This page tells you about the cancer drug combination called RICE and its possible side effects. There is information about
RICE is the name of a combination of cancer drugs for non Hodgkin lymphoma or Hodgkin lymphoma that has come back after previous treatment. It is the ICE chemotherapy combination with the drug rituximab. Most people who have this type of chemotherapy will also have a stem cell transplant. Your doctor or chemotherapy nurse will explain this treatment to you in detail.
RICE is made up of the drugs
- R – Rituximab (Mabthera), a type of biological therapy called a monoclonal antibody
- I – Ifosfamide
- C – Carboplatin
- E – Etoposide
You have the drugs 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 ifosfamide with another drug called mesna, either as a drip (infusion) or as tablets. It is very important that you take tablets according to the instructions your doctor or pharmacist gives you. For example, whether you have a full or empty stomach can affect how much of a drug gets into your bloodstream. You should take the right dose, not more or less. Mesna stops the ifosfamide from irritating your bladder and causing bleeding.
You usually have RICE drugs as cycles of treatment. You may have 3 cycles. Each cycle lasts 3 weeks.
Some people have an allergic reaction to rituximab, causing flu like symptoms such as a fever, chills and shivering (rigors), a headache and feeling sick. So you have the first dose slowly by drip over a few hours. To help prevent an allergic reaction you will have paracetamol and an antihistamine drug before the treatment. You may also have steroids. If you have a reaction, your nurse will stop the drip and start it again at a slower rate once your symptoms have reduced.
Different hospitals give RICE in different ways. Two common ways are described below as schedule A and schedule B.
- On the 1st day of the treatment cycle you have a rituximab drip
- On the 2nd day you have a rituximab drip
- On the 3rd day you have a drip of etoposide over about 1 hour
- On the 4th day you have an etoposide drip plus a drip of carboplatin over 1 hour and you start a 24 hour drip of ifosfamide and mesna
- On the 5th day you have a drip of etoposide before you go home
- From the 7th to the 14th day you have daily injections of a growth factor drug called G-CSF (granulocyte colony stimulating factor). This drug stimulates your bone marrow to produce white blood cells to reduce the risk of infection. A nurse may do the injections or they may teach you how to give them to yourself. Or you may have one injection of pegfilgrastim, which releases G-CSF slowly over a week.
One week after the growth factor injections finish, you start another cycle of treatment.
- On the 1st day of the treatment cycle you have a rituximab drip and an etoposide drip
- On the 2nd day you have a rituximab drip plus a drip of carboplatin over 1 hour. You also start a 24 hour drip of ifosfamide and mesna
- On the 3rd day you have a drip of etoposide for an hour
- From the 7th to the 14th day you have daily injections of G-CSF (granulocyte colony stimulating factor). Or you may have one injection of pegfilgrastim.
One week after the growth factor injections finish, you start another cycle of treatment.
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 RICE treatment 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 RICE 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) during and after treatment – most people find their energy levels are back to normal within 6 months to a year
- An allergic reaction to rituximab, causing flu like symptoms such as a fever, chills and shivering (rigors), a headache and feeling sick – let your doctor or nurse know if you have any of these effects
- Hair loss – most people have complete hair loss
- Feeling or being sick is usually well controlled with anti sickness medicines
- Irritation of the bladder and kidneys – drink plenty of water to flush out the chemotherapy. You may have fluids into your drip before and after your treatment. Tell your nurse or doctor straight away if you have pain or bleeding when passing urine
- Kidney damage – you will have fluids through your drip to flush the drugs through
- Loss of appetite
- Taste changes, including loss of taste
- A drop in blood pressure can happen if etoposide is given quickly – if you feel dizzy or faint, call your nurse straight away to slow down the drip
- Feeling weak occurs in about 1 out of 4 people (25%)
- Numbness or tingling in fingers and toes happens in 1 out of 4 people (25%). It can cause difficulty doing small things such as doing up buttons. This starts a few days or weeks after treatment and usually goes within a few months of finishing treatment
- Night sweats occur in about 3 out of 20 people (15%)
- Tummy (abdominal) pain
- A runny nose during the rituximab drip – this is usually mild
- A skin rash, which may be itchy
- Confusion, sleepiness or extreme lack of energy (lethargy) and hallucinations happen in about 1 out of 8 people (12%). If you have any of these effects, it is important to tell your treatment team straight away
- 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
Between 1 and 10 in every 100 people have one or more of these effects.
- Low blood pressure occurs in about 1 out of 10 people (10%) and more rarely, raised blood pressure
- Flushing of the face and a sudden feeling of warmth during the rituximab drip affects about 1 out of 20 people (5%)
- Your ability to hear some high pitched sounds may be reduced – this usually gets better on its own
- Ringing in the ears (tinnitus) occurs in about 1 in 100 people (1%)
- Inflammation around the drip site – if you notice any signs of redness, swelling or leaking at your drip site, tell your nurse straight away
- Reddening of the skin in areas where you have had radiotherapy in the past, and the skin may get dry and flaky and feel sore and hot – this goes away on its own but keep affected areas out of the sun
- Liver changes that are very mild and unlikely to cause symptoms may occur – the liver will almost certainly go back to normal when treatment finishes
- A sore mouth
- Diarrhoea or constipation
- A cough and breathlessness may occur – rituximab can cause irritation of the lungs, so tell your doctor or nurse if you have this
There is a small risk that you may get a second cancer some years after RICE treatment. If this happens, it most often occurs 5 to 8 years after 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
This drug 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 drug 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.
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.
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