CTD

CTD is a combination of the chemotherapy drug cyclophosphamide along with thalidomide (an immunotherapy drug) and dexamethasone (a steroid). It is used to treat myeloma.

It is best to read this information with our general information about chemotherapy, steroids, immunotherapy and the type of cancer you have.

CTD is usually given as capsules and tablets. You usually have it as an outpatient. Your cancer doctor, nurse or pharmacist will tell you how often you will have it.

CTD 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 CTD?

CTD is used to treat myeloma. It is best to read this information with our general information about chemotherapy, steroids, immunotherapy and the type of cancer you have.

CTD comes from the initials of the drugs used:

Your doctor will talk to you about this treatment and its possible side effects before you agree (consent) to have treatment.

Chemotherapy

This video provides a brief overview of chemotherapy treatment, how it can be given, how it works and possible side effects.

About our cancer information videos

Chemotherapy

This video provides a brief overview of chemotherapy treatment, how it can be given, how it works and possible side effects.

About our cancer information videos


How CTD is given

During treatment you usually see a cancer doctor, 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 for you to have treatment.

You will see a doctor or nurse before you have treatment. They will ask you how you have been feeling. If your blood results are okay, the pharmacist will prepare your treatment. Your nurse will tell you when your treatment is likely to be ready.

Your course of CTD

CTD comes in capsules and tablets. You can take it at home.

  • cyclophosphamide and dexamethasone come as tablets
  • thalidomide comes as capsules

Cancer treatment is usually given as a course of several cycles of treatment over a few months. A cycle of CTD is usually given over 21 days (3 weeks) or 28 days (4 weeks). Your nurse or doctor will tell you which cycle you are going to have.

21-day cycle

  • You take cyclophosphamide on days 1, 8 and 15.
  • You take thalidomide for the whole 21 days.
  • You take dexamethasone on days 1 to 4 and 12 to 15.

28-day cycle

  • You take cyclophosphamide on days 1, 8, 15, and 22.
  • You take thalidomide for the whole 28 days.
  • You take dexamethasone on days 1 to 4 and 15 to 18.

Your nurse or doctor will discuss your treatment plan with you. They may give you a copy of the treatment plan to take home with you.

The nurse or pharmacist will give you the capsules and tablets to take home. You may be given capsules and tablets of different strengths.

Your nurse or pharmacist may also give you anti-sickness drugs and other medicines to take home. Take all your capsules and tablets exactly the way you have been told to.

Taking CTD

You should swallow all the tablets and capsules whole with a glass of water. They should not be chewed, opened or crushed. Take them at the same time every day.

Always take them exactly as explained. This is important to make sure they work as well as possible for you.

It is important to take dexamethasone with or just after breakfast. Take thalidomide at bed-time, as it can make you feel sleepy.

During treatment with cyclophosphamide you should avoid grapefruit and grapefruit juice. This is because it can affect how cyclophosphamide works.

If you forget to take the cyclophosphamide or dexamethasone you should take the missed dose as soon as possible within the same day. If it has been a full day, tell your doctor or nurse.

If you forget to take the thalidomide and less than 12 hours have passed, take your capsules straight away. If more than 12 hours have passed, do not take your missed dose. Just take your usual dose at the usual time the next day. Tell your doctor or nurse.

Do not take a double dose unless your doctor tells you to.

Other things to remember about your capsules and tablets:

  • Keep them in the original package and at room temperature, away from heat and direct sunlight.
  • Keep them safe and out of sight and reach of children.
  • If you are sick (vomit) just after taking the capsules or tablets, contact the hospital. Do not take another dose.
  • If your treatment is stopped, return any unused capsules or tablets to the pharmacist.

Having your central line put in

This is a short animation about how you can have a central line (or skin-tunnelled venous catheter) put in.

About our cancer information videos

Having your central line put in

This is a short animation about how you can have a central line (or skin-tunnelled venous catheter) put in.

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Having your PICC line put in

This is a short animation about having a PICC line (Peripherally inserted central catheter) put in.

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Having your PICC line put in

This is a short animation about having a PICC line (Peripherally inserted central catheter) put in.

About our cancer information videos


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. 

If you are also having treatment with other cancer drugs, you may 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) for more detailed information.


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.

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.

Blood clot risk

Cancer and this treatment 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.

Feeling sick

You may feel sick during this treatment. Your doctor will give you anti-sickness drugs to help prevent or control sickness. Take the drugs exactly as your nurse or pharmacist tells you. It is easier to prevent sickness than to treat it after it has started.

If you feel sick, take small sips of fluids and eat small amounts often. If you continue to feel sick, or if you vomit more than once in 24 hours, contact the hospital as soon as possible. They will give you advice and may change the anti-sickness drug to one that works better for you.

Tummy pain or indigestion

Steroids can irritate the stomach lining. Let your doctor or nurse know if you have pain in your tummy (abdomen) or indigestion. They can give you drugs to help reduce stomach irritation. Take your tablets with food to help protect your stomach.

Increased appetite

Steroids can make you feel more hungry than usual and you may gain weight. Your appetite will go back to normal when you stop taking them. If you are worried about gaining weight, talk to your doctor or nurse.

