Carfilzomib, lenalidomide and dexamethasone (KRD)

Carfilzomib is given as a drip into a vein (intravenous infusion). You usually have it in a chemotherapy day unit or clinic as an outpatient. Lenalidomide and dexamethasone are capsules or tablets that you take at home.

During your course of treatment, you will meet someone from your cancer team, such as a:

• a blood cancer doctor called a haematologist 
• chemotherapy nurse or specialist nurse
• specialist pharmacist. 

This is who we mean when we mention doctor, nurse or pharmacist in this information.

Before or on the day of each treatment, you will have a blood test. This is to check that it is safe for you to have treatment. 

You will meet with a doctor, nurse or pharmacist before you have treatment. They will talk to you about your blood results and ask how you have been feeling. If your blood results are okay and you are well enough for treatment, the pharmacy team will prepare your cancer drugs. 

You usually have a course of several cycles of KRD over a few months. Each cycle lasts 28 days (4 weeks). The cycle includes days when you are given treatment and days when you do not have treatment. These days are called rest periods.

You will have carfilzomib twice a week for the first 3 weeks of each cycle. This will be given on days 1, 2, 8, 9, 15 and 16 of your cycle. 

You take lenalidomide once a day on days 1 to 21 of each 4-week cycle.

Your cancer team will explain when to take dexamethasone. Follow their instructions carefully. 

You usually keep having this treatment as long as it is effective and any side effects can be managed. If you are having this treatment for more than 12 cycles, your cancer team may make changes to your treatment plan. This will depend on how the cancer responds to the treatment. Your cancer team will discuss your treatment plan with you. They may give you a copy of the plan to take home.

Carfilzomib is given as a drip into a vein (intravenous infusion). It is given over 10 or 30 minutes depending on the dose. It can be given through:

• a cannula – a short, thin tube the nurse puts into a vein in your arm or hand
• a central line – a fine tube that goes under the skin of your chest and into a vein close by
• a PICC line – a fine tube that is put into a vein in your arm and goes up into a vein in your chest
• an implantable port (portacath) – a disc that is put under the skin on your chest or arm and goes into a vein in your chest.

Portacaths are rarely used to give this treatment. You are more likely to have carfilzomib through 1 of the other ways mentioned.

You may be asked to wait in the hospital for 1 to 2 hours after the injection. This is to check for any signs of a reaction to the treatment.

These drugs come in capsules or tablets. This means you can take them at home.

Your doctor, nurse or pharmacist will explain when and how to take each drug. They may give you capsules or tablets of different strengths. Make sure you understand which days you should take each drug and what dose you should take.

They may also give you anti-sickness drugs and other medicines to take home. Take all your capsules or tablets exactly as they have been explained to you.

You can take lenalidomide with or without food. This drug can make you sleepy, so you may want to take it in the evening. 

You should take dexamethasone with or after food, or with plenty of water. This drug can cause difficulty sleeping, so it is best to take it with breakfast or lunch. 

Swallow the lenalidomide and dexamethasone whole with a glass of water. Do not chew, open, break or crush the capsules or tablets. 

If you forget to take dexamethasone, take the missed dose as soon as possible. 

If you forget to take lenalidomide and there is less than 12 hours until your next dose, do not take the missed dose. Take the next dose at the usual time and tell your doctor, nurse or pharmacist. Do not take a double dose. Contact the hospital on the 24-hour number you have been given for advice if you are unsure. 

Other things to remember about your capsules or tablets:

• Wash your hands after taking them.
• Other people should avoid direct contact with them. If possible, you should handle the capsules yourself. If you need help, the person helping you should wear disposable gloves. If pregnant, the person should not touch or handle them at all. 
• If you are sick (vomit) just after taking them, do not take an extra dose. Take your next dose at the usual time.
• Keep them in the original package and at room temperature, away from moisture, heat and direct sunlight.
• Keep them safe, where children cannot see or reach them.
• Do not throw away unused capsules or tablets. Return them to your cancer team at the hospital.

