R-CHOP: side effects and what to do

Slightly raised temperature

A slightly raised temperature, otherwise well.

Fever: always an emergency during chemotherapy

A temperature of 38.0°C (100.4°F) or more, even once. Or shivering, chills, or feeling suddenly very unwell.

• Keep a thermometer at home. Check your temperature whenever you feel unwell, hot, cold or shivery.
• Do not take paracetamol before checking: it can hide a fever.
• Wash hands often; avoid crowds and people with colds, cough or chickenpox.
• Eat freshly cooked food; avoid raw salads, cut fruit and street food when counts are low.
• Brush gently, keep cuts clean, and do not squeeze pimples.

• Growth factor injections (G-CSF) may be given after chemotherapy to raise white cells.
• Antibiotics are given by us when needed. Do not start antibiotics from home without telling us.

Mild (grade 1)

Feeling sick and eating a little less than usual, no vomiting.

Moderate (