Raised blood sugar levels

Steroids can raise your blood sugar levels. Your nurse will check your blood sugar regularly for this. They may also test your urine for sugar. Symptoms of raised blood sugar include:

  • feeling thirsty
  • needing to pass urine often
  • feeling tired.

Tell your doctor or nurse if you have these symptoms.

If you have diabetes, your blood sugar levels may be higher than usual. Your doctor will talk to you about how to manage this. You may need to adjust your insulin or tablet dose.

Mood and behaviour changes

Steroids can affect your mood. You may:

  • feel anxious or restless
  • have mood swings
  • have problems sleeping.

Taking your steroids in the morning may help you sleep better at night.

Tell your doctor or nurse if you have any of these side effects. They may make some changes to your treatment if the side effects become a problem.

Sore mouth

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.

Feeling tired

Feeling tired is a common side effect. It is often worse towards the end of treatment and for some weeks after it has finished. 

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.

Feeling drowsy

Thalidomide may cause you to feel drowsy (very sleepy). Do not drink alcohol while you are taking thalidomide. This is because alcohol can make you sleepy and thalidomide can make you even sleepier.

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.

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

If you have diarrhoea, contact the hospital for advice. 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.

Skin changes

CTD 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. CTD can cause a rash, which may be itchy.

Sometimes, thalidomide can cause a more serious skin rash that blisters. Let your doctor know straight away if this happens.

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.

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.

Build-up of fluid

Your ankles and legs may swell because of fluid building up. Tell your doctor or nurse if this happens. They may give you medicines that can help. If the swelling is uncomfortable, they may also give you support stockings. It can also help to put your legs up on a foot stool or cushion. The swelling will usually get better when treatment finishes.

Bladder irritation

Cyclophosphamide may irritate your bladder and cause discomfort when you pass urine. Drink at least 2 litres (3½ pints) of fluids every day, especially 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.

Contact the hospital straight away if you feel any discomfort or stinging when you pass urine, or if you notice any blood in your urine.

Low blood pressure

Thalidomide can cause a temporary fall in your blood pressure. This can make you feel dizzy for a few moments if you stand up quickly. It can help to move slowly from lying to sit-ting and from sitting to standing.

Tell your doctor or nurse if you have ever had problems with your blood pressure.

Effects on the heart

Sometimes thalidomide can affect your heart. It may feel like your heart is beating too slowly. If you notice this, tell your doctor straight away. They can check your heart rate.

It is also important to contact a doctor straight away if you:

  • have pain or tightness in your chest
  • feel breathless
  • feel your heart is beating too fast.

Other conditions can cause these symptoms, but it is important to get them checked by a doctor.

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.

Eye problems

You may notice your vision is blurry during treatment. Tell your doctor or nurse if you notice this. Do not drive if your vision is affected.

Changes in the way the kidneys and liver work

CTD can affect how your kidneys and liver work. This is usually mild and goes back to normal after treatment. You will have blood tests to check how well your kidneys and liver are working.

A photo of Stuart talking about neutropenic sepsis

Neutropenic sepsis

Stuart talks about he how coped with neutropenic sepsis, an infection which can be a side effect of chemotherapy.

About our cancer information videos

Neutropenic sepsis

Stuart talks about he how coped with neutropenic sepsis, an infection which can be a side effect of chemotherapy.

About our cancer information videos

Watch our hair loss video playlist

In these videos, people with experience of cancer and hair loss share their stories. You can also watch tutorials on wigs, headwear and eye make up.

Watch our hair loss video playlist

In these videos, people with experience of cancer and hair loss share their stories. You can also watch tutorials on wigs, headwear and eye make up.

Coping with fatigue

Denton describes how he coped with fatigue (tiredness) during his treatment for prostate cancer.

About our cancer information videos

Coping with fatigue

Denton describes how he coped with fatigue (tiredness) during his treatment for prostate cancer.

About our cancer information videos


Other information

Preventing pregnancy

You must take part in a pregnancy prevention programme while taking thalidomide. Your doctor will give you information about not becoming pregnant or fathering a child during and after treatment with thalidomide. This is because thalidomide can cause birth defects in developing babies. Both men and women taking thalidomide can pass this risk on to an un-born child.

Your doctor or specialist nurse will give you some written information about the risks of thalidomide and the best ways to prevent pregnancy. They will ask you to sign a consent form once you have read the information.

Women taking thalidomide

If you have not yet had your menopause you will have a pregnancy test before starting treatment with thalidomide. This will be repeated every 4 weeks during treatment. You will also have a pregnancy test 4 weeks after treatment finishes.

You must use an effective form of contraception, such as:

  • an implant
  • injection
  • or a progesterone-only oral pill.

The combined oral contraceptive pill is not recommended because it increases your risk of developing blood clots. You must use contraception for 4 weeks before treatment, during treatment, and for 4 weeks after treatment finishes. If you think you may be pregnant at any time during your treatment, contact your doctor or specialist nurse straight away.

Men taking thalidomide

You must use a condom during sex while taking thalidomide and for 1 week after treat-ment finishes. This is to protect your partner from thalidomide, which can pass into your semen.

If your partner thinks they might be pregnant during your treatment, contact your doctor or specialist nurse straight away.

Other medicines

Some medicines can affect this treatment 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 vitamins, herbal drugs and complementary therapies.

Breastfeeding

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

Fertility

This treatment 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.

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

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.