This treatment may contain lactose. If you have a lactose allergy or intolerance, ask your doctor, nurse or pharmacist for more information.

We explain the most common side effects of this treatment here. We also include some that are less common.

You may get some of the side effects we mention, but you are unlikely to get all of them. And you may have some side effects, including rarer ones, that we have not listed here. 

Always tell your doctor, nurse or pharmacist about any side effects you have. They can give you: 

• drugs to help control some side effects
• advice about managing side effects. 

It is important to take any drugs exactly as explained. This means they will be more likely to work for you. 

Some cancer treatments can cause serious side effects. Sometimes, these may be life-threatening. Your doctor, nurse or pharmacist can explain the risk of these side effects to you.

Your doctor, nurse or pharmacist will give you 24-hour contact numbers for the hospital. If you feel unwell or need advice, you can call at any time of the day or night. Save these numbers in your phone or keep them somewhere safe.

This treatment can reduce the number of white blood cells in your blood. These cells fight infection. If your white blood cell count is low, you may be more likely to get an infection. A low white blood cell count is called neutropenia.

An infection can be very serious when the number of white blood cells is low. Your doctor may give you antibiotics and other drugs to take during this treatment. These may help reduce your risk of getting an infection. 

But it is still important to get any infection treated as soon as possible. If you have any of the following symptoms, contact the hospital straight away on the 24-hour number:

• a temperature above 37.5°C 
• a temperature below 36°C
• you feel unwell, even with a normal temperature
• you have symptoms of an infection.

Symptoms of an infection include:

• feeling shivery and shaking
• a sore throat
• a cough 
• breathlessness
• diarrhoea
• needing to pass urine (pee) often, or discomfort when you pass urine.

It is important to follow any specific advice your cancer treatment team gives you.

Your white blood cell count 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, until your cell count increases.

You may be given a drug called G-CSF. This encourages the body to make more white blood cells. You have it as a small injection under the skin.

This treatment may cause high blood pressure. Less commonly, it can cause low blood pressure. Tell your doctor, nurse or pharmacist if you have ever had any problems with your blood pressure. They will check your blood pressure regularly during treatment. Tell them if you feel dizzy or have any headaches.

You may feel dizzy, light-headed or faint when you get up from sitting or lying down. It can help to move around slowly. Drinking plenty of fluids can also help.

If you are taking medicine to lower your blood pressure, the dose of this medicine may need to be adjusted.

This treatment can reduce the number of platelets in your blood. Platelets are cells that help the blood to clot.

If the number of platelets is low, you may bruise or bleed easily. You may have:

• nosebleeds
• bleeding gums
• heavy periods
• blood in your urine (pee) or stools (poo)
• tiny red, brown or purple spots that may look like a rash – these spots can be harder to see if you have black or brown skin. 

If you have any unexplained bruising or bleeding, contact the hospital straight away on the 24-hour number. You may need a drip to give you extra platelets. This is called a platelet transfusion.

This treatment can reduce the number of red blood cells in your blood. Red blood cells carry oxygen around the body. If the number of red blood cells is low, this is called anaemia. You may feel:

• very low in energy
• breathless 
• dizzy and light-headed. 

If you have these symptoms, contact the hospital straight away on the 24-hour number. You may need treatment for anaemia. If you are very anaemic, you may need a drip to give you extra red blood cells. This is called a blood transfusion.

This treatment can increase the risk of a blood clot. Your cancer team will give you drugs called anticoagulants. These thin the blood. Your doctor, nurse or pharmacist can give you more information about preventing and treating blood clots.

Contact the hospital straight away on the 24-hour number if you have any of these symptoms during or after treatment:

• throbbing pain or swelling in a leg or arm
• reddening of the skin in the area – if you have black or brown skin, this can be harder to notice, but the skin might become darker
• suddenly feeling breathless or coughing.

