This page tells you about the cancer drug combination R-ESHAP and its possible side effects. You can read about
R-ESHAP is the name of a combination of cancer drugs used to treat non Hodgkin lymphoma (NHL). It is ESHAP chemotherapy with the drug rituximab. Most people who have this type of treatment also have a stem cell transplant.
R-ESHAP is made up of the drugs
- R – Rituximab (Mabthera), a type of biological therapy called a monoclonal antibody
- E – Etoposide (a chemotherapy drug)
- SH – Methylprednisolone, which is a steroid
- A – Cytarabine (also known as Ara C) – a chemotherapy drug
- P – Cisplatin – a chemotherapy drug
All the R-ESHAP drugs are clear colourless fluids. You have them into your bloodstream (intravenously). You can have them through a thin, short tube (a cannula) put into a vein in your arm each time you have treatment. Or you may have them through a central line, a portacath, or a PICC line. These are long, plastic tubes that give the drugs directly into a large vein in your chest. You have the tube put in before or during your course of treatment and it stays in place as long as you need it.
You can read our information about having chemotherapy into a vein.
You usually have R-ESHAP as cycles of treatment. Each cycle lasts 4 weeks. You usually have between 2 and 8 cycles.
Each cycle of treatment is given in the following way.
On the 1st day you have
- Rituximab as a slow drip (infusion) before all the other drugs – see details below
- Etoposide as a drip for 1 hour
- Methylprednisolone (steroid) as a drip for 15 to 30 minutes
- Cytarabine as a drip for 2 hours – this may be on the 5th day instead
- Cisplatin as a drip that lasts for 96 hours (4 days)
On the 2nd, 3rd and 4th days you
- Continue with your cisplatin
- Repeat the etoposide and methylprednisolone drips
On the 5th day the cisplatin finishes and you have
- Another dose of methylprednisolone
- Another dose of cytarabine
You have no treatment for just over 3 weeks. Then you start the next cycle.
Some people can have an allergic reaction to rituximab so your first dose is given slowly over a few hours (about 4 hours). To help prevent a reaction your doctor or nurse will give you paracetamol and another drug called chlorphenamine (Piriton). If you do have a reaction they will stop the infusion and start it again once your symptoms have reduced. If you don't have a reaction you should be able to have further doses of rituximab at a faster rate (over 2 hours).
You will need to stay in hospital for the 5 days of treatment. But you will be able to move around the ward even while the drips are going through. You will also have drips of fluids (hydration). Cisplatin can cause kidney damage and the extra fluids keep your kidneys working properly. You may also have a drug called mannitol as a drip alongside your cisplatin. Mannitol helps your kidneys produce more urine.
You can go home once the treatment is finished. Your doctor or nurse will give you anti sickness medicines to take home and some steroid eye drops. You will need to use these as prescribed by your doctor for the next 5 to 7 days. You may also need to take them before going into hospital to have your treatment and your doctor or nurse will discuss this with you.
You have blood tests before starting treatment and regularly during your treatment. The tests check your levels of blood cells. They also check how well your liver and kidneys are working.
We've listed the side effects associated with R-ESHAP below. You can use the links to find out more about each side effect. Where there is no link, please go to our cancer drug side effects section or use the search box at the top of the page.
You may have a few side effects. They may be mild or more severe. A side effect may get better or worse through your course of treatment. Or more side effects may develop as the course goes on. This depends on
- How many times you've had the drug before
- Your general health
- The amount of the drug you have (the dose)
The side effects may be different if you are having R-ESHAP with other drugs.
Tell your doctor or nurse straight away if any of the side effects get severe.
More than 10 in every 100 people have one or more of the side effects listed below.
