ICE

ICE is the name of a chemotherapy combination. It includes the drugs we list below. Next to each drug we have included how you pronounce the drug name in brackets. 

• ifosfamide (eye-foss-fa-mide)
• carboplatin (car-bo-pla-tin)
• etoposide (ee-top-o-side) - also known as Vepesid or Etopophos

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

How does ICE work?

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

How do you have ICE?

You have ifosfamide, carboplatin and etoposide as a drip into your bloodstream (intravenously).

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

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 (G-CSF). This makes your bone marrow produce white blood cells more quickly after the chemotherapy. It helps lower your risk of getting an infection after having this treatment.

How often do you have ICE?

You usually have ICE chemotherapy as cycles of treatment. This means that you have the drugs and then a rest to allow your body to recover.

You might have between 2 and 4 cycles. Each cycle lasts 21 days (3 weeks). So the whole course of chemotherapy may last from 6 to 12 weeks.

You can have ICE chemotherapy in a number of ways. A common way of having it is described below.

You then start a new treatment cycle. 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.

What are the side effects of ICE?

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:

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 (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.

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.

Loss of appetite 

You might lose your appetite for various reasons while 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 healthcare team if you think you are constipated. 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, 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 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.

Inflammation of the bladder (cystitis)

You might feel that you have to pass urine more often than usual or find it difficult to pass urine. And you may have a burning feeling when you do. Or you might feel that you can't wait when you need to go. This is called cystitis. 

It helps to drink plenty of fluids. Don't take any over the counter medicines for cystitis. Contact your advice line instead.

Changes in the levels of minerals in your blood

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.

You might also have a drug called allopurinol. It lowers the amount of uric acid in the blood and so helps to reduce the symptoms of gout. 

Feeling weak and generally unwell 

This is usually mild. You can do things to help yourself, including some gentle exercise. It’s important not to push yourself too hard and eat a well balanced diet.

Talk to your doctor or nurse if this effect is stopping you from doing your usual daily activities.

Skin changes

The colour of your skin might get darker.

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:

• an allergic reaction that can cause shortness of breath and redness or swelling of the face
• dizziness
• heart problems such as an irregular heartbeat and heart attack
• high blood pressure (hypertension)
• diarrhoea
• mouth sores, ulcers and the lining of your throat and food pipe might become sore and swollen
• skin problems such as a rash, itching, reddening or raised itchy bumpy skin
• redness, swelling, pain or leaking at your drip site
• numbness or tingling in fingers and toes can make it difficult to do fiddly things such as doing up buttons
• burning or prickling sensation
• taste changes or loss of taste
• hearing changes such as ringing in your ears or hearing loss loss
• problems with your eyes such as worsening of your eyesight
• lung problems that can cause difficulty breathing such as tightening of the chest, wheezing, dry cough, fast and shallow breathing
• a second cancer such as acute leukaemia
• sore muscles, joints and bones
• nerve damage that reduces the reflex reaction between tendons and bones

Rare side effect

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

• fits (seizures)
• 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
• low blood pressure (hypotension)
• reddening of the skin in areas treated with radiotherapy
• problems swallowing (dysphagia)

Other side effects

The following side effects have also been reported. But it's not clear how often they happen. You might have one or more of them. They include:

• inflammation of the pancreas – symptoms include severe tummy pain, feeling or being sick, a high temperature or you may have loose poo
• 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
• changes in the brain that are usually reversible, causing a sudden onset of symptoms including headaches, dizziness, confusion, fits (seizures) and changes to vision
• changes to the levels of chemicals in your blood due to the breakdown of tumour cells (tumour lysis syndrome) - you have regular blood tests to check for this
• a blood disorder where your red blood cells get destroyed faster than they can be made (haemolytic anaemia)
• small blood clots developing throughout the bloodstream, blocking small blood vessels
• imbalance of substances in your blood (metabolic acidosis) – it can cause confusion, tiredness, shortness of breath and headaches
• • slow wound healing - Ifosfamide can slow wound healing. If you need to have an operation your doctor will normally stop the ifosfamide for a while beforehand. They will let you know when you can start having it again

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, foods and drinks 

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 might harm a baby developing in the womb. It is important not to become pregnant or get someone pregnant while you're having treatment and for a few months 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. 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.