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R-ESHAP

R-ESHAP is the name of a cancer drug combination that includes:

  • R – rituximab
  • E – etoposide
  • S – solu-medrone (also called methylprednisolone, which is a steroid)
  • HA – high dose cytarabine, also known as Ara C
  • P – cisplatin (which is a type of platinum chemotherapy)

It is a possible treatment for lymphoma. It is usually used before having a stem cell transplant.

How it works

These cancer drugs destroy quickly dividing cells, such as cancer cells.

How you have it

You have all drugs as a drip into your bloodstream (intravenously).

Drugs into your bloodstream

You have the treatment through a drip into your arm or hand. A nurse puts a small tube (a cannula) into one of your veins and connects the drip to it.

You might need a central line. This is a long plastic tube that gives the drugs into a large vein, either in your chest or through a vein in your arm. It stays in while you’re having treatment, which may be for a few months.

When you have R-ESHAP

You usually have R-ESHAP as cycles of treatment. Each cycle lasts 3 to 4 weeks. Depending on your needs, you might have between 2 and 3 cycles of treatment. 

You usually have each treatment cycle in the following way:

Day 1
  • You have rituximab as a slow drip into your bloodstream (intravenously)
  • You have etoposide as a drip into your bloodstream for 1 hour
  • You have methylprednisolone as a drip into your bloodstream for 15 to 30 minutes
  • You have cytarabine as a drip into your bloodstream for 2 hours
  • You start cisplatin as a continuous drip into your bloodstream that lasts 4 days
Days 2, 3 and 4
  • You have etoposide as a drip into your bloodstream for 1 hour
  • You have methylprednisolone as a drip into your bloodstream for 15 to 30 minutes
  • You continue with the cisplatin drip
Day 5
  • You have methylprednisolone as a drip into your bloodstream for 15 to 30 minutes
  • You finish the cisplatin drip
Day 6 to day 21 (or day 28)
  • You have no treatment

Then you start the next treatment cycle.

You stay in hospital during the 5 days of treatment. You will be able to move around the ward even when the drip is going through. You also have fluids (hydration) during treatment. This is because R-ESHAP can cause kidney damage and the extra fluids help to keep your kidneys working properly.

Your doctor or nurse might also give you steroid eye drops to use for a few days. This helps to stop your eyes from getting sore.

Allergic reaction

Some people have an allergic reaction to rituximab. To help prevent a reaction your nurse will give you paracetamol and another drug called chlorphenamine (Piriton). They give your first rituximab dose slowly over about 4 hours. 

If you have a reaction, your nurse will stop the infusion and start it again once your symptoms have reduced. You may be able to have the next doses of rituximab at a faster rate (over 2 hours) if you don't have a reaction.

Tests

You have blood tests before and during your treatment. They check your levels of blood cells and other substances in the blood. They also check how well your liver and kidneys are working.

Side effects

We haven't listed all the side effects. It's very unlikely that you will have all of these side effects, but you might have some of them at the same time.

How often and how severe the side effects are can vary from person to person. They also depend on what other treatments you're having. For example, your side effects could be worse if you're also having other drugs or radiotherapy.

When to contact your team

Your doctor, nurse or pharmacist will go through the possible side effects. They will monitor you closely during treatment and check how you are at your appointments. Contact your advice line as soon as possible if:

  • you have severe side effects 
  • your side effects aren’t getting any better
  • your side effects are getting worse

Early treatment can help manage side effects better. 

Contact your doctor or nurse immediately if you have signs of infection, including a temperature above 37.5C or below 36C.

Common side effects

These side effects happen in more than 10 in 100 people (10%). You might have one or more of them. They include:

Risk of infection 

Increased risk of getting an infection is due to a drop in white blood cells. Symptoms include a change in temperature, aching muscles, headaches, feeling cold and shivery and generally unwell. You might have other symptoms depending on where the infection is.

Infections can sometimes be life threatening. You should contact your advice line urgently if you think you have an infection. 