Always call 999 if you have:

• chest pain
• difficulty breathing.

This treatment may affect the nerves in your fingers and toes. This can cause numbness, tingling or pain in your hands or feet. This is called peripheral neuropathy. You might find it hard to do fiddly tasks such as fastening buttons or tying shoelaces.

If you have these symptoms, always tell your doctor, nurse or pharmacist. They sometimes need to change the drug or the dose of the drug. The symptoms usually improve slowly after treatment ends. But for some people they continue and are a long-term side effect of treatment.

You may feel sick during this treatment, but this is usually mild. Your doctor, nurse or pharmacist may prescribe you anti-sickness drugs to help prevent or control sickness. Take the drugs exactly as they tell you to. If you feel sick, take small sips of fluid often and eat small amounts regularly. It is important to drink enough fluids.

If you continue to feel sick, or if you are sick (vomit) 1 to 2 times in 24 hours, contact the hospital on the 24-hour number as soon as possible. They will give you advice.

This treatment may cause diarrhoea. Diarrhoea means passing more stools (poo) than is normal for you, or having watery or loose stools. You may also have stomach cramps. If you have a stoma, it may be more active than usual. 

If you are passing loose stools 3 or more times a day and this is not normal for you, contact the hospital as soon as possible on the 24-hour number. Follow the advice they give you about:

• taking anti-diarrhoea medicines 
• drinking enough fluids to keep you hydrated and to replace lost salts and minerals
• any changes to your diet that might help. 

They might also ask you for a specimen of your stool to check for infection.

This treatment can cause constipation. Constipation means that you are not able to pass stools (poo) as often as you normally do. It can become difficult or painful. 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 on the 24-hour number for advice. They can give you drugs called laxatives to help. 

If you have not been able to pass stools for over 2 days and are being sick, contact the 24-hour number straight away. 

You may get pain in your tummy (abdomen), or have indigestion. Your doctor, nurse or pharmacist can give you advice or treatment to help. Contact the hospital straight away on the 24-hour number if your symptoms do not go away, or get worse.

This treatment can affect your appetite. Don’t worry if you do not eat much for 1 or 2 days. But if your appetite does not come back after a few days, or if you are losing weight, tell your doctor, nurse or pharmacist. They can give you advice. They may give you food or drink supplements. Or they may suggest changes to your diet or eating habits to help.

Feeling tired is a common side effect of this treatment. It is often worse towards the end of treatment and for some weeks after it ends. Try to pace yourself and plan your day so you have time to rest. Gentle exercise, like short walks, can help you feel less tired. 

If you feel sleepy, do not drive or use machinery.

You may get pain in your muscles or joints for a few days after treatment. If this happens, tell your doctor, nurse or pharmacist. They can give you painkillers and advice. They can also tell you if any of the painkillers you usually take are suitable. 

Tell them if the pain does not get better. Having warm baths and resting regularly may help. 

This treatment may cause headaches. If you have headaches, tell your doctor, nurse or pharmacist. They can give you advice about painkillers that may help. Tell them if the headache does not get better, or gets worse.

This treatment can cause a build-up of fluid in the body. This will slowly get better after treatment ends. Contact the hospital on the 24-hour number if you:

• are gaining weight 
• have swelling in your face, legs or ankles.

They can give you advice and treatment to help.

This treatment can affect your skin. If your skin feels dry, try using soap-free cleansers and unperfumed moisturising cream every day.

This treatment can also:

• cause a rash, which may be itchy 
• make your skin darker in some areas. 

Always tell your doctor, nurse or pharmacist about any skin changes. They can give you advice or prescribe creams or medicines to help. Changes to your skin are usually temporary and improve when treatment ends. 

This treatment may cause a sore mouth and throat. You may also get mouth ulcers. This can make you more likely to get a mouth or throat infection. Use a soft toothbrush to clean your teeth or dentures in the morning, at night and after meals.

