R-GDP

R-GDP is a cancer drug combination. You have:

• R – rituximab (pronounced ri-tuk-si-mab)
• G – gemcitabine (jem-site-uh-been)
• D – dexamethasone (deks-uh-meth-uh-zone
• P – cisplatin (sis-pla-tin)

It is a treatment for Hodgkin and non-Hodgkin lymphoma.

How does R-GDP work?

Rituximab is a type of targeted cancer drug called a monoclonal antibody  . It targets a protein called CD20 on the surface of the cancer cells. Rituximab sticks to all the CD20 proteins it finds. Then the cells of the immune system pick out the marked cells and kill them.

Gemcitabine and cisplatin are chemotherapy drugs. These drugs destroy quickly dividing cells, such as cancer cells.

Dexamethasone is a steroid. It treats lymphoma by stopping the cancer cells growing and killing them. It may also help you feel less sick during treatment. And help reduce your body’s immune response, to try and prevent an allergic reaction to rituximab.

How do you have R-GDP?

You take dexamethasone as tablets. You swallow them 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 have rituximab, gemcitabine and cisplatin as a drip into your bloodstream (intravenously).

Into your bloodstream

You might have treatment through a long plastic tube that goes into a large vein in your chest. The tube stays in place throughout the course of treatment. This can be a:

• central line
• PICC line
• portacath

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

Risk of tissue damage

When you are having this treatment through a cannula it could damage the tissue if it leaks out of the vein. This is called extravasation. This can happen anywhere along the vein that the drug is going into. It doesn’t happen very often. Tell your nurse straight away if you notice any changes such as swelling, redness, pain, burning, or a stinging feeling.

Your nurse will stop the drug treatment. And they will treat the area to relieve symptoms and reduce tissue damage. Contact your healthcare team if you develop any of these symptoms when you are at home.

Taking your tablets

Whether you have a full or empty stomach can affect how much of a drug gets into your bloodstream.

You should take the right dose, not more or less.

Talk to your healthcare team before you stop taking a cancer drug, or if you have missed a dose.

How often do you have R-GDP?

You have R-GDP as cycles of treatment. This means that you have the drugs and then a rest to allow your body to recover.

Each cycle of treatment lasts 21 days (3 weeks). You might have up to 6 cycles of R-GDP.

Rituximab can cause an allergic reaction. So before each dose you have paracetamol, a steroid and an antihistamine drug such as chlorphenamine (Piriton).

For the first cycle of rituximab, you have it as a drip into your bloodstream slowly over a few hours. This is to prevent an allergic reaction. Your nurse will increase how fast it goes in (rate). This is approximately every 30 minutes if you have no allergic reaction.

Your next rituximab drip will usually go in quicker, but this will depend on how you got on with the first cycle.

Exactly how you have R-GDP depends on your situation. The following is an example:

You then start the next cycle of treatment.

G-CSF injection

You usually also have G-CSF. This is an injection under the skin (subcutaneous). It helps your body make white blood cells to lower your chance of getting an infection.

Your doctor will tell you if you need G-CSF and for how long. 

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.

Before treatment starts you may have a blood test to check for viruses such as hepatitis B, hepatitis C, and HIV . This is called a viral screen.

It’s important for your doctor to know if you have had any of these viruses. This is because this treatment can weaken your immune system and can cause the virus to become active again (reactivation). 

What are the side effects of R-GDP?

Side effects can vary from person to person. They also depend on what other treatments you're having. 

When to contact your team

Your doctor, nurse or pharmacist will go through the possible side effects. They will monitor you 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. 

We haven't listed all the side effects here. Talk to your healthcare team if you have any new symptoms that you think might be a side effect of your treatment.

Remember it is very unlikely that you will have all of these side effects. But you might have some of them at the same time.

Common side effects

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

Increased 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, cough, headaches, feeling cold and shivery, pain or a burning feeling when peeing, or generally feeling 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. 

Bruising, bleeding gums or nosebleeds

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. This is known as petechiae.

Breathlessness and looking pale

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

An allergic reaction

Some people have an allergic reaction to rituximab. This reaction is most likely to happen during treatment and when you first have the treatment. Symptoms of an allergic reaction include high temperature (fever), chills, feeling or being sick and difficulty breathing. 

Your nurse will give you medicines beforehand to try to prevent a reaction. Tell your nurse straight away if you have any symptoms of an allergic reaction. They will slow down or stop your drip for a while.

Swelling of different parts of the body

A build up of fluid that may cause swelling in your arms, hands, ankles, legs, face and other parts of the body. This is called oedema. It usually gets better after treatment finishes. Contact your healthcare team if this happens to you.

