Daratumumab, lenalidomide and dexamethasone (DRD)

DRD is the name of a cancer drug combination. It includes the drugs below. How to pronounce the drug names are in brackets.

• daratumumab (dar-rah-too-moo-mab), this is also known as Darzalex

• lenalidomide (len-ah-lid-oh-mide) also known as Revlimid

• dexamethasone (deks-ah-meth-uh-zone)

It’s a treatment for myeloma . It is for people who have not previously had treatment for myeloma and are not suitable for a stem cell transplant . 

How does daratumumab, lenalidomide and dexamethasone (DRD) work?

Daratumumab and lenalidomide are targeted cancer drugs .

Daratumumab is a type of targeted cancer drug called a monoclonal antibody. These target proteins on the surface of cancer cells. The immune system can then attack and kill the myeloma cells.

Lenalidomide is an anti angiogenic drug. Anti angiogenic drugs stop cancers from growing their own blood vessels. 

Dexamethasone is a steroid , it kills myeloma cells. It can also help to reduce an allergic reaction to daratumumab.

How do you have daratumumab, lenalidomide and dexamethasone (DRD)?

You have daratumumab as an injection under the skin. You take lenalidomide as capsules and dexamethasone as tablets. You might have dexamethasone as a drip into the vein (intravenously) before having daratumumab.

Injection under the skin (subcutaneous injection)

You usually have daratumumab as an injection under your skin into your tummy (abdomen) over 3 to 5 minutes.

You might have stinging or a dull ache for a short time after this type of injection, but they don't usually hurt much. The skin in the area may go red and itchy for a while.

Taking your tablets or capsules

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

You should take dexamethasone tablets after a meal or with milk as they can irritate your stomach. Taking them in the morning might help to stop difficulty in sleeping (insomnia).

You usually take your lenalidomide capsules at bedtime. This helps you to feel less sleepy at other times of the day. They can be taken with or without food.

How often do you have daratumumab, lenalidomide and dexamethasone?

You have daratumumab, lenalidomide and dexamethasone as cycles of treatment. This means that you have the drugs and then rest to allow your body to recover.  

Each cycle of treatment lasts 28 days (4 weeks).

You continue having daratumumab, lenalidomide and dexamethasone for as long as the treatment is working, and you are not having too many side effects. With each cycle, you have some of your treatment at the hospital and you take some of your tablets and capsules at home.

Exactly how you have your drugs may depend on your treatment centre and your circumstances. The following is an example:

For cycle 1 and 2

Cycles 3 to 6

For cycles 3 to 6 you have:

• daratumumab as a subcutaneous injection on day 1 and day 15

• dexamethasone as a tablet or infusion on days 1, 2, 15 and 16

• lenalidomide as a capsule at night on days 1 to 21

• no treatment from day 22 to day 28

Cycle 7 onwards

From cycle 7 you have:

• daratumumab as a subcutaneous injection on day 1

• dexamethasone on day 1, 2, 8, 16, 22

• lenalidomide as a capsule at night on days 1 to 21

• no treatment from day 23 to day 28

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). 

Blood transfusions

Daratumumab can affect a blood test called an indirect Coombs test. This is one of the tests you have before a blood transfusion. The test helps to make sure you are matched with the right blood for your transfusion. Tell the person doing the test that you are taking daratumumab. You might also have a card explaining this to keep with you to show the person taking the test.

What are the side effects of daratumumab, lenalidomide and dexamethasone?

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 burning feeling when weeing, 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 (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.

Loss of appetite and weight loss

You might not feel like eating and may lose weight. Eating several small meals and snacks throughout the day can be easier to manage. You can talk to a dietitian if you are concerned about your appetite or weight loss.

Numbness and tingling in your hands and feet

Numbness or tingling in fingers or toes is often temporary and can improve after you finish treatment. But lenalidomide can sometimes cause long term or permanent numbness. 

Tell your healthcare team if you're finding it difficult to walk or complete fiddly tasks such as doing up buttons. 

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.

Headaches

Tell your doctor or nurse if you keep getting headaches. They can give you painkillers to help.

Indigestion or heartburn

Contact your nurse or pharmacist if you have indigestion or heartburn. They can prescribe medicines to help.

