Vincristine, actinomycin D and ifosfamide (VAI)

VAI is the name of a chemotherapy combination that includes:

  • vincristine
  • actinomycin D (also known as dactinomycin or by its brand name Cosmegen Lyovac)
  • ifosfamide

It is a treatment for Ewing's sarcoma.

Ewing's sarcoma is a type of bone cancer. It can also start in the soft tissues of the body. Ewing’s sarcoma usually affects teenagers and young adults.

How VAI works

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

How you have VAI

You have all these drugs into your bloodstream (intravenously).

Into your bloodstream

You usually have treatment through a central line.

A central line 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 the whole time you are having treatment.

You might have VAI through a drip in your hand or arm if you don’t have a central line. A nurse puts a small tube (a cannula) into one of your veins and connects the drip to it.

When you have VAI

You usually have VAI chemotherapy after surgery. Before your surgery you may also have another type of combination chemotherapy called VIDE.

You have VAI in cycles of treatment. This means that you have all the drugs and then have a rest to allow your body to recover. Each cycle of VAI lasts 3 weeks.

You might have up to 8 cycles, taking around 6 months in total. You usually have each cycle of treatment in the following way:

Day 1
  • You have vincristine as a quick drip into your bloodstream.
  • You have actinomycin D as a drip or a slow injection into your bloodstream.
  • You have ifosfamide as a drip - this takes around 3 hours.
Day 2
  • You have actinomycin D as a drip or a slow injection into your bloodstream.
  • You have ifosfamide as a drip - this takes around 3 hours.
Day 3 - 21
  • You have no treatment.

You then start the next treatment cycle.

You also have a drug called mesna as a drip into your bloodstream on day 1 and day 2 of each treatment cycle. Mesna isn't chemotherapy. It helps to stop the ifosfamide from irritating your bladder and making it bleed.


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 is 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 treatment you are having. For example, your side effects could be worse if you are 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. 

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 (known as petechiae).

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. 

Inflammation of the bladder

Inflammation of the bladder causes a burning feeling when passing urine and the need to pass urine often. You may see blood in your urine.

Let your doctor or nurse know if this happens and drink plenty of fluids.

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.

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.

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:

  • loss of appetite
  • irritation and pain at the drip site
  • changes to how your liver works - you will have blood tests to check how well your liver works

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: 

  • problems with your heart -  some heart problems can be serious or life threatening
  • low blood pressure
  • diarrhoea
  • sore mouth or mouth ulcers
  • skin irritation or rash
  • feeling very tired

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:

  • a severe whole body infection that can be life threatening (sepsis)
  • a serious allergic reaction which can be life threatening
  • numbness or tingling in fingers or toes
  • breathlessness and looking pale due to a drop in red blood cells
  • breathing problems, including feeling short of breath or inflammation of the lungs
  • jaw pain – this can be severe
  • swelling underneath the skin which comes on quickly, often on the face, tongue or arms and legs
  • an itchy red rash (hives)
  • breakdown of tumour cells which can cause high levels of uric acid and other substances in your body
  • changes to the levels of minerals and salts in your body, including low levels of calcium in the blood
  • feeling very thirsty
  • fits (seizures)
  • feeling dizzy or like everything is spinning around you
  • changes in your mental state including feeling confused, over active and excited, panicky or thinking and feeling under threat
  • problems with your eyes such as vision worsening or itchy or irritated eyes
  • hearing problems such as ringing in your ears (tinnitus), partial or total deafness
  • high blood pressure
  • periods stopping or early menopause
  • fever or chills
  • constipation
  • bowel not working
  • pain in different parts of the body such as the tummy (abdomen), back and muscles
  • ulcer in the stomach or bowel
  • a sore throat
  • difficulty swallowing
  • increased difficulty passing urine
  • weight loss
  • some of the veins in the liver becoming blocked - this may cause liver damage and can be life threatening
  • a build up of fluid in your tummy (abdomen)
  • a second cancer such as leukaemia

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

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 drink

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 might harm a baby developing in the womb. It is important not to become pregnant or father a child while you're having treatment and for a few months afterwards. Talk to your doctor or nurse about effective contraception before starting treatment.


Don’t breastfeed during this treatment 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.


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 one of the shingles vaccines called Zostavax.

You can 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 it in relation to your cancer treatment

Members of your household who are aged 5 years or over are also able to have the COVID-19 vaccine. This is to help lower your risk of getting COVID-19 while having cancer treatment and until your immune system Open a glossary item recovers from treatment.

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. Sometimes people who have had the live shingles vaccine can get a shingles type rash. If this happens they should keep the area covered.

If your immune system is severely weakened, you should avoid contact with children who have had the flu vaccine as a nasal spray as this is a live vaccine. 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.

This page is due for review. We will update this as soon as possible.

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