Feeling or being sick

Feeling or being sick is usually well controlled with anti sickness medicines. It might help to avoid fatty or fried foods, eat small meals and snacks and take regular sips of water. Relaxation techniques might also 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 treat it once it has started.

Skin reactions and changes

You might get a skin rash with this combination of drugs. The skin rash can be a reaction to the treatment.

Another common skin problem includes itching. Less commonly you might have a raised itchy rash on the skin also known as hives.

Your skin usually goes back to normal when your treatment finishes. Your healthcare team can tell you what products you can use on your skin to help.

Rituximab can also cause a severe skin reaction, but this is rare. Symptoms usually 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.

Hair loss

You could lose all your hair. This includes your eyelashes, eyebrows, underarms, legs 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. 

Headaches

Tell your healthcare team if you keep getting headaches. They can give you painkillers to help.

Tiredness and weakness

You might feel very tired and as though you lack energy.

Various things can help you to reduce tiredness and cope with it, for example exercise. Some research has shown that taking gentle exercise can give you more energy. It is important to balance exercise with resting.

High temperature or chills

You might get a high temperature. Or you might feel cold or start shivering (chills). 

Flu like symptoms 

These may include headaches, muscle aches, a high temperature, shivering and generally feeling tired and weak. Other symptoms can include a cough, runny nose and generally feeling unwell.

Ask your healthcare team if you can take medicines such as paracetamol to help.

Low levels of an antibody called immunoglobulin G in your body 

Immunoglobulin G is an antibody made by the immune system to fight bacteria and viruses. You have regular blood tests during and after treatment to check for this.

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.

Blood and protein in your pee

You might have small amounts of blood and protein in your pee. These may be picked up when your nurse tests your pee. This usually goes away on its own. If there are large amounts of protein you may have tests to check how well your kidneys are working.

Difficulty breathing

You may have difficulty breathing with this treatment. It might be mild and not need any treatment. 

Rarely you might have breathlessness, tightening of the chest, chest pain, wheezing or a cough. This could be because there is damage to the lungs, asthma, or temporary narrowing of the bronchial tubes.

Let your healthcare team know immediately if you have any breathing problems. 

Changes in blood test results 

This treatment can cause changes to the levels of minerals and enzymes in your blood.

You may have a low level of sodium in your blood. Less commonly your calcium levels and an enzyme called LDH may drop. You might also have a low level of magnesium but this is rare.

You may have other changes picked up in blood tests, for example changes to how well your pancreas is working.

Some of the changes may cause symptoms or they might just be picked up on blood tests. Symptoms vary depending on what is affected. For example low calcium can cause muscle twitching, spasms and cramps, numbness or tingling in feet and hands or around the mouth. Low magnesium levels can cause muscle cramps, tiredness, and nausea.

You have regular blood tests during treatment to check your levels. Let your healthcare team know if you have any symptoms. They usually go back to normal after treatment finishes.

Occasional side effects

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

• sepsis - a serious reaction to an infection. Signs can include feeling very unwell, not peeing, a very high or very low temperature, shivering, slurred speech or confusion, breathlessness, mottled or discoloured skin, extreme shivering or muscle pain. Call 999 or go to accident and emergency (A&E) immediately if you have any of these symptoms
• diarrhoea
• constipation
• loss of appetite
• an infection with hepatitis B can become active again if you've had it in the past
• changes to your blood sugar levels – symptoms might include feeling very thirsty, a dry mouth, passing urine very often, feeling tired, blurred vision or weight loss. You have regular blood tests to check this 
• unusual feelings of the skin – such as numbness, tingling, pricking, burning, a creeping skin feeling, or reduced sense of touch
• mood changes such as feeling agitated and anxious. Rarely you might feel nervous and very low in mood (depressed). Let your healthcare team know if you are struggling with how you feel
• difficulty falling or staying asleep (insomnia)
• feeling sleepy or very drowsy
• eye problems such as dry or watery eyes or red, sore, itchy eyes (conjunctivitis)
• feeling dizzy
• hearing changes such as ringing or buzzing in the ear (tinnitus) and ear pain
• heart problems such as an abnormal heart rhythm, slow or fast heartbeat and a heart attack. Other rare heart problems include the sudden stopping of your heart
• low blood pressure that can cause you to feel lightheaded or dizzy, sometimes this can happen when you stand up from sitting or lying down (orthostatic hypotension)
• high blood pressure that might cause headaches, confusion, vision problems or chest pain
• a blocked, runny or itchy nose or sneezing
• pain in different parts of your body such as your tummy (abdomen), muscles, joints, back, neck or where the cancer is
• pain at the drip site
• mouth sores and ulcers
• sore throat
• indigestion – symptoms include heartburn, bloating and burping
• sweating and night sweats
• muscle aches and pain or tightening of your muscles
• generally feeling unwell
• flushing – sudden reddening and warmth of the neck, upper chest and face
• several body parts (organs) stopping working
• blood clots that can be life threatening; signs are pain, redness and swelling where the clot is. Feeling breathless can be a sign of a blood clot in the lung. Contact your advice line or doctor straight away if you have any of these symptoms
• cough
• difficulty swallowing

