RICE

RICE 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.

• rituximab (ri-tuk-si-mab)
• ifosfamide (eye-foss-fa-mide)
• carboplatin (car-bo-pla-tin)
• etoposide(ee-top-o-side)

RICE is a treatment for non-Hodgkin lymphoma and Hodgkin lymphoma that has come back after treatment.

It is sometimes given for primary or secondary lymphoma of the brain or spinal cord. This is also known as central nervous system (CNS) lymphoma.

Most people who have this type of treatment also have a stem cell transplant . Your doctor or nurse will explain this treatment to you in detail.

How does RICE work?

Ifosfamide, carboplatin, and etoposide are chemotherapy drugs. They destroy quickly dividing cells, such as cancer cells.

Rituximab is a type of targeted drug called a monoclonal antibody. Monoclonal antibodies target proteins on the surface of cells.

Rituximab targets a protein known as CD20. CD20 is found on white blood cells called B cells. It is the B cells that are cancerous in the most common types of lymphoma.

Rituximab attaches itself to the B cells and marks them. The cells of the immune system then recognise the marked cells and kill them.

How do you have RICE?

You have these drugs through 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

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.

Mesna and G-CSF

Mesna 

You usually have ifosfamide with another drug called mesna. You have mesna either as a drip (infusion) into your bloodstream or you might have it as a tablet.

Mesna is not a chemotherapy drug. It stops the ifosfamide from irritating your bladder and making the lining of the bladder bleed.

G-CSF

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.

You usually start G-CSF at the end of each cycle of chemotherapy, and you have it for a few days. Your healthcare team will tell you more about this.

How often do you have RICE?

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

Each cycle lasts 21 days (3 weeks). You might have between 3 and 6 cycles. 

Rituximab can cause an allergic reaction. Before each dose you have paracetamol, a steroid, and an antihistamine drug such as chlorphenamine (Piriton). This helps to reduce the chance of you having an allergic reaction.

For the first cycle of rituximab, you have it as a drip into your bloodstream slowly over a few hours. Your nurse will increase how fast it goes approximately every 30 minutes if you have no allergic reaction.

Your healthcare team will explain more about how you have your treatment.

Different hospitals give RICE in different ways. A common way of having RICE is described below.

You then start a new cycle of treatment. You may need to stay in hospital overnight between days 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.

Before you have rituximab, you have a blood test to check for viruses such as Hepatitis B 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 RICE?

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. 

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).

General swelling

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

Feeling or being sick 

Feeling or being sick is usually well controlled with anti sickness medicines. Avoid fatty or fried foods. Eating small meals and snacks, drinking plenty of water, and relaxation techniques can all 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 treating it once it has started.

Tiredness and weakness 

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.

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 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.

Pain in different parts of your body 

You might get tummy pain, tell your treatment team if you have this. They can check the cause and give you medicine to help. 

You might get pain in other parts of the body including your muscles, joints, back, neck, and in the area where your cancer is, but this is less common.

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.

Irritation of the lining of the bladder (cystitis) 

You might feel that you have to wee more often than usual or have a burning feeling when you have a wee or notice blood. Sometimes there might be a lot of blood. Or you might feel that you can't wait when you need to have a wee. It helps to drink plenty of fluids.

Let your healthcare team know if you have any of these symptoms. 

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 side effect is stopping you from doing your usual daily activities.

Skin changes 

Skin problems include a skin rash, dry skin, and itching. Or your skin may become darker.  Less commonly you might have a raised itchy rash on the skin also known as hives.

Rituximab can also cause a severe skin reaction, but this is rare. Symptoms usually 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

Skin problems usually go back to normal when your treatment finishes. Let your doctor, nurse, or pharmacist know of any skin changes.

Changes in the levels of minerals in your body

You may have changes in levels of minerals and salts in your blood, including low levels of sodium, potassium, calcium, and magnesium. Or less commonly you might have 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.

An allergic reaction

Some people may have an allergic reaction to rituximab. 

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. 

Headaches 

Let your doctor or nurse know if you have headaches. They can give you painkillers such as paracetamol to 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:

• heart problems such as abnormal heart rhythm and a heart attack
• 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
• high blood pressure that might cause headaches, confusion, problems with your eye sight, or chest pain
• loose or watery poo (diarrhoea)
• difficulty swallowing
• mouth sores, ulcers, and the lining of your throat and food pipe might become sore and swollen
• changes in your taste
• unusual feelings of the skin – such as numbness, tingling, pricking, burning, a creeping skin feeling, or reduced sense of touch
• weight loss
• hearing loss especially with high pitched sounds and ringing in your ears (tinnitus)
• eye problems such as dry or watery eyes or red, sore, itchy eyes (conjunctivitis)
• a second cancer some years after treatment
• a severe infection called sepsis that can be life threatening
• high blood sugar levels - symptoms might include feeling very thirsty, a dry mouth, passing urine very often, feeling tired, blurred vision, or weight loss
• high levels of a substance (enzyme) called LDH in the blood. You will have blood tests to check this
• difficulty falling or staying sleeping (insomnia)
• indigestion - symptoms include heartburn, bloating, and burping
• a blocked, runny or itchy nose, or sneezing
• sweating, including night sweats
• flushing - sudden reddening and warmth of the neck, upper chest and face
• nerve damage that reduces the reflex reaction between tendons and bones
• redness, swelling, pain, or leaking at your drip site
• lung problems - symptoms include difficulty with breathing, shortness of breath, tightening of the chest, chest pain, and a cough. Rarely you might have asthma, low levels of oxygen, or a build up of scar tissue in your lungs (fibrosis)

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:

• fits (seizures)
• a blood disorder where your red blood cells get destroyed faster than they can be made (haemolytic anaemia)
• depression
• a hole in your stomach or bowel (perforation) - contact your healthcare straight away if you have pain, severe cramps, feeling tightness or bloating in the tummy area
• a condition where your bone marrow stops making your blood cells (aplastic anaemia)
• swollen lymph nodes
• changes to the levels of chemicals in your body caused by a breakdown of tumour cells (tumour lysis syndrome) - you will have regular blood tests to check for this
• changes to the way your blood clots - too little clotting causing bleeding or too much clotting causing blood clots
• 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

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:

• inflammation of the pancreas – symptoms include severe tummy pain, feeling or being sick, and a high temperature. You might also 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
• imbalance of substances in your blood (metabolic acidosis) – it can cause confusion, tiredness, shortness of breath and headaches

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 father a child 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.    

Contraception and pregnancy 

This treatment may harm a baby developing in the womb. It is important not to become pregnant while you are having treatment with RICE and for at least a year afterward. Men should not father a child during treatment and for at least 6 months afterwards.

Talk to your doctor, nurse, or pharmacist about effective contraception before starting treatment. Let them know straight away if you or your partner falls pregnant while having treatment.

Breastfeeding 

Don’t breastfeed during this treatment and for 6 months afterwards. 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.