Breathlessness 

You might be breathless and look pale due to a drop in red blood cells. This is called anaemia.

Bruising and bleeding 

This is due to a drop in the number of platelets in your blood. These blood cells help the blood to clot when we cut ourselves. 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 petechia).

Fatigue 

Tiredness and weakness (fatigue) can happen during and after treatment - doing gentle exercises each day can keep your energy up. Don't push yourself, rest when you start to feel tired and ask others for help.

Hair loss

You could lose all your hair. This includes your eyelashes, eyebrows, underarm, leg and sometimes pubic hair. Your hair will usually grow back once treatment has finished but it is likely to be softer. It may grow back a different colour or be curlier than before. 

Kidney damage 

To help prevent kidney damage, it is important to drink plenty of water. You might also have fluids into your vein before, during and after treatment. You have blood tests before your treatments to check how well your kidneys are working.

Hearing changes

You might have some hearing loss, especially with high pitched sounds. You might also have some ringing in your ears (tinnitus). Tell your doctor or nurse if you notice any changes.

Taste changes 

Taste changes may make you go off certain foods and drinks. You may also find that some foods taste different from usual or that you prefer to eat spicier foods. Your taste gradually goes back to normal a few weeks after your treatment finishes.

Low blood pressure 

Tell your doctor or nurse if you feel light headed or dizzy. You have your blood pressure checked regularly.

Sore and red eyes 

Sore, red eyes can happen because cytarabine is partly removed from your body (excreted) in your tears. You will have steroid eye drops to help prevent sore eyes.

Low levels of sodium in your body 

You may have changes in levels of minerals and salts in your blood, such as low sodium. This will most likely go back to normal when you finish treatment. You have regular blood tests during treatment to check this.

Tummy (abdominal) pain 

Tell your treatment team if you have this. They can check the cause and give you medicine to help. 

Loss of appetite 

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

Constipation 

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.

Liver changes 

You might have liver changes that are usually mild and unlikely to cause symptoms. They usually go back to normal when treatment finishes. You have regular blood tests to check for any changes in the way your liver is working.

High levels of uric acid in your body

High levels of uric acid in your blood can lead to a build up of crystals in body tissues and cause a type of arthritis known as gout. You’ll have regular blood tests to check these levels.

Skin changes 

Skin problems include a skin rash, dry skin and itching. This usually goes back to normal when your treatment finishes. Your nurse will tell you what products you can use on your skin to help.

Feeling or being sick 

Feeling or being sick is usually well controlled with anti sickness medicines. Avoiding fatty or fried foods, eating small meals and snacks, drinking plenty of water, and relaxation techniques, can all help.

It is important to take anti sickness medicines as prescribed even if you don’t feel sick. It is easier to prevent sickness rather than treating it once it has started.

An allergic reaction 

A reaction may happen during the infusion, causing a skin rash, itching, swelling of the lips, face or throat, breathing difficulties, fever and chills. Your nurse will give you medicines beforehand to try to prevent a reaction. Tell your nurse or doctor immediately if at any time you feel unwell. They will slow or stop your drip for a while.

Headaches 

Tell your doctor or nurse if you keep getting headaches. They can give you painkillers to help.

Occasional side effects

These side effects happen in between 1 and 10 out of every 100 people (1 to 10%). You might have one or more of them. They include:

  • numbness or tingling in fingers and toes can make it difficult to do fiddly things such as doing up buttons
  • a severe allergic reaction that can cause shortness of breath and redness or swelling of the face
  • mouth sores and ulcers
  • mood changes such as depression and anxiety
  • indigestion or heartburn
  • loose or watery poo (diarrhoea)
  • low levels of magnesium, calcium and potassium in your body
  • changes to the way your heart works which can cause an irregular heart beat, high blood pressure or a heart attack
  • dizziness
  • redness, swelling and pain at the site of injection
  • a build up of fluid in your hands and feet
  • difficulty sleeping
  • slow wound healing
  • muscle and bone weakness
  • a severe whole body infection (sepsis) which can cause high temperatures, confusion and dizziness
  • high blood sugar levels
  • weight loss
  • swelling on your face, hands and feet
  • night sweats
  • difficulty breathing and cough
  • pain in different parts of your body such as the chest, muscles, back and neck

