R-DHAP

R-DHAP is the name of a combination of drugs used to treat high grade non hodgkin’s lymphoma that has come back. R-DHAP is DHAP chemotherapy with the drug rituximab. Rituximab is a type of biological therapy called a monoclonal antibody. R-DHAP is made up of the drugs

• R = Rituximab (also called Mabthera)
• DH = Dexamethasone, which is a steroid
• A = Cytarabine (also known as Ara C) – a chemotherapy drug
• P = Cisplatin – a chemotherapy drug

Cytarabine, cisplatin and rituximab are all colourless fluids given 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 just before your course of treatment starts and it stays in place as long as you need it.

You usually have the steroid (dexamethasone) as tablets (orally) but you may have it into the vein as well.

You usually have chemotherapy as cycles of treatment. You may have 1 or 2 treatments of R-DHAP. Each cycle of treatment lasts 3 weeks.

You have each cycle in the following way.

• On the first day you start taking the dexamethasone tablets (or you have it as a drip). You also have a slow drip (infusion) of rituximab followed by cisplatin as a drip for 24 hours
• On the second day you have cytarabine (Ara C) as a drip twice. Each drip lasts for 3 hours and you have them 12 hours apart. You also take the dexamethasone tablets
• On the third and fourth days you carry on taking the dexamethasone either as tablets or through a drip. If you are having it as tablets you will be able to take them home with you. You need to swallow the tablets whole after a meal, or with milk, as they can irritate your stomach. It is best to take them early in the day, immediately after breakfast.

You also have fluids (hydration) into the drip during your first two days of treatment. This is because R-DHAP can cause kidney damage and the extra fluids help to keep your kidneys working properly.

Your nurse or doctor will give you steroid eye drops to use for 5 to 7 days to help prevent your eyes becoming sore.

Once you have finished the dexamethasone you have no treatment for 3 weeks. You then start a new treatment cycle.

Some people can have an allergic reaction to rituximab so the first dose is given slowly over about 4 hours. To help prevent a reaction you will have paracetamol and a drug called chlorphenamine (Piriton). If you have a reaction your nurse will stop the drip. They will start it again once your symptoms have reduced. You should be able to have further doses of rituximab at a faster rate (about 2 hours).

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 R-DHAP are listed below. You can use the underlined links to find out more about each one. For general information, see our side effects of cancer drugs section.

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 happens in 4 out of 10 people having R-DHAP (40%) – 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 effects. Your doctor will check your blood counts regularly to see how well your bone marrow is working.

Other common side effects include

• Kidney changes – you will have regular blood tests to check how well your kidneys are working and will have fluids to flush the drugs through
• Fatigue during and after treatment – most people find their energy levels are back to normal within 6 months to a year
• Feeling or being sick is usually well controlled with anti sickness medicines
• Diarrhoea may happen up to a week after your treatment – make sure that you drink plenty of fluid and tell your doctor or nurse if it becomes severe, or continues for more than 3 days. 1 in 5 people (20%) have severe diarrhoea
• Sore mouth or ulcers
• Loss of appetite – this is more likely if you have sickness, diarrhoea, or a sore mouth
• Flu like symptoms including fever and chills happen in 1 out of 2 people (50%) – taking paracetamol as your doctor or nurse prescribes can help
• Changes in your blood sugar levels – steroids can change your blood sugar levels so you will have regular blood tests to check this. You may also need to check your urine for sugar
• Ringing in the ears (tinnitus) happens to about 3 in 10 people treated (30%) and usually gets better on its own
• Women may stop having periods (amenorrhoea) – this may be temporary
• R-DHAP 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
• Loss of fertility – you may not be able to get pregnant or father a child after treatment with these drugs. Talk to your doctor about your fertility before starting treatment if having a baby is important to you
• Sore, red eyes because some of the cytarabine is removed from your body (excreted) in your tears
• Skin changes – your skin may be sore and red, particularly on the hands and feet and you may also have an itchy rash
• A reaction while having rituximab can cause flu like symptoms, such as a fever, chills and shivering (rigors), a headache and feeling sick – let your doctor or nurse know straight away if you have this
• Feeling weak occurs in about 1 in 4 people (25%)
• Night sweats occur in about 3 in 20 people (15%)
• Stomach pains
• Low blood pressure in about 1 in 10 people (10%) and more rarely, raised blood pressure
• A runny nose (rhinitis), which is usually mild and goes away within an hour of the infusion

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

• High uric acid levels in your blood due to cancer cells being broken down by the body – you will have regular blood tests and will be asked to drink plenty of fluids to flush out the uric acid. Your doctors may also give you a drug called allopurinol
• Numbness or tingling in hands or feet – this usually improves a few months after the treatment ends. Some people have some permanent numbness
• Loss of taste or a metallic taste in your mouth
• Hair loss or thinning
• Aching muscles (myalgia) and bones
• Drowsiness and confusion – happens in up to 1 in 10 people (10%) but is usually mild and gets better on its own. It is more likely if you are over 40, or have liver or kidney problems
• Cough and breathlessness – tell your doctor if this continues
• Liver changes that are very mild and unlikely to cause symptoms – your liver will almost certainly go back to normal when treatment is finished, but you will have regular blood tests to check how well it is working
• Indigestion
• Dizziness
• Flushing in about 1 in 20 people (5%) – when you are having the rituximab drip you may have a sudden feeling of warmth and your face may go red

There is a small risk that you may get a second cancer some years after R-DHAP treatment.

Not everyone will get these side effects. You may have 1 or 2 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)
• The way you take the drugs (tablets or drip)
• 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.