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Side effects of fludarabine, cyclophosphamide and rituximab (FCR)

Find out about the side effects of the cancer drug combination FCR. 

Tell your doctor or nurse if you have any side effects so they can help you manage them. Your nurse will give you a contact number to ring if you have any questions or problems. If in doubt, call them.

Contact your doctor or nurse immediately if any of your side effects get severe or if you have signs of infection, including a temperature above 37.5C.

The side effects may be different if you are having FCR with other cancer treatments. 

Common side effects

Each of these effects happens in more than 1 in 10 people (10%). You might have one or more of them.

Signs of an infection include headaches, aching muscles, a cough, a sore throat, pain passing urine, or feeling cold and shivery.

Contact your treatment centre straight away if you have any of these signs or if your temperature goes above 37.5C. Severe infections can be life threatening.

Cancer treatments can reduce the number of white blood cells in the blood. This increases your risk of infections. White blood cells help fight infections.

When the level is very low it is called neutropenia (pronounced new-troh-pee-nee-ah).

You have antibiotics if you develop an infection. You might have them as tablets or as injections into the bloodstream (intravenously). To have them into your bloodstream you need to go into hospital.

Cancer treatment can cause the level of red blood cells to fall (anaemia). This makes you breathless and look pale.

Red blood cells contain haemoglobin, which carries oxygen around the body. When the level of red blood cells is low you have less oxygen going to your cells.

You can also feel tired and depressed when your blood count is low and feel better once it is back to normal. The levels can rise and fall during your treatment. So it can feel like you are on an emotional and physical roller coaster.

You have regular blood tests to check your red blood cell levels. You might need a blood transfusion if the level is very low. After a transfusion, you will be less breathless and less pale.

Tell your doctor or nurse if you feel breathless.

You might notice you:

  • bruise more easily
  • have nosebleeds
  • have bleeding gums when you brush your teeth

This is due to a drop in the number of platelets that help clot your blood.

If your platelets get very low you may have lots of tiny red spots or bruises on your arms or legs called petechiae.

Tell your doctor or nurse straight away if you have petechiae.

You have a platelet transfusion if your platelet count is very low. It is a drip of a clear fluid containing platelets. It takes about 15 to 30 minutes. The new platelets start to work right away. 

Feeling or being sick can start a few hours after treatment and last for a few days. Anti sickness injections and tablets can control it. Tell your doctor or nurse if you feel sick. You might need to try different anti sickness medicines to find one that works.

Contact your doctor or nurse straight away if you’ve been sick more than once in a day.

Tips

  • Avoid eating or preparing food when you feel sick.
  • Avoid foods that are fried, fatty, or have a strong smell.
  • Drink plenty of liquid to stop you from getting dehydrated.
  • Relaxation techniques help control sickness for some people.
  • Ginger can help – try it as crystallised stem ginger, ginger tea or ginger ale.
  • Fizzy drinks help some people when they’re feeling sick.

You might feel very tired during your treatment. It might take 6 months to a year for your energy levels to get back to normal after the treatment ends. A low red blood cell count will also make you feel tired.

You can do things to help yourself, including some gentle exercise. It’s important not to push yourself too hard. Try to eat a well balanced diet.

Talk to your doctor or nurse if you are finding the tiredness difficult to manage.

Tell your doctor or nurse if you have diarrhoea. They can prescribe medicine to help you. 

Drink at least 2.5 litres of fluid a day. This helps to keep you hydrated.

Ask your nurse about soothing creams to apply around your back passage (rectum). The skin in that area can get very sore and even break if you have severe diarrhoea.

Contact your doctor or nurse immediately if you have diarrhoea 4 or more times a day, or any diarrhoea at night.

Constipation is easier to sort out if you treat it early. Drink plenty of fluids and eat as much fresh fruit and vegetables as you can. Try to take gentle exercise, such as walking.

Tell your doctor or nurse if you are constipated for more than 3 days. They can prescribe a laxative.

You may have headaches, muscle aches (myalgia), a high temperature and shivering.

You could lose all your hair or it may become thinner. This includes your eyelashes, eyebrows, underarm, leg and sometimes pubic hair. It usually starts gradually within 2 to 3 weeks after treatment starts.

Your hair will grow back once your treatment has finished. This can take several months and your hair is likely to be softer. It can also grow back a different colour or be curlier than before.

Tips

  • Ask about getting a wig before you start treatment so you can match the colour and texture of your real hair.
  • You could choose a wig for a whole new look.
  • Think about having your hair cut short before your treatment starts.
  • Some people shave their hair off completely so they don't have to cope with their hair falling out.
  • Wear a hairnet at night so you won't wake up with hair all over your pillow.

