Cyclophosphamide, thalidomide and dexamethasone (CTD)

CTD is the name of a combination of cancer drugs and is a treatment for myeloma.

What is CTD?

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

• cyclophosphamide
• thalidomide
• dexamethasone

It is a treatment for myeloma.

How does CTD work?

The chemotherapy drug cyclophosphamide works by stopping cells dividing into two. Dexamethasone is a steroid and can help chemotherapy to work better.

Thalidomide is a type of cancer growth blocker that affects all sorts of cell processes. It:

• interferes with chemicals that cells use to tell each other to grow
• stimulates some of the immune system cells to attack the cancer cells
• stops cancers making their own blood vessels that they need in order to grow

How do you have CTD?

You take all of these drugs by mouth. Cyclophosphamide and dexamethasone are tablets and thalidomide is a capsule.

Usually you take dexamethasone tablets in the morning after breakfast and thalidomide capsules at night.

Taking your tablets or capsules

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 or miss a dose of a cancer drug.

How often do you have CTD?

You usually have CTD as cycles of treatment.

Each cycle lasts either 21 days (3 weeks) or 28 days (4 weeks). Depending on your individual situation, you might have between 4 and 8 cycles.

You then start the cycle again.

You then start the cycle again.

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.

What are the side effects of CTD?

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. 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, 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 and looking pale

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).

Inflammation and soreness of the bladder (cystitis)

You might find it painful or feel as though it burns or stings when passing urine. Cystitis can cause other symptoms such as making you need to pass urine often or more urgently. Less commonly you might pass blood.

Tell your nurse or doctor if this is happening and try to drink 8 to 12 cups of fluid a day to try to prevent this.

Numbness or tingling in fingers and toes

Numbness or tingling in fingers or toes is often temporary and can improve after you finish treatment. Tell your healthcare team if you're finding it difficult to walk or complete fiddly tasks such as doing up buttons. 

You might have an unusual sensation on the skin, such as crawling sensation.

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 healthcare team if you think you are constipated. They can prescribe a laxative.

Tiredness and weakness (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.

Fluid build up 

You may have swelling of your hands and legs due to a build up of fluid (oedema). 

Dizziness 

This drug may make you feel drowsy or dizzy. Don’t drive or operate machinery if you have this.

Tremor 

You may develop shaky hands (tremor) with this treatment. This usually gets better when treatment stops. 

Feeling sleepy or drowsy

Speak to your team if you are very sleepy or are finding it hard to stay awake.

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. 

Kidney problems

Haemolytic uremic syndrome (HUS) is a kidney condition. It affects the blood cells and causes inflammation of the small blood vessels inside the kidneys. This causes small blood clots in the vessels to form and stop the kidneys from working properly. 

Kidney failure is another less common kidney problem. Symptoms might include passing urine less often, a build up of fluid in your ankles and legs, confusion, shortness of breath and weakness.

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:

• 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
• sore mouth and dry mouth
• rash and dry skin
• mood changes such as feeling low in mood (depression), anxious or confused
• hearing problems such as changes to your hearing or hearing loss
• heart problems such as a slow heart rate, fluttering, or rarely a heart attack
• feeling generally unwell
• changes to how well your liver is working – you will have regular blood tests to check for this
• a second cancer such as acute myeloid leukaemia (AML), bladder cancer, or a blood disorder called myelodysplastic syndrome
• feeling or being sick
• changes to your coordination
• sudden jerking or unusual movements (convulsions)
• low blood pressure – rarely this can happen suddenly when standing from a sitting or lying position
• feeling light headed or fainting
• blurred vision
• indigestion
• changes in blood supply to the brain (transient ischaemic attack) – call 999 if you have drooping on one side of the face, changes to speech or vision, or problems raising your arms

Rare side effects

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

• a blocked bowel
• loss of appetite
• flushing
• an allergic reaction that can cause a rash, shortness of breath, redness or swelling of the face and dizziness - some allergic reactions can be life-threatening, alert your nurse or doctor if notice any of these symptoms
• a stroke
• tear in the bowel causing an infection and inflammation of the peritoneum (peritonitis)
• inflammation of the mucous lining of the bronchial tubes (called bronchitis) – you might have a cough

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:

• difficulty sleeping
• increased appetite and weight gain
• changes in blood sugar levels
• soreness, redness and peeling on palms of hands and soles of feet
• Cushing’s 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
• changes in the brain that are usually reversible, causing a sudden onset of symptoms including headaches, dizziness, confusion, fits (seizures) and changes to vision

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.

Drinks containing caffeine should be avoided.

Alcohol

Do not drink alcohol while you are taking Thalidomide capsules. This is because alcohol can make you sleepy and Thalidomide capsules can make you even sleepier.

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 father a child while you are having treatment and for 12 months afterwards. Talk to your doctor or nurse about effective contraception before starting treatment.

Women of child bearing age will have a pregnancy test before and every 4 weeks during treatment. You will also have one 4 weeks after finishing your treatment. You’ll have to start using reliable contraception 4 weeks before starting this treatment. 

Men need to use a condom if their partner is pregnant or is able to become pregnant, if their partner is not using effective contraception.

Handling of Thalidomide

Some people worry about taking thalidomide but it does not cause physical defects in adults. Pregnant women and children should not touch or handle thalidomide. You must store it in a place where pregnant women or children cannot reach it.

Breastfeeding

Don’t breastfeed during this treatment. This is because the drugs may come through in your 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, 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 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 and possible side effects go to the electronic Medicines Compendium (eMC) website. You can find the patient information leaflet 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.

24.11.23 SmPC for thalidomide says that you should not donate blood or sperm during treatment and for 7 days afterwards. Thalidomide is approved for other conditions. Discussed with Debs and decided that we don't need to include information on our pages because most people with a history of cancer cannot donate blood and although it is less clear re. sperm condition in cancer pts,we feelthis is very unlikely to be allowed so soon after treatment for cancer. Helen T