R-CHOP

R-CHOP is a cancer drug combination. It includes the drugs we list below, next to each drug, we have how you pronounce the drug name in brackets.

• R – rituximab (ri-tuk-si-mab)
• C – cyclophosphamide (sye-cloh-foss-fah-mide )
• H – doxorubicin (doks-oh-roo-bi-sin)
• O – vincristine (which used to be called Oncovin) – (vin-kris-teen)
• P – prednisolone (a steroid) – (pred-ni-suh-lown)

It is a treatment for: 

• non-Hodgkin lymphoma
• the advanced form of a rare type of Hodgkin lymphoma called nodular lymphocyte predominant Hodgkin lymphoma (NLPHL) 

How does R-CHOP work?

Rituximab is a type of targeted cancer drug called a monoclonal antibody . It targets a protein called CD20 on the surface of the lymphoma 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.

Cyclophosphamide, doxorubicin and vincristine are chemotherapy drugs. These drugs destroy quickly dividing cells, such as cancer cells.

Prednisolone is a type of 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-CHOP?

You take prednisolone as tablets. You swallow the tablets whole after a meal, or with milk, as they can irritate your stomach. It is best to take them after breakfast.  

You usually have all the other drugs into your bloodstream (intravenously).

Taking your tablets

Speak to your pharmacist if you have problems swallowing the tablets.

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

You should take the right dose, no more or less.

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

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

How often do you have R-CHOP?

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

You can have R-CHOP over 14 days (2 weeks) or 21 days (3 weeks), but the 3 week cycle is usually used. The number of cycles you have depends on your cancer type. Your doctor or nurse will tell you more about this.

Older people may have a lower dose regime. This is also called mini CHOP.

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) 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.

21 day (3 weeks) cycle

A cycle of R-CHOP over 3 weeks looks like:

You then start the next cycle of treatment.

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 have a blood test to check for viruses such as Hepatitis B infection or Cytomegalovirus (CMV). This is because infection with these viruses can become active again if you’ve had them in the past.

You may also have tests to check how well your heart works.

What are the side effects of R-CHOP?

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, 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).

Allergic reaction

A reaction may happen during the infusion. Symptoms can include a skin rash, itching, swelling of the lips, face or throat, breathing difficulties, fever and chills. Your nurse will give you medicines beforehand to try to prevent a reaction. 

Tumour lysis syndrome

This is when you have changes to the levels of substances in your blood, due to the breakdown of cancer cells. It usually happens when you first start treatment, but you have regular blood tests to check for this.

You may need a drip with fluid and medicines such as allopurinol or rasburicase. This is to help prevent kidney damage and other side effects such as changes in your hearts rhythm and seizures (fits).

If you are at risk of developing tumour lysis syndrome you will have close monitoring when you first start treatment.   

General swelling

A build up of fluid may cause swelling in your arms, hands, ankles, legs, face and other parts of the body. 

Rarely you might have fluid building up in the lungs. This can make it difficult to breathe and to get enough oxygen into the bloodstream.

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 and nail changes

You may notice changes in your skin, such as dryness, itching, rashes, reddening and it might also be more sensitive to sunlight. You may also notice nail changes such as them separating from their nail beds. 

Less commonly, you might have darkened nails or skin or hives. If you’ve had radiotherapy in the past, the area might get sore and inflamed.

If your skin gets dry or itchy, applying an unperfumed moisturising cream may help. Check with your healthcare team before using any creams or lotions. Wear a high factor sunblock if you’re going out in the sun.

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. 

Inflammation of the bladder

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.

Less commonly, you might have blood in your urine.

Tiredness and weakness (fatigue)

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

A sore mouth and inflammation of the digestive system

You might get a sore mouth and mouth ulcers. It may be painful to swallow drinks or food. You will have mouth washes to keep your mouth healthy.

You can have painkillers to reduce the soreness. Take them half an hour before meals to make eating easier.

Less commonly, you might have inflammation of the food pipe (oesophagus), tummy (abdominal) pain or a burning feeling in your tummy.

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.

Rarely, you might have bloody diarrhoea with cramping and a fever due to an infection of the colon. Contact your healthcare team straight away if you have this.

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.

Soreness, redness and peeling on palms and soles of feet

The skin on your hands and feet may become sore, red, or may peel. You may also have tingling, numbness, pain and dryness. This is called hand-foot syndrome or palmar plantar syndrome.

Moisturise your skin regularly. Your healthcare team will tell you what moisturiser to use.

Heart changes

You might have changes to how your heart works, such as your heart rhythm - a heart trace (ECG) might pick this up. Or, your heart might also be less able to pump blood around the body.

Occasionally this treatment can cause a heart attack. Symptoms include an overwhelming pain in the chest that might feel heavy, tight or as through its squeezing the chest. Other symptoms of a heart attack include feeling lightheaded, dizzy, pain in different parts of the body, sweating or anxious.

Rarely, you might have a thickened, stiff or stretched heart muscle. Or you might develop inflammation of the heart muscle (myocarditis) or the thin layers of tissue around the heart (pericarditis). This can cause chest pain or shortness of breath. 