Contact the hospital straight away on the 24-hour number, if:

• a sore mouth or throat affects how much you can drink or eat 
• your mouth, tongue, throat or lips have any blisters, ulcers or white patches. 

They can give you advice, and mouthwash or medicines to help with the pain or to treat any infection. Follow their advice and make sure you:

• drink plenty of fluids
• avoid alcohol and tobacco
• avoid food or drinks that irritate your mouth and throat.

This treatment can affect your eyes and eyesight. Contact the hospital straight away on the 24-hour number if you have any of these symptoms during treatment or after it ends:

• sore, painful, or swollen eyes
• eyes that are sensitive to light
• changes to your eyesight.

You may need steroids or other treatments. A specialist eye doctor (ophthalmologist) may also need to check your eyes.

This treatment can cause low levels of potassium in the blood. You will have regular blood tests to check your potassium levels. If your levels are very low, you may need treatment. Eating potassium-rich foods such as bananas can help maintain your potassium levels.

This treatment can cause changes to the lungs. Tell your doctor, nurse or pharmacist if you develop: 

• a cough that does not go away
• wheezing
• breathlessness.

You should also tell them if any existing breathing problems get worse. You may have tests to check your lungs.

This treatment can affect how your kidneys or liver work. This is usually mild and goes back to normal after treatment ends. You will have blood tests to check how well your kidneys and liver are working. Contact the hospital on the 24-hour number if you:

• have blood in your urine (pee)
• are passing less urine or peeing less often than usual.

Drinking fluids also helps protect your kidneys. The advice is usually to try to drink at least 2 litres (3½ pints) of fluid each day. But follow any advice from your doctor, nurse or pharmacist about how much is right for you.

Some viral infections can become active again while you are taking this treatment. These may need treatment with anti-viral drugs. This includes hepatitis B (a liver infection) and herpes zoster (shingles). Your doctor or nurse will talk to you about this. Before you start treatment you will have a blood test to check if you have had hepatitis B.

This treatment can increase the risk of developing a second cancer years later. This is rare. The benefits of treatment usually far outweigh this risk. Your doctor, nurse or pharmacist can give you more information.

You must not give blood or donate sperm during treatment or for 1 week after treatment has finished. 

Some medicines can affect how this treatment works or be harmful while you are having it. Always tell your cancer doctor, nurse or pharmacist about any drugs you are taking or planning to take, such as: 

• medicines you have been prescribed
• medicines you buy in a shop, pharmacy or online
• vitamins or supplements 
• herbal drugs and complementary or homeopathic therapies
• recreational drugs – for example, cannabis.

Cancer doctors usually recommend that people with cancer have vaccinations for flu and coronavirus (covid). They may also recommend other vaccines, such as Shingrix^® for shingles. These all help reduce your risk of serious illness from these infections. Most people can have these vaccines, including people with weak immune systems.

You should not have live vaccines if your immune system is weak. This includes if you are having or recently had chemotherapy, radiotherapy or other cancer treatments that affect your immune system. Live vaccines can make you unwell because they contain a very weak version of the illness they protect you against. There are several live vaccines, including the yellow fever vaccine.

It is important to ask your doctor, nurse or pharmacist for advice about having vaccinations. They can explain what vaccines are right for you and when it is best to have them.

You are advised not to breastfeed while having this treatment, or for some time after treatment ends. This is because the drugs could be passed to the baby through breast milk. 

Your doctor, nurse or pharmacist can give you more information.

Some cancer drugs can affect whether you can get pregnant or make someone pregnant. If you are worried about this, it is important to talk with your doctor before you start treatment.

If you need medical treatment for any reason other than cancer, always tell the healthcare professional that you are having cancer treatment. Give them the contact details for your cancer doctor or cancer team so they can ask for advice.

If you have appointments with a dentist, always tell them you are having cancer treatment. Talk to your cancer team before you have any dental treatment.