Rare side effects

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

• changes to the way your blood clots - either too little clotting causing bleeding or too much clotting causing blood clots
• a blood disorder where your red blood cells get destroyed faster than they can be made (haemolytic anaemia)
• a condition where your bone marrow stops making your blood cells (aplastic anaemia)
• taste changes
• changes to the levels of chemicals in your body caused by a breakdown of tumour cells (tumour lysis syndrome) - you will have regular blood tests to check for this
• a condition called cytokine release syndrome - when your immune system makes a large amount of cytokines . Symptoms include fever, chills, a headache, difficulty breathing and dizziness
• inflammation of your blood vessels – symptoms can vary depending on which blood vessels are affected - general symptoms include feeling very tired, loss of appetite, weight loss, a high temperature, and aches and pains
• posterior reversible encephalopathy syndrome (PRES) - a rare disorder of the nerves causing headache, fits, confusion and changes in vision - contact your health team straight away. This condition is reversible
• kidney problems such as kidney failure or small blood clots in the blood vessels inside the kidney (haemolytic uremic syndrome)
• a stroke
• abnormal sperm production in men
• fits (seizures)
• a second cancer such as acute leukaemia
• swollen lymph nodes 
• a hole in your stomach or bowel (perforation) - contact your doctor straight away if you have pain, severe cramps, feeling tightness or bloating in the stomach area

Other side effects

There isn't enough information to work out how often these side effects might happen. You might have one or more of them. They include:

• changes to your face and appearance – such as puffy face, stretch marks, acne or increased facial hair
• weakened bones that are fragile and more likely to break (osteoporosis)
• adrenal insufficiency - your adrenal glands don’t make enough of the hormones your body needs to handle stress, control blood pressure, and balance salt and sugar levels. This can lead to symptoms such as extreme tiredness, low blood pressure and weight loss
• increased appetite and weight gain
• inflammation of your pancreas - symptoms include severe tummy pain, feeling or being sick, a high temperature or you may have loose poo. Tell your doctor or nurse if you get these symptoms
• slow wound healing
• hiccups
• high levels of types of fat in your blood called cholesterol and triglycerides. You will have regular blood tests to check this
• a build up of a type of white blood cell in the air spaces in the lungs – symptoms include a cough and shortness of breath

If you have side effects that aren't listed on this page, you can look at the individual drug pages:

• rituximab
• gemcitabine 
• dexamethasone 
• cisplatin 

Coping with side effects

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

What else do you need to know?

Other medicines, food and drink

Cancer drugs can interact with medicines, herbal products, and some food and drinks. We are unable to list all the possible interactions that may happen. An example is grapefruit or grapefruit juice which can increase the side effects of certain drugs.

Tell your healthcare team about any medicines you are taking. This includes vitamins, herbal supplements and over the counter remedies. Also let them know about any other medical conditions or allergies you may have.

Loss of fertility 

You may not be able to become pregnant or get someone pregnant 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.    

Pregnancy and contraception 

This treatment may harm a baby developing in the womb. It is important not to become pregnant or get someone pregnant while you are having this treatment and for at least a year afterwards.

Talk to your doctor or nurse about effective contraception before starting treatment. Let them know straight away if you or your partner become pregnant while having treatment.

Breastfeeding

Don’t breastfeed during this treatment and for 6 months afterwards. This is because the drugs may come through in the breast milk.

Treatment for other conditions 

If you are having tests or treatment for anything else, always mention your cancer treatment. For example, if you are visiting your dentist.

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, and yellow fever.

You can usually have:

• other vaccines, but they might not give you as much protection as usual
• the flu vaccine (as an injection)
• the coronavirus (COVID-19) vaccine

Talk to your doctor or pharmacist about the best time to have a vaccine in relation to your cancer treatment.

Contact with others who have had immunisations 

You can be in contact with other people who have had live vaccines as injections. If someone has had a live vaccine by mouth or nasal spray there may be a small risk the vaccine virus can be passed onto you if your immune system is weakened.

Your healthcare team will let you know if you need to take any precautions if you are in close contact with someone who has had a live vaccine.

More information

For further information about each drug and the possible side effects go to the electronic Medicines Compendium (eMC) website. You can find patient information leaflets for each drug on this website.

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