R-CVP

R-CVP is the name of a combination of cancer drugs used to treat low grade non-Hodgkin lymphoma. It is made up of the drugs:

• R – rituximab (ri-tuk-si-mab)
• C – cyclophosphamide (sike-low-foss-fa-mide)
• V – vincristine (vin-kris-teen)
• P – (pred-nis-oh-lone)

How does R-CVP 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 and vincristine are chemotherapy drugs. These chemotherapy 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-CVP?

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 with or after breakfast.  

You usually have all the other drugs as a drip 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

If you don't have a central line

You might have treatment through a thin short tube (a cannula) that goes into a vein in your arm. You have a new cannula each time you have treatment.

How often do you have R-CVP?

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

You have between 4 to 8 cycles. Each cycle lasts 21 days (3 weeks). 

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.

You have R-CVP in the following way:

You then start a new 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.  

What are the side effects of R-CVP?

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:

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 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).

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.

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.

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.

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 

Inflammation of the bladder (cystitis) can cause pain such as a burning feeling when you go.  You might feel that you have to pass urine more often than usual or find it difficult to pass urine. Occasionally you might notice blood when passing urine. Tell your doctor if this happens.

It helps to drink plenty of fluids. Don't take any over the counter medicines for cystitis as they could be harmful.

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. 

General swelling

A build up of fluid may cause swelling in your arms, hands, ankles, legs, face and other parts of the body. Contact your doctor if this happens to you.

Numbness or tingling in fingers or 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. 

Headache

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

Skin changes

Skin problems include a skin rash, dry skin and itching. This usually goes back to normal when your treatment finishes. Your healthcare team can tell you what products you can use on your skin to 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:

• sore mouth and ulcers - keep your mouth and teeth clean and drink plenty of fluids
• a change to the way your liver works that are usually mild and not likely to cause symptoms
• a high level of sugar in your blood
• weight loss or weight gain
• a high level of a substance (enzyme) called LDH in your blood
• a low level of calcium in your blood
• feeling agitated and anxious or depressed
• difficulty staying or getting to sleep
• widening of the blood vessels causing low blood pressure and flushing of the skin
• dizziness
• eye problems such a dry, watery or itchy eyes
• ringing in the ear (tinnitus) and ear pain. Very rarely deafness
• changes to your heart rhythm, it can also cause a heart attack. Contact your healthcare team straight away if you feel tightness or pain in your chest, lightheaded, dizzy, sweating or anxious
• high or low blood pressure
• tightening of the muscles that line the airways (bronchospasm), cough and shortness of breath
• runny nose
• diarrhoea
• tummy (abdominal) pain
• difficulty swallowing or throat irritation
• indigestion and heart burn
• loss of appetite
• increase in sweating or night sweats
• tight muscles
• pain in different parts of the body such as in your muscles, joints, chest, back, neck and pain where the cancer is
• mood and mental health changes such as suicidal thoughts, irritability, moodiness, losing touch with reality (delusions), seeing, hearing, smelling, feeling things that nobody else can (hallucinations). Tell your healthcare team if this happens.
• a virus called Hepatitis B to become active again if you've had it in the past
• high cholesterol
• low red blood cells (anaemia)
• organ failure
• shivering
• feeling weak and generally unwell (malaise)
• changes to your face and appearance such as swollen or puffy face, acne, growth of facial hair, weight gain around your tummy and stretch marks (Cushing’s syndrome)
• low levels of adrenal hormones causing weight loss, loss of appetite, nausea, vomiting and low blood pressure
• changes to the levels of sodium and potassium in the blood. You have regular blood tests to check for this
• loss of fat and muscle in the body
• weak fragile bones that are more likely to break (osteoporosis)
• thinning of the skin
• wounds take longer to heal

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:

• nerve damage causing pain
• problems with the way your blood clots
• swollen lymph nodes
• taste changes
• large tummy (abdomen)
• pain around the drip site
• a condition where the red blood cells are destroyed faster than they can be made (haemolytic anaemia)
• a condition where the bone marrow is unable to make all types of blood cells (aplastic anaemia)
• raised C-reactive protein levels
• low levels of certain hormones in the body (female sex hormones)
• cataracts and glaucoma
• an excessive uncontrolled release of a hormone called antidiuretic hormone (ADH) causing sickness, loss of appetite, sore muscles and weakness

Other side effects

For more information about the side effects of individual drugs:

• rituximab 
• cyclophosphamide
• vincristine
• prednisolone

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 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 this drug. 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 because the drug may come through into 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.

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.