Problems with your lungs

You might have a severe chest infection (pneumonia) or other problems in your lungs and airways. Symptoms include difficulty breathing, a high temperature, feeling tired and achy, chest pain or pain when you cough, a sore throat, and a runny nose. Less commonly, you might get a build up of fluid in the lungs (pulmonary oedema).

Let your doctor or nurse know straight away if you develop a cough.

Diarrhoea

Contact your advice line if you have diarrhoea. For example, in one day you have 2 or more loose bowel movements than usual. If you have a stoma , you might have more output than normal. Your doctor may give you anti diarrhoea medicine to take home with you after treatment.

Try to eat small meals and snacks regularly. It’s best to try to have a healthy balanced diet if you can. You don’t necessarily need to stop eating foods that contain fibre. But if your diet is normally very high in fibre, it might help to cut back on high fibre foods such as beans, nuts, seeds, dried fruit, bran and raw vegetables. 

Drink plenty to try and replace the fluid lost. Aim for 8 to 10 glasses per day.

Constipation

Constipation is easier to sort out if you treat it early. Drink plenty 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 give you a laxative if needed.

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 problems

Skin problems include a skin rash, dry skin and itching. Lenalidomide can sometimes cause a severe skin rash. You might notice your skin is thinning or have stretch marks or small broken red blood vessels. You might also notice your skin become darker or rarely your skin may be sensitive to light. 

Your healthcare team can tell you what products you can use on your skin to help. 

Pain in your back, muscles and joints

You may have painful bones, joints, and muscles, and you might have back pain. You might also have muscle spasms or cramps that can also be painful. Less commonly you might have muscular chest pain, or you may notice swelling in your joints.

Speak to your healthcare team if you have any pain. They can talk to you about the best ways to reduce and relieve your pain. 

Swelling of hands and feet (oedema)

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

High temperature (fever)

You might have a high temperature with this treatment. This is because it can affect your body’s ability to control temperature. Having a fever doesn’t always mean you have an infection. But you should call your advice line, as an infection can be serious if not treated quickly.

Inflammation of the digestive tract and bowel 

You might have inflammation of your digestive system . Symptoms can include abdominal cramps, diarrhoea, feeling sick and a fever. You might have inflammation of the bowel, but this is less common.

Call your hospital advice line if you have tummy pain, bleeding when you have a poo, or notice changes in your regular bowel habits. 

Inflammation of the nose, back of the throat and sinus

You might have inflammation in your nose, the back of your throat, and your sinuses. Or you may notice you have a runny or itchy nose. You may find you are sneezing or coughing more than usual.

Changes to your mineral and salt levels in the blood

You may have changes in levels of minerals and salts in your blood, including low levels of sodium. The symptoms might include feeling sick, tired, or restless. Or you might have low levels potassium, which can cause symptoms such as tummy pain and muscle cramps. You have regular blood tests during treatment to check for changes in your blood.

Changes to your blood sugar levels

You have regular blood and urine tests to check this. If you have diabetes you may need to check your blood sugar levels more often than usual. 

Pain in your tummy (abdomen)

This treatment can cause tummy pain. Let your healthcare team know so they can advise you on how to relieve and reduce it.

Problems with your liver

You might have changes in your liver function blood tests. You will be monitored throughout treatment.

Problems with your eyesight

You might have blurred vision or clouding of the lens (cataracts). You might find it more difficult to see and rarely you might have loss of sight. There is also a risk of glaucoma (a build up of pressure around the eye that can affect eyesight) and eye infections. But it is not known how frequently this happens.

Contact your healthcare team if you have any new problems with your sight.

Allergic reaction

It's very common to have a reaction to daratumumab. It's most likely to happen on the day of treatment but symptoms of an allergic reaction can appear up to 4 days after having daratumumab.

Your nurse will check you regularly. Symptoms include fever, chills, chest pain, rash, vomiting, facial swelling or difficulty breathing. You have a steroid tablet called dexamethasone before and after to try to prevent a reaction.

Less commonly you might have an allergic reaction to one of the other drugs.

Feeling shaky (tremors)

Your hands or other parts of the body could feel shaky. Talk to the team looking after you about this.

Taste changes

Taste changes may make you go off certain foods and drinks. You may also find that some foods taste different from usual or that you prefer to eat spicier foods. Your taste gradually returns to normal a few weeks after your treatment finishes.