Rare side effects

These side effects happen in fewer than 1 in 100 people (1%). You might have one or more of them. They include:

  • a second cancer some years after this treatment
  • fits
  • bleeding
  • lung problems such as inflammation or fibrosis of the lung tissue
  • difficulty swallowing
  • inflammation of the food pipe
  • a hole in your stomach or bowel (perforation)
  • changes to the levels of chemicals in your body caused by a breakdown of tumour cells (tumour lysis syndrome)
  • a severe skin reaction that may start as tender red patches which leads to peeling or blistering of the skin. You might also feel feverish and your eyes may be more sensitive to light. This is serious and could be life threatening

Coping with side effects

We have more information about side effects and tips on how to cope with them.

What else do I need to know?

Other medicines, foods and drinks 

Cancer drugs can interact with some other medicines and herbal products. Tell your doctor or pharmacist about any medicines you are taking. This includes vitamins, herbal supplements and over the counter remedies.

Loss of fertility 

You may not be able to become pregnant or father a child after treatment with these drugs. 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. Women may be able to store eggs or ovarian tissue but this is rare.

Pregnancy and contraception 

This treatment may harm a baby developing in the womb. It is important not to become pregnant or father a child while you are having treatment with this drug and for at least a year afterwards. Talk to your doctor or nurse about effective contraception before starting treatment.

Breastfeeding 

Don’t breastfeed during this treatment and for a year afterwards because the drugs may come through in your breast milk.

Treatment for other conditions 

Always tell other doctors, nurses, pharmacists or dentists that you’re having this treatment if you need treatment for anything else, including teeth problems.

Immunisations 

Don’t have immunisations with live vaccines while you’re having treatment and for up to 12 months afterwards. The length of time depends on the treatment you are having. Ask your doctor or pharmacist how long you should avoid live vaccinations.

In the UK, live vaccines include rubella, mumps, measles, BCG, yellow fever and the shingles vaccine (Zostavax).

You can:

  • have other vaccines, but they might not give you as much protection as usual
  • have the flu vaccine (as an injection)
  • be in contact with other people who have had live vaccines as injections

Avoid close contact with people who have recently had live vaccines taken by mouth (oral vaccines) such as oral polio or the typhoid vaccine.

This also includes the rotavirus vaccine given to babies. The virus is in the baby’s poo for up to 2 weeks and could make you ill. So avoid changing their nappies for 2 weeks after their vaccination if possible. Or wear disposable gloves and wash your hands well afterwards.

You should also avoid close contact with children who have had the flu vaccine nasal spray. You should do so for 2 weeks following their vaccination if you have a severely weakened immune system.

More information about this treatment

For further information about this treatment go to the electronic Medicines Compendium (eMC) website.

You can report any side effect you have to the Medicines Health and Regulatory Authority (MHRA) as part of their Yellow Card Scheme.

Last reviewed: 
04 Mar 2019
  • Electronic Medicines Compendium

    Accessed March 2019

  • Handbook of Cancer Chemotherapy (8th edition)
    Roland K Keel
    Lippincott Williams and Wilkins, 2012

  • Immunisation against infectious disease: Chapter 6: General contraindications to vaccination
    Public Health England
    First published: March 2013 and regularly updated on the Gov.UK website

  • R-ESHAP as salvage therapy for patients with relapsed or refractory diffuse large B-cell lymphoma: the influence of prior exposure to rituximab on outcome. A GEL/TAMO study.
    A Martin and others 
    Haematologica, 2008. Vol 93, Issue 12, Pages 1829-1836

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