- An increased risk of getting an infection from a drop in white blood cells – it is harder to fight infections and you can become very ill. You may have headaches, aching muscles, a cough, a sore throat, pain passing urine, or you may feel cold and shivery. If you have a severe infection this can be life threatening. Contact your treatment centre straight away if you have any of these effects or if your temperature goes above 38°C
- Tiredness and breathlessness due to a drop in red blood cells (anaemia) – you may need a blood transfusion
- Bruising more easily due to a drop in platelets – you may have nosebleeds, or bleeding gums after brushing your teeth. Or you may have lots of tiny red spots or bruises on your arms or legs (known as petechiae)
- Tiredness and weakness (fatigue) that may continue after treatment has finished – most people find their energy levels are back to normal within 6 months to a year
- Feeling or being sick – this is usually well controlled with anti sickness medicines
- Hair loss
- Kidney changes – you will have fluids to flush the drugs through
- Hearing changes – you may have ringing in the ears (tinnitus) or have problems hearing. These effects usually get better on their own
- Loss of taste or a metallic taste in your mouth
- Changes to your blood sugar levels due to steroids – you will have regular blood tests and may also need to check your urine for sugar
- Sore, red eyes can occur because cytarabine is removed from your body (excreted) in your tears – you will have steroid eye drops to prevent this
- Women may stop having periods (amenorrhoea) – this may be temporary
- Loss of fertility – you may not be able to become pregnant or father a child after this treatment. Talk to your doctor before starting treatment if you think you may want to have a baby in the future. Men may be able to store sperm before starting treatment
- Skin changes – your skin may become red and sore or you may have an itchy rash
- Night sweats happen in about 3 in 20 people (15%)
- Tummy (abdominal) pains – let your doctor or nurse know if you have these
- Feeling weak affects about 1 in 4 people (25%)
- A runny nose (rhinitis) may happen during the rituximab drip – this is usually mild
- Flu like symptoms including fever and chills occur in 5 out of 10 people (50%) – taking paracetamol can help
- Low blood pressure affects about 1 in 10 people (10%)
Between 1 and 10 in every 100 people have one or more of these effects.
- Numbness or tingling in hands or feet that usually improves a few months after the treatment ends – some people may have permanent numbness
- Allergic reactions can happen while any of the drugs are going into your bloodstream – let your nurse know if you feel hot or have any skin rashes, itching, dizziness, headaches, or shivering. Also let them know if you have breathlessness, anxiety, flushing of the face, or a sudden need to pass urine
- A sore mouth
- Mood changes
- Diarrhoea or constipation – drink plenty of fluids and let your nurse know if this lasts for more than 3 days
- A cough and breathlessness – rituximab can cause irritation of the lungs so tell your doctor or nurse if you have this
- Liver changes that are very mild and unlikely to cause symptoms – the liver will almost certainly go back to normal when treatment is finished
- Loss of appetite
- Flushing of the face affects about 1 in 20 people (5%) – during the rituximab drip you may have a sudden feeling of warmth and your face may go red
A very small number of people get a second cancer some years after R-ESHAP treatment.
Talk to your doctor, pharmacist or nurse about all your side effects so they can help you manage them. They can give you advice or reassure you. Your nurse will give you a contact number to ring if you have any questions or problems. If in doubt, call them.
Tell your doctor about any other medicines you are taking, including vitamins, herbal supplements and over the counter remedies. Some drugs can react together.
Pregnancy and contraception
These drugs may harm a baby developing in the womb. It is important not to become pregnant or father a child while you are having treatment and for a few months afterwards. Talk to your doctor or nurse about effective contraception before starting treatment.
Do not breastfeed during this treatment because the drugs may come through in the breast milk.
You should not have immunisations with live vaccines while you are having chemotherapy or for at least 6 months afterwards. In the UK, these include rubella, mumps, measles (usually given together as MMR), BCG, yellow fever and Zostavax (shingles vaccine).
You can have other vaccines, but they may not give you as much protection as usual until your immune system has fully recovered from your chemotherapy. It is safe to have the flu vaccine.
It is safe for you to be in contact with other people who've had live vaccines as injections. There can be problems with vaccines you take by mouth (oral vaccines), but not many people in the UK have these now. So there is usually no problem in being with any baby or child who has recently had any vaccination in the UK. You might need to make sure that you aren't in contact with anyone who has had oral polio, cholera or typhoid vaccination recently, particularly if you live abroad.
On this website you can read about
Etoposide (a chemotherapy drug)
Methylprednisolone, which is a steroid
Cytarabine (also known as Ara C) – a chemotherapy drug
Cisplatin – a chemotherapy drug
This page does not list all the very rare side effects of this treatment that are very unlikely to affect you. For further information look at the Electronic Medicines Compendium website at www.medicines.org.uk.
If you have a side effect not mentioned here that you think may be due to this treatment you can report it to the Medicines Health and Regulatory Authority (MHRA) at www.mhra.gov.uk.
Question about cancer? Contact our information nurse team