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RICE

RICE is the name of a combination of cancer drugs that includes:

  • rituximab
  • ifosfamide
  • carboplatin
  • etoposide

It is a treatment for non-Hodgkin lymphoma or Hodgkin lymphoma that has come back after treatment. Most people who have this type of treatment also have a stem cell transplant. Your doctor or nurse will explain this treatment to you in detail.

How RICE works

Ifosfamide, carboplatin and etoposide are chemotherapy drugs. They destroy quickly dividing cells, such as cancer cells.

Rituximab is a type of targeted drug called a monoclonal antibody. Monoclonal antibodies target proteins on the surface of cells. Rituximab targets a protein known as CD20. CD20 is found on white blood cells called B cells. It is the B cells that are cancerous in the most common types of lymphoma.

Rituximab attaches itself to the B cells and marks them. The cells of immune system then recognise the marked cells and kill them.

How you have RICE

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

Into your bloodstream

You can have the drug through a thin short tube (a cannula) that goes into a vein in your arm each time you have treatment.

Or you might have it through a long line: a central line, a PICC line or a Portacath.

These are long plastic tubes that give the drug into a large vein in your chest. The tube stays in place throughout the course of treatment.

Mesna and GCSF

You usually have ifosfamide with another drug called mesna. You have mesna either as a drip (infusion) into your bloodstream or as tablets.

Mesna is not a chemotherapy drug. It stops the ifosfamide from irritating your bladder and making the lining bleed.

You usually also have a drug called granulocyte colony stimulating factor (GCSF). This makes your bone marrow produce white blood cells more quickly after the chemotherapy.

When you have RICE

You have RICE as cycles of treatment. Each cycle lasts 3 weeks. You usually have 3 cycles of treatment. 

Some people have an allergic reaction to rituximab. This can cause flu like symptoms such as fever and sickness. To prevent an allergic reaction you usually have the first dose of rituximab slowly over a few hours. You may also have paracetamol, steroids and an antihistamine drug before the treatment. 

Different hospitals give RICE in different ways. A common way of having RICE is described below.

Day 1
  • You have rituximab as a drip into your bloodstream.
  • You have etoposide as a drip into your bloodstream.
Day 2
  • You have etoposide as a drip into your bloodstream.
  • You have carboplatin as a drip into your bloodstream.
  • You have ifosfamide as a drip into your bloodstream.
Day 3
  • You have etoposide as a drip into your bloodstream.
Day 4 to 21
  • You have no treatment.

You then start a new cycle of treatment. You may need to stay in hospital overnight between day 2 and 3 of each cycle. 

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 petechiae).

Tiredness and weakness 

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.

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.

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.

Tummy (abdominal) pain

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

Liver problems

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.

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.

Irritation of the lining of the bladder 

This treatment can irritate your bladder and kidneys. Drink as much water as possible to flush out the drugs. Make sure that you pass urine often, especially before you go to sleep. You might also have a drug called Mesna to protect your bladder and kidneys.

Changes in the levels of minerals in your body

You may have changes in levels of minerals and salts in your blood, including low levels of sodium or high levels of uric acid (causing gout). You have regular blood tests during treatment to check this.

Inflammation around the drip site 

Tell your nurse straight away if you have any pain, redness, swelling or leaking around your drip site.

Skin rash 

A rash can also be itchy. Tell your doctor or nurse if you have a skin rash. They can prescribe medicine to stop the itching and soothe your skin.

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 

Let your doctor or nurse know if you have headaches. They can give you painkillers such as paracetamol to help.

High temperature (fever) and chills 

You might get a high temperature (fever), weakness and chills. Contact your doctor or nurse if you have this.

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:

  • dizziness and anxiety
  • heart problems such as an irregular heartbeat and changes to your blood pressure levels
  • loose or watery poo (diarrhoea)
  • a sore mouth and taste changes
  • numbness or tingling in fingers and toes that can make it difficult to do fiddly things such as doing up buttons
  • weight loss
  • hearing loss especially with high pitched sounds and ringing in your ears (tinnitus)
  • problems with your eyes such as inflammation and increased production of tears
  • lung problems that can cause difficulty breathing, cough and chest pain
  • a second cancer some years after treatment
  • a severe infection called sepsis that can be life threatening
  • swelling (oedema) in your face, arms and legs
  • pain in different parts of the body such as your muscles, joints, back, neck and the tumour site

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:

  • fits (seizures)
  • a build up of scar tissue in your lungs (fibrosis)
  • a severe skin reaction that may start as tender red patches which leads to peeling or blistering of the skin. You may also feel feverish and your eyes might be more sensitive to light. This is serious and could be life threatening
  • depression
  • severe heart problems such as angina and a heart attack
  • a hole in the bowel, stomach or food pipe

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 might be able to store sperm before starting treatment. And women might be able to store eggs or ovarian tissue. But these services are not available in every hospital, so you would need to ask your doctor about this.    

Contraception and pregnancy 

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 12 months afterwards because the drugs may come through in the 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)

Contact with others who have had immunisations - You can 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 the oral typhoid vaccine.

If your immune system is severely weakened, you should avoid contact with children who have had the flu vaccine as a nasal spray. This is for 2 weeks following their vaccination.

Babies have the live rotavirus vaccine. The virus is in the baby’s poo for about 2 weeks and could make you ill if your immunity is low. Get someone else to change their nappies during this time if you can. If this isn't possible, wash your hands well after changing their nappy.

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: 
20 May 2019
  • Electronic Medicines Compendium (eMC) 

    Last accessed January 2019

  • Rituximab and ICE (RICE) as second-line therapy prior to autologous stem cell transplantation for relapsed or primary refractory diffuse large B-cell lymphoma
    T Kewalramani and others
    Blood, 2004. Vol 103, Issue 10. Pages 3684-3688

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