poo) than is usual for you, or having watery or loose stools. If you have a stoma, it will be more active than usual.
Your hospital team may give you anti-diarrhoea drugs to take at home.
If you have diarrhoea or a mild increase in stoma activity:
- follow any advice from your cancer team about taking anti-diarrhoea drugs
- drink at least 2 litres (3½ pints) of fluids each day
- avoid alcohol, caffeine, milk products, high-fat foods and high-fibre foods.
Contact the hospital straight away if:
- you have diarrhoea at night
- you have diarrhoea more than 4 times in a day
- you have a moderate or severe increase in stoma activity
- the anti-diarrhoea drugs do not work within 24 hours.
You may need to go to hospital to have fluids through a drip.
Numb or tingling hands or feet (peripheral neuropathy)
This treatment affects the nerves, which can cause numb, tingling or painful hands or feet. You may find it hard to fasten buttons or do other fiddly tasks.
Tell your doctor if you have these symptoms. They sometimes need to lower the dose of the drug. The symptoms usually improve slowly after treatment finishes, but for some people they may never go away. Talk to your doctor if you are worried about this.
You may get a sore mouth or mouth ulcers. This can make you more likely to get a mouth infection.
Use a soft toothbrush to clean your teeth or dentures in the morning, at night and after meals.
If your mouth is sore:
- tell your nurse or doctor – they can give you a mouthwash or medicines to help
- try to drink plenty of fluids
- avoid alcohol, tobacco, and foods that irritate your mouth.
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. You may get a rash, which may be itchy.
Always tell your doctor or nurse about any skin changes. They can give you advice and may give you creams or medicines to help. Any changes to your skin are usually temporary and improve when treatment finishes.
This treatment may cause headaches. If this happens, tell your doctor or nurse. They can give you painkillers.
Effects on the kidneys
This treatment can affect how your kidneys work. This is usually mild and goes back to normal after treatment. You will have blood and urine tests to check how well your kidneys are working.
It is important to drink at least 2 litres (3 ½ pints) of fluids each day to help protect your kidneys.
Changes in the way the liver works
This treatment 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.
Loss of appetite
This treatment can affect your appetite. Your nurse or dietician will give you advice. They may give you food or drink supplements to take.
Changes to your taste
You may get a bitter or metal taste in your mouth. Sucking sugar-free sweets may help with this. Some foods may taste different or have no taste. Try different foods to find out what tastes best to you. Taste changes usually get better after treatment finishes. Your nurse can give you more advice.
Changes to your hearing
Some people may notice some hearing loss or deafness. Tell your doctor if you notice any changes to your hearing.
Muscle or joint pain
You may get pain in your muscles or joints for a few days after treatment. If this happens, tell your doctor so they can give you painkillers. Tell them if the pain does not get better. Having warm baths and taking regular rests may help.
Effects on the heart
Chemotherapy can affect the way the heart works. You may have tests to see how well your heart is working. These may be done before, during, and sometimes after treatment. If the treatment is causing heart problems, your doctor can change the type of chemotherapy you are having.
Contact a doctor straight away if you:
- have pain or tightness in your chest
- feel breathless or dizzy
- feel your heart is beating too fast or too slowly.
Other conditions can cause these symptoms, but it is important to get them checked by a doctor.
Some chemotherapy drugs can increase the risk of heart problems later in life. Your doctor can give you more information about this.
Effects on the lungs
This treatment can cause changes to the lungs. Tell your doctor if you develop:
- a cough
- a fever (high temperature)
You should also tell them if any existing breathing problems get worse. You may have tests to check your lungs.
Effects on the nervous system
This treatment can affect the nervous system. You may feel drowsy or confused, dizzy or unsteady. 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 is important not to drive or operate machinery if you notice these effects. Rarely, this treatment can cause seizures (fits).
Vincristine may cause pain in your jaw. Tell your nurse or doctor if you notice this.
Let your doctor know if you develop any pain in your tummy (abdomen). It can usually be controlled with mild painkillers.
Raised levels of uric acid in the blood (tumour lysis syndrome)
This treatment may cause the cancer cells to break down quickly. This releases uric acid (a waste product) into the blood. The kidneys usually get rid of uric acid but may not be able cope with large amounts. Too much uric acid can cause swelling and pain in the joints (gout).
Your doctor may give you drugs to help prevent this. Drinking at least 2 litres (3½ pints) of fluid a day will also help. You will have regular blood tests to check the uric acid levels.
Blood clot risk
Cancer and some cancer treatments can increase the risk of a blood clot. Symptoms of a blood clot include:
- pain, redness or swelling in a leg or arm
- chest pain.
If you have any of these symptoms, contact a doctor straight away.
A blood clot is serious, but can be treated with drugs that thin the blood. Your doctor or nurse can give you more information.
Your doctor may advise you not to drink alcohol while having treatment. This is to help protect your kidneys.
Do not drive if you feel dizzy or tired, or if your vision is affected. If you are being given cytarabine into the spinal cord, do not drive on the day of your treatment.
Talk to your doctor for advice if you are not sure whether you are safe to drive.
Some medicines can affect how this treatment works or be harmful when you are having it. Always tell your cancer doctor about any drugs you are taking or planning to take, such as:
- medicines you have been prescribed
- medicines you buy in a shop or chemist
- vitamins, herbal drugs and complementary therapies.
Tell other doctors, pharmacists or dentists who prescribe or give you medicines that you are having this cancer treatment.
You can visit the electronic Medicines Compendium (eMC) for more detailed information about your treatment.
Your doctor will advise you not to get pregnant or make someone pregnant while having this treatment. The drugs may harm a developing baby. It is important to use contraception during your treatment and for a while after treatment finishes. Your doctor, nurse or pharmacist can tell you more about this.
Women are advised not to breastfeed while having this treatment. This is because the drugs could be passed to the baby through breast milk.
Some cancer drugs can affect whether you can get pregnant or make someone pregnant.
If you are a woman, your periods may become irregular or stop. This may be temporary, but for some women it is permanent. Your menopause may start sooner than it would have done.
If you have sex in the first few days after chemotherapy, you need to use a condom. This is to protect your partner in case there is any chemotherapy in semen or vaginal fluids.
Medical and dental treatment
If you need medical treatment for any reason other than cancer, always tell the doctors and nurses that you are having cancer treatment. Give them the contact details for your cancer doctor so they can ask for advice.
If you think you need dental treatment, talk to your cancer doctor or nurse. Always tell your dentist you are having cancer treatment.