Changes in taste can make you go off certain foods. Many people go off tea and coffee, for example. You might also find that some foods taste different. Some people find that they prefer to eat spicier foods.

Your taste usually gradually goes back to normal when your treatment is over. It may take a few weeks.

Tips

  • Choose foods that have strong flavours, such as herbs, spices, marinades and sauces if all your food tastes the same.
  • Season your food with spices or herbs, such as rosemary, basil and mint.
  • Garnish cold meat or cheese with pickle or chutney.
  • Try lemon or green tea if tea or coffee taste strange.
  • Sharp tasting fizzy drinks such as lemonade or ginger beer are refreshing.
  • Some people find that cold foods taste better than hot foods.

This treatment can cause haemolytic anaemia. This is a type of anaemia caused by the abnormal breakdown of red blood cells, either in the blood vessels (called intravascular hemolysis) or elsewhere in the body (extravascular haemolysis).  

People with haemolytic anaemia have low levels of red blood cells, which can cause a faster heart rate, breathlessness, chest pain (angina), weakness and looking pale. Some people may have jaundice. The breakdown of red cells can also lead to gallstones and high blood pressure in the arteries of the lungs.

Women might stop having periods (amenorrhoea) but this may be temporary.

Occasional side effects

Each of these effects happens in more than 1 in 100 people (1%). You might have one or more of them.

A small number of people have an allergic reaction while having this treatment. 

Tell your doctor or nurse immediately if you have any of these symptoms: 

  • a rash
  • shortness of breath
  • redness or swelling of the face
  • feeling hot
  • dizziness
  • a sudden need to pass urine

You might lose your appetite for various reasons when you are having cancer treatment. Sickness, taste changes or tiredness can all put you off food and drinks.

Tips

  • Eating several small meals and snacks throughout the day can be easier to manage.
  • Ask your doctor or nurse to recommend high calorie drinks to sip between treatments, if you are worried about losing weight.
  • You can make up calories between treatments for the days when you really don’t feel like eating.
  • Drink plenty of fluids even if you can't eat.
  • Don't fill your stomach with a large amount of liquid before eating.
  • Try to eat high calorie foods to keep your weight up.

Warmth and reddening of the face during the rituximab drip occurs in around 1 in 20 people (5%). 

Tell your nurse straight away if this happens to you.

Don’t drive or operate machinery if you have this.

Contact your doctor or pharmacist if you have indigestion or heartburn. They can prescribe medicines to help.

Skin problems include a rash, dry skin and itching.

During treatment, your nails may:

  • become brittle and dry
  • change colour
  • develop ridges

Tips

  • Check with your doctor whether you need to do anything to protect your skin.
  • Tell your doctor if you have any rashes or itching.
  • Don't go swimming if you have a rash, the chlorine can make it worse.
  • Use unperfumed moisturising cream if your skin gets dry and itchy, check with your doctor first if you have had radiotherapy to the area.
  • Wear a high factor sun block if you are going out in the sun.
  • Use nail oils or moisturising creams if your nails are flaking.

Rare side effects

Each of these effects happens in fewer than 1 in 100 people (1%). You might have one or more of them.

There is a small risk that you may get a second cancer some years after this treatment. Your doctor will discuss this with you.

High uric acid levels in the blood are due to the breakdown of tumour cells (tumour lysis syndrome). You will have regular blood tests to check your uric acid levels and may have a tablet called allopurinol to take. Drinking plenty of fluids helps to flush out the excess uric acid.

About FCR

More information about this treatment

We haven't listed all the very rare side effects of this treatment. For further information see the electronic Medicines Compendium (eMC) website.

You can report any side effect you have that isn’t listed here to the Medicines Health and Regulatory Authority (MHRA) as part of their Yellow Card Scheme.

Last reviewed: 
22 Nov 2017
  • Electronic Medicines Compendium 
    Accessed November 2017

  • Fludarabine, Cyclophosphamide, Rituximab (FCR) for CLL

    South East London Cancer Alliance

    Accessed November 2017 

  • Chemoimmunotherapy With Fludarabine, Cyclophosphamide, and Rituximab for Relapsed and Refractory Chronic Lymphocytic Leukemia

    W Wierda and others

    Journal of Clinical Oncology, 2005. Vol 23, issue 18

  • Long-term results of the fludarabine, cyclophosphamide, and rituximab regimen as initial therapy of chronic lymphocytic leukaemia

    C S Tam and others

    Blood, 2008. Vol 112, issue 4

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