Blood clots

Blood clots can develop in the deep veins of your body, usually the leg. This is called deep vein thrombosis (DVT). A blood clot can be very serious if it travels to your lungs (pulmonary embolism), although this isn’t common.

Symptoms of a blood clot include:

•    pain, redness and swelling around the area where the clot is and may feel warm to touch
•    breathlessness
•    pain in your chest or upper back – dial 999 if you have chest pain
•    coughing up blood

Low blood pressure (hypotension)

Tell your doctor or nurse if you feel lightheaded or dizzy. Your blood pressure might also drop when standing up. Take extra care when standing up quickly.

You have your blood pressure checked regularly when you are in the hospital.

Dry, sore mouth

Your mouth might get sore with this treatment. You will have mouthwashes to keep your mouth healthy. You can have painkillers to reduce the soreness. Take them half an hour before meals to make eating easier.

If you have a dry mouth it can help to drink plenty of fluids after treatment. An artificial saliva spray into your mouth might help. Ask your healthcare team about this.

Kidney problems

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.

Mood changes and difficulty sleeping

Talk to your healthcare team if your mood is affected or you are feeling low or depressed.

If you are not sleeping well it can help to change a few things about how you try to sleep. Try to go to bed and get up at the same time each day and spend some time relaxing before you go to bed. Some light exercise each day may also help.

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 infection in your urinary tract. You might find it difficult to have a wee, want to wee urgently, or more often. There may be pain or burning when you have a wee. You may see blood in your wee, or it might have a bad smell or look cloudy
• sepsis - this a serious reaction to an infection, signs can include feeling very unwell, not passing urine, being sick, having a very high or very low temperature or shivering - call 999 if you have any signs of sepsis
• a condition where you have low levels of immunoglobulins and antibodies  
• feeling dizzy and fainting 
• changes in your heart function and an irregular heartbeat - you might have a heart trace test (ECG) to check for this
• high blood pressure 
• inflammation of the pancreas (pancreatitis)
• risk of developing a second cancer including myelodysplastic syndrome . There is also a risk of developing types of skin cancer called basal cell carcinoma and squamous cell skin cancer
• difficulty getting an erection
• low levels of thyroid hormones, which can cause tiredness 
• difficulty with walking, balancing and co-ordination - you might need to be extra careful to avoid falling
• hearing problems such as hearing loss or ringing in your ears (tinnitus)
• indigestion
• nerve pain
• changes to your voice
• sweating more than usual

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:

• hepatitis B (a viral infection affecting the liver) can flare up - your doctor will check to see if you’ve had this virus in the past
• cytomegalovirus (CMV) infection - this type of infection is quite common but can be serious in people having treatment that lowers their immune system. Symptoms are the same as other infections. For example, a high temperature, aching muscles, and feeling sick. Call your advice line straight away if you have any symptoms of an infection
• 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
• loss of interest in sex 
• conditions that affect your blood clotting
• a condition where red blood cells are broken down too soon. Symptoms include feeling tired and dizzy and breathless

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:

• weaker bones due to bone loss (osteoporosis). This can increase your risk of your bones breaking

• changes to your face and appearance. You might develop a swollen or puffy face, stretch marks, acne, or more facial hair

• if you have epilepsy, this may get worse when taking steroids

• delayed wound healing

• increased appetite and weight gain

• changes to your menstrual cycle. Symptoms include irregular periods, or they might stop altogether

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

• daratumumab
• lenalidomide
• dexamethasone

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.

Pregnancy and contraception

Lenalidomide can cause birth defects in children. It is important not to become pregnant or get someone pregnant while you're having this treatment. Some people may worry about taking lenalidomide but it doesn’t cause physical defects in adults.

Because lenalidomide causes birth defects, your doctor will talk to you before you start treatment. They will make sure that you understand the risks of this treatment and agree to use contraception. You should continue to use contraception for at least 3 months after you stop taking this drug combination.

Let your doctor know straight away if you or your partner become pregnant.

Fertility 

It is not known whether this treatment affects fertility in people. Talk to your doctor before starting treatment if you think you may want to have a baby in the future.

Breastfeeding

It is not known whether these drugs come through into the breast milk. Doctors usually advise that you don’t breastfeed during this treatment.

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.

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.