ICE

ICE is the name of a combination of chemotherapy drugs used to treat non Hodgkin’s lymphoma that has come back after treatment. It is made up of the drugs

• I = Ifosfamide
• C = Carboplatin
• E = Etoposide (also known as Vepesid)

The links above take you to more information about individual side effects of each of these drugs.

The side effects of a combination of drugs are usually a mixture of those of each drug. The combination may increase or decrease your chance of getting each side effect or it may change the severity. The side effects associated with ICE are listed below. You can use the underlined links to find out more about each one. For general information, see our cancer drugs side effects section.

Most people who have ICE chemotherapy will also have a stem cell transplant. Your doctor will explain this treatment to you in detail.

You have ICE 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 these tubes put in just before your course of treatment starts and they stay in place as long as you need them.

You usually have ifosfamide with another drug called mesna, either as a drip (infusion) or as tablets. If you have the tablets you must take them exactly as your doctor prescribes. Mesna is not a chemotherapy drug. It stops the ifosfamide from irritating your bladder and making it bleed. You usually also have a drug called GCSF (growth factor stimulating factor) to make your bone marrow produce white blood cells more quickly after the chemotherapy.

You usually have ICE chemotherapy as cycles of treatment. You may have between 2 and 4 cycles. Each cycle lasts 3 weeks so the whole course of chemotherapy may last from 6 to 12 weeks.

ICE chemotherapy can be given in a number of ways. Two common ways are described below as schedule A and schedule B. Your doctor or nurse will explain to you exactly how you will have treatment.

Schedule A

On the first day you have a carboplatin drip (infusion) for 1 hour, an etoposide drip for 1 hour and then an ifosfamide drip for 6 hours.

On the second day you have an ifosfamide drip for 18 hours. Then you have an etoposide drip for 1 hour and a mesna drip for 6 hours. You usually need to stay in hospital overnight.

Then you have no treatment for 18 days before starting your next treatment cycle.

Schedule B

On the first day you have an etoposide drip for 1 hour. On the second day you have an etoposide drip for 1 hour and a carboplatin drip for 1 hour. You then start a 24 hour drip of ifosfamide and mesna and may need to stay in hospital overnight. On the third day you finish the ifosfamide and mesna drip and have an etoposide drip for 1 hour. You then start a 12 hour drip of mesna or your doctor may give you mesna tablets to take.

Then you have no treatment for 18 days before starting your next treatment cycle.

More than 10 in every 100 people have one or more of the side effects listed below.

Temporary drop in the number of blood cells made by the bone marrow, causing

• 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, sore throat, pain passing urine or feel cold and shivery
• 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, bleeding gums after brushing your teeth, or lots of tiny red spots or bruises on your arms or legs (known as petechia)

Some of these side effects can be life threatening, particularly infections. You should contact your doctor if you have any of these side effects. Your doctor will check your blood counts regularly to see how well your bone marrow is working.

Other common side effects include

• Fatigue during and after treatment – most people find their energy levels are back to normal within 6 months to a year
• Numbness or tingling in fingers and toes occurs in 1 in 4 people (25%) and can cause difficulty doing small things such as doing up buttons – it starts a few days or weeks after treatment and usually goes within a few months of finishing treatment
• Feeling or being sick is usually well controlled with anti sickness drugs
• Hair loss – most people have complete hair loss but it will grow back when the treatment ends
• Irritation of the lining 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 doctor or nurse if you have bleeding or pain when passing urine. You may also have a drug called mesna to help protect the bladder lining
• Kidney damage due to carboplatin – you will have blood tests before your treatment to make sure your kidneys are able to cope with the drug
• Loss of appetite
• Metallic taste when having the drugs through a drip, or loss of taste
• Confusion, sleepiness or extreme lack of energy (lethargy) and hallucinations happen in about 1 in 8 people (12%) who have ifosfamide – if you have any of these effects, it is important to tell your doctor straight away
• 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
• Women may stop having periods (amenorrhoea) – this may be temporary
• Loss of fertility – we don’t know exactly how this drug affects fertility so do talk with your doctor before starting treatment if having a baby is important to you
• This drug may have a harmful effect on a developing baby – do talk to your doctor about contraception before having treatment if there is any chance that you or your partner could become pregnant

Between 1 and 10 in every 100 people have one or more of these.

• Your ability to hear some high pitched sounds may be reduced by carboplatin – this usually gets better on its own
• Ringing in their ears (tinnitus) affects about 1 in 100 people treated with carboplatin (1%)
• Inflammation around the drip site – if you notice any signs of redness, swelling or leaking at your drip site, tell your chemotherapy nurse immediately
• 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 can occur with ifosfamide – the liver will almost certainly go back to normal when treatment finishes, but you will have regular blood tests to check how well your liver is working
• A skin rash
• A sore mouth
• Diarrhoea or constipation can occur with high doses of etoposide
• An allergic reaction with chills, fever, wheezing, a racing heart, drop in blood pressure and swelling of the face happens in 1 or 2 out of every 100 (1 to 2%) people who have etoposide or carboplatin

There is a small risk that you may get a second cancer some years after ICE treatment. If this does happen, it most often occurs 5 to 8 years afterwards.

Not everyone will get these side effects. You may have none or several. A side effect may get worse through your course of treatment. Or you may have more side effects as the course goes on. This depends on

• How many times you've had a drug before
• Your general health
• How much of the drug you have (the dose)
• Other drugs you are having

Talk to your doctor, pharmacist or nurse about all your side effects so they can help you manage them. Your nurse will give you a contact number. You can ring them if you have any questions or problems. They can give you advice or reassure you. If in doubt, call them.

Tell your doctor about any other medicines you are taking, including vitamins, herbal supplements and other over the counter remedies – some drugs can react together.

You should not have immunisations with live vaccines while you are having this treatment or for at least 6 months afterwards. In the UK, these include rubella, mumps, measles (usually given together as MMR), BCG and yellow fever. You can have other vaccines, but they may not give you as much protection as usual until your immune system has fully recovered.

It is safe for you to be in contact with other people who've had live vaccines as injections. There can be problems with oral vaccines, but not many people in the UK have oral vaccines 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.