CODOX-M chemotherapy

CODOX-M is a combination treatment 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 given into a vein and as an injection into the fluid around your spinal cord. It is often given during a stay in hospital. Some people may have their treatment in a chemotherapy day unit. Your cancer doctor, haematologist, nurse or pharmacist will tell you how often you will have it.

CODOX-M can cause side effects. Some of the side effects can be serious, so it is important to read the detailed information below.

Your healthcare team can give you advice on how to manage any side effects. Tell your doctor or nurse straight away if you:

  • have a temperature
  • feel unwell
  • have severe side effects, including any we do not mention here.

Rarely, side effects may be life-threatening. Your cancer doctor or nurse can explain the risk of these side effects to you.

If you need medical attention for any reason other than cancer, always tell the healthcare staff that you are having this treatment.

What is CODOX-M?

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:

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.


How CODOX-M is given

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).

PICC lines and central lines playlist

Watch our short animated videos about having PICC lines and central lines put in.

PICC lines and central lines playlist

Watch our short animated videos about having PICC lines and central lines put in.


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.

It’s just the thought of chemotherapy that’s a bit frightening, but you get used to it. It doesn’t hurt and it’s over and done with in a few minutes.

Trevor


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 haven’t 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.

More information

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.


Side effects while treatment is being given

Some people may have side effects while they are being given the chemotherapy or shortly after they have it:

Allergic reaction

Some people have an allergic reaction while having this treatment. Signs of a reaction can include:

  • feeling hot or flushed 
  • a skin rash
  • itching
  • shivering
  • 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

This treatment can cause 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 this happens it can damage the tissue around the vein. This is called extravasation. Extravasation is not common but if it happens it is important that it is dealt with 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 number they gave you.


Common side effects

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
  • diarrhoea
  • 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:

  • nosebleeds
  • 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.

Feeling sick

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.

Bladder problems

Cyclophosphamide may irritate your bladder and cause discomfort when you pass urine. Drink at least 2 litres (3 and ½ pints) of fluids during the 24 hours following chemotherapy. It is also important to empty your bladder regularly and to try to pee (pass urine) as soon as you feel the need to go.

Contact the hospital straight away if you feel any discomfort or stinging when you pee, or if you notice any blood in it.

Discoloured urine

Your urine may be a pink-red colour for up to 48 hours after you have had your treatment. This is due to the colour of doxorubicin.

Hair loss

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.

Feeling tired

This treatment will make you feel very tired and you will need a lot of rest. You will get tired easily for some months after treatment too. Gentle exercise, like short walks, can give you more energy. The tiredness will gradually get better.

Constipation

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.

Diarrhoea

Capecitabine may cause diarrhoea. This can be severe. Your nurse or doctor may give you anti-diarrhoea drugs to take at home.

If you have diarrhoea:

  • follow any advice you have been given 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 6 times in a day
  • the anti-diarrhoea drugs do not work within 24 hours.

Your doctor may ask you to stop taking capecitabine. When the diarrhoea is better, they will tell you if you can start taking it again. Sometimes the dose is reduced.

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 or delay treatment for a short time. 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.

Sore mouth

You may get a sore mouth or mouth ulcers. This can make you more likely to get a mouth infection. To help prevent this from happening 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.

Skin changes

This treatment 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. This treatment can cause 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.

Headaches

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.

Effects on the liver

This treatment can 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. 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.

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 chemotherapy. 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.


Less common side effects

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
  • wheezing
  • a fever (high temperature)
  • breathlessness.

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

CODOX-M can affect the nervous system. You may feel drowsy, 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 the symptoms 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).

Jaw pain

Vincristine may cause pain in your jaw. Tell your nurse or doctor if you notice this.

Abdominal pain

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 (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 to cope with large amounts. Too much uric acid can cause swelling and pain in the joints, which is called gout.

Your doctor may give you a drug called allopurinol or one called rasburicase 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.

Second cancer

CODOX-M 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.


Other information about CODOX‑M

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
  • breathlessness
  • 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.

Grapefruit

You may be advised to avoid eating grapefruit or drinking grapefruit drinks while you are having this treatment. This is because it can make the side effects worse.

Alcohol

Your doctor may advise you not to drink alcohol while having treatment. This is to help protect your kidneys.

Driving

Don't 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.

Other medicines

Some medicines can affect chemotherapy or be harmful when you are having it. This includes medicines you can buy in a shop or chemist. Tell your cancer doctor about any drugs you are taking, including over-the-counter drugs, complementary therapies and herbal drugs.

Contraception

Your doctor will advise you not to get pregnant or father a child while having this treatment. The drugs may harm the developing baby. It is important to use effective contraception during your treatment.

Breastfeeding

Women are advised not to breastfeed while having this treatment. This is because the drugs could be passed to the baby through breast milk.

Fertility

Some chemotherapy drugs can affect whether you can get pregnant or father a child.

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.

There may be ways to preserve fertility for men and women. If you are worried about fertility, it is important to talk with your doctor before you start chemotherapy treatment.

Sex

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.