R-ICE is used to treat lymphoma. It is best to read this information with our general information about chemotherapy and the type of lymphoma you have.
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.
Your doctor will talk to you about this treatment and its possible side effects before you agree (consent) to have treatment.
You will be given R-ICE during a 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, and a specialist pharmacist. 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 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 test 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. The chemotherapy drugs can be given through:
- a short thin tube the nurse puts into the vein in your arm or hand (cannula)
- a fine tube that goes under the skin of the chest and into a vein close by (central line)
- a fine tube that is put into a vein in the arm and goes up into a vein in your chest (PICC line).
You will have each drug separately through a drip (infusion). You usually have the infusion through a pump. This gives you the treatment over a set time. Because there are lots of drugs and fluids given with R-ICE chemotherapy, 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 or tablets of a drug called mesna. There is more information about bladder irritation in the common side effects section of this information.
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 the length of cycle you will have. R-ICE can be given in different ways. Your doctor will tell you more about this.
Sometimes you may be given rituximab through a drip (infusion) 2 days before having the other drugs.
The rest of the course is given as follows:
- Day 1: Your nurse will give you rituximab as an infusion. They will also give you a 1-hour infusion of etoposide.
- Day 2: Your nurse will give you a 1-hour infusion of etoposide and a 1-hour infusion of carboplatin. They will also give you an infusion of mesna for about 15 minutes. Then they give you a 24-hour infusion of ifosfamide and mesna. You may also have some extra fluids with mesna in.
- Day 3: Your nurse will give you a 1-hour infusion of etoposide. When the 24-hour infusion of ifosfamide and mesna from day 2 has finished, the nurse will give you a 12-hour infusion of mesna.
You will then have a rest period with no chemotherapy for 18 or 25 days, before you start your next cycle of R‑ICE. During and after your second cycle, you will only have rituximab on day 1. Usually, you have 2 to 4 cycles of treatment over 2 to 4 months. This is called a course of treatment. Your nurse or doctor will talk about your treatment plan with you.
The nurse or pharmacist will give you medicines to take at home. These will include medicines:
- for anti-sickness
- to help prevent infections
- for mouth care.
Take all your medicines exactly as they have been explained to you.
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 to rituximab while they are having it. A reaction is most likely to happen with the first infusion, so it is given slowly over a few hours. Before treatment, you will be given medicines to help prevent or reduce any reaction.
Signs of a reaction can include:
- feeling hot or flushed
- a skin rash
- feeling dizzy
- a headache
- feeling breathless or wheezy
- 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 infusion. 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 happens a few hours after treatment. If you develop any signs or feel unwell after you get home, contact the hospital straight away.
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.
Pain along the vein
Ifosfamide can cause pain at the place where the tube goes into 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.
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. Sometimes, rituximab can make your blood pressure go up. Your nurse will check your blood pressure regularly.
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 sometimes called neutropenia.
An infection can be very serious when the number of white blood cells is low. It is important to get any infection treated as soon as possible. Contact the hospital straight away on the 24-hour contact number you have been given 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
- your temperature goes below 36°C (96.8°F).
Symptoms of an infection include:
- feeling shivery and shaking
- a sore throat
- a cough
- needing to pass urine (pee) a lot, or discomfort when you pass urine.
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, 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.
Bruising and bleeding
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:
- bleeding gums
- heavy periods
- blood in your urine (pee) or stools (poo)
- tiny red or purple spots on the skin that may look like a rash.
Tell your doctor if you have any unexplained bruising or bleeding. You may need a drip to give you 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. Red blood cells carry oxygen around the body. If the number of red blood cells is low, this is called anaemia. You may have symptoms such as:
- pale skin
- lack of energy
- feeling breathless
- feeling dizzy and light-headed.
Tell your doctor or nurse if you have these symptoms.
If you are very anaemic, you may need a drip to give you extra red blood cells. This is called a blood transfusion.
The nurses will give you anti-sickness drugs regularly to help prevent or control sickness during your treatment. If you feel sick or are sick (vomit), tell your nurse or doctor. They may change the anti-sickness drug to one that works better for you.
Ifosfamide may irritate the bladder and cause discomfort when you pass urine (pee). You should try to drink at least 2 litres (3½ pints) of fluids during the 24 hours following chemotherapy. It is also important to empty your bladder regularly. Try to pass urine as soon as you feel the need to go.
During treatment, you will have fluids through a drip (infusion). You will also be given a drug called mesna as an infusion or tablets, or both. If you are given mesna tablets to take, make sure you take them exactly as explained. Mesna helps to prevent bladder irritation.
Tell your nurse or doctor straight away if you notice:
- pain low in your tummy area (pelvis)
- discomfort or stinging when you pass urine
- blood in your urine.
Your hair will get thinner. Or you may lose all the hair from your head. You may also lose your eyelashes and eyebrows, as well as 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. Your scalp may be sensitive. It is important to cover your head to protect your skin when you are out in the sun.
Hair loss is almost always temporary. Your hair will usually grow back after treatment ends.
If you have diarrhoea, tell your nurse. Try to drink at least 2 litres (3½ pints) of fluids every day. It can help to avoid alcohol, caffeine, milk products, high-fat foods and high-fibre foods.
Sore mouth and throat
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.
If your mouth or throat 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 and throat.
Sucking ice chips may sometimes help relieve mouth or throat pain. But if you are having radiotherapy to the head or neck, do not suck on ice. It can cause damage.
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.
Skin changes or rash
R-ICE may affect your skin. Your doctor, nurse or pharmacist can tell you how your skin may be affected and what will help. R-ICE can cause a rash, which may be itchy. If your skin feels dry, try using an unperfumed moisturising cream every day.
During treatment and for some months after, you will be more sensitive to the sun. Your skin may burn more easily. Cover up with clothing and a hat. Use a sun cream with a sun protection factor (SPF) of at least 30 and at least 4 or 5 UVA stars. Your skin may get darker but will return to its normal colour after you finish treatment. If you have had radiotherapy, the area that was treated may become red or sore.
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.
Feeling tired is a common side effect. Try to pace yourself and plan your day so you have time to rest. Gentle exercise, like short walks, can give you more energy. If you feel sleepy, do not drive or operate machinery.
Loss of appetite
This treatment can affect your appetite. Do not worry if you do not eat much for a day or two. But if your appetite does not come back after a few days, tell your nurse or dietitian. They will give you advice. They may give you food or drink supplements.
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 for advice. Your doctor can give you drugs called laxatives to help.
Effects on the heart
This treatment can affect how the heart works. You may have tests to see how well your heart is working. These may be done before, during and after treatment.
If the treatment is causing heart problems, your doctor may change the type of treatment you are having.
Contact your doctor straight away on the 24-hour number the hospital has given you if you have any of these symptoms during or after treatment:
- pain or tightness in your chest
- changes to your heartbeat.
Other conditions can cause these symptoms, but it is important to get them checked by a doctor. If you cannot get through to your doctor, call the NHS urgent advice number on 111.
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 regular blood tests to check how well your kidneys and liver are working.
It is important to drink at least 2 litres (3 ½ pints) of fluids each day to help protect your kidneys.
Effects on the nervous system
Ifosfamide can affect the nervous system. You may experience:
- fits (seizures), although these are rare.
Tell your doctor or nurse straight away if you have any of these symptoms. They may make some changes to your treatment.
It is important not to drive or operate machinery if you have these side effects.
Raised levels of uric acid (tumour lysis syndrome)
R-ICE may cause the cancer cells to break down quickly. This releases a waste product called uric acid into the blood. The kidneys usually get rid of uric acid but may not be able to get rid of large amounts. Too much uric acid in the body can cause swelling and pain in the joints. This is called gout.
Your doctor may give you allopurinol (Zyloric®) tablets 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.
This treatment may cause hearing changes, including hearing loss. You may have ringing in the ears. This is called tinnitus. You may also become unable to hear some high-pitched sounds. Hearing changes usually get better after this treatment ends. But some can be permanent. Tell your doctor if you notice any changes in your hearing.
Effects on the lungs
This treatment can cause changes to the lungs. Tell your doctor if you develop:
- a cough
You should also tell them if any existing breathing problems get worse. You may have tests to check your lungs.
R-ICE 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 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 from R-ICE. This includes any we do not mention here.
Blood clot risk
Cancer and some cancer treatments can increase the risk of a blood clot. Symptoms of a blood clot include:
- throbbing pain, redness or swelling in a leg or arm
- suddenly feeling breathless or coughing
- sharp chest pain, which may be worse when you cough or take a deep breath.
If you have any of these symptoms, contact the hospital straight away on the 24-hour contact number you have been given. If you cannot get through to your doctor, call the NHS urgent advice number on 111.
A blood clot is serious, but it can be treated with drugs that thin the blood (anticoagulants). Your doctor or nurse can give you more information.You can help reduce the risk of developing a blood clot by:
- staying active during treatment
- drinking plenty of fluids, especially water.
You may be given anticoagulants to help prevent a clot.
This treatment contains alcohol. If having alcohol is a problem for you, tell your doctor, nurse or pharmacist. Your blood alcohol level may be above the legal limit after you have the treatment. Do not drive or operate machinery for a few hours after having this treatment, even if you feel okay. Tell the nurse, pharmacist or doctor if you notice any effects of the alcohol after having this treatment.
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.
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.
Women are advised not to breastfeed while having this treatment. This is because the drugs could be passed to the baby through breast milk.
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 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.
Vaccinations can reduce your risk of getting certain infections. Your doctor or nurse may talk to you about having vaccinations.
Doctors usually recommend that people with cancer have a flu vaccination and a coronavirus vaccination. These are both inactivated vaccinations that can help reduce the risk of infection. People with weak immune systems can have these, as they are not live vaccinations.
If your immune system is weak, you need to avoid live vaccinations. This is because they can make you unwell. Live vaccines, such as shingles, contain a very weak version of the illness they are vaccinating you against. Your cancer doctor or GP can tell you more about live and inactivated vaccinations.