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.

Rarely, you might get inflammation of the liver (hepatitis), blocking of the veins taking blood to the liver or an enlarged liver.

You have regular blood tests to check for any changes in the way your liver is working.

Weight changes

You may gain weight while having this treatment. You may be able to control it with diet and exercise. Tell your healthcare team if you are finding it difficult to control your weight. 

Less commonly, you might lose weight.

Nerve changes

Numbness or tingling in fingers or toes can be temporary or persistent. It can improve after you finish treatment. 

Some people have nerve pain. It is also called neuropathic pain. It can feel like a burning, shooting or tingling pain, or a feeling of crawling under their skin.

You may also have difficulty walking or changes to the way you walk. This can be caused by uncontrolled body movements or weak muscles.

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

Red or pink urine 

This won't harm you. It’s due to the colour of the chemotherapy and lasts for one or two days.

Changes to your veins

You might have inflammation of a vein caused by a blood clot in the vein.

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

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:

• changes to your blood sugar levels (hyperglycaemia). Symptoms might include feeling very thirsty, a dry mouth, passing urine very often, feeling tired, blurred vision, weight loss, feeling or being sick, and fruity smelling breath
• high levels of a substance (enzyme) called LDH in the blood. You will have blood tests to check this
• low calcium levels in the blood causing symptoms such as painful muscle spasms and cramps twitching of muscles, numbness or tingling in feet and hands or around the mouth
• feeling agitated or anxious, rarely a previous mental health problem might be triggered. Or you might feel depressed or have an elevated mood and energy (mania)
• difficulty falling or staying asleep (insomnia)
• 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
• lung changes such as tightening of the muscles that lines the airway (bronchospasm), chest pain or coughing. Rarely you might have asthma or scarring (fibrosis) of the lungs - making it difficult to breath and getting enough oxygen into the bloodstream
• a blocked, runny or itchy nose, or sneezing
• eye changes such as dry or watery eyes or red, sore, itchy eyes (conjunctivitis). Rarely you might have a cloudy area in the lens of the eye (cataract) or damage of the eye nerve (glaucoma) causing vision changes, or loss of vision
• ringing or buzzing in the ears (tinnitus) or ear pain. Rarely, you might have deafness which can be partial or total. This can be temporary or permanent
• indigestion symptoms include heartburn, bloating, and burping
• difficulty swallowing
• throat irritation
• sweating and, or night sweats
• tense or tight muscles
• a general feeling of discomfort
• flushing - sudden reddening and warmth of the neck, upper chest and face
• several body parts (organs) stopping working
• low levels of adrenal hormones causing symptoms such as weight loss, loss of appetite weakness, nausea, vomiting, and low blood pressure
• Cushing-like symptoms such as a red and puffy face
• changes to the levels of substances in the blood such as low potassium and high sodium, rarely you might have low levels of sodium
• a loss of fat and muscle in the body
• weakened bones that are fragile and more likely to break (osteoporosis)
• wounds taking long to heal
• flaring up of previous hepatitis B infection – an infection of the liver caused by a virus
• a loss of appetite, rarely you might have taste changes

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:

• swollen lymph nodes
• low levels of female sex hormones
• 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
• a condition affecting part of the brain causing clumsiness, weakness, or difficulty speaking or thinking
• a tear in the bowel wall (perforation) – contact your doctor immediately if you have a painful and a firm, bloated tummy
• Stevens Johnson syndrome (SJS) or toxic epidermal necrolysis - 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
• kidneys stopping working or a condition where the small blood vessels in your kidneys become damaged and inflamed – you will have tests to check how well your kidneys work
• an excessive uncontrolled release of a hormone called antidiuretic hormone (ADH) causing sickness, loss of appetite, sore muscles and weakness
• small blood clots developing throughout the bloodstream, blocking small blood vessels (disseminated intravascular coagulation)
• not having enough fluid in your body (dehydration)
• seizures (fits)
• changes to how the blood clots – too little clotting causing bleeding or too much clotting causing blood clots
• a type of anaemia called aplastic anaemia where the bone marrow no longer is able to make red blood cells – your doctor will tell you more about how it will be treated
• 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
• second cancers such as acute lymphocytic leukaemia or acute myeloid leukaemia 
• a hole in the stomach or bleeding in the digestive system – contact your doctor or nurse immediately if you have dark, smelly stools
• redness and swelling may develop at site of injection – tell your nurse or doctor straight away if this happens

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 condition where your bowel temporarily stops working
• inflammation of the brain causing a headache, stiff neck, sensitivity to light, confusion and seizures (fits)
• a life threatening condition that happens when taking prednisolone, symptoms include a high blood pressure, heart failure, a fast heartbeat, headaches, and tummy or chest pain
• the build up of acid in the body (metabolic acidosis)
• suicidal thoughts or a change in mental health such as losing touch with reality (delusions and hallucinations)

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 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 treatment. Women must not become pregnant for at least a year after the end of treatment. Men should not get someone pregnant for at least 6 months after treatment. 

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 12 months afterwards. The drug 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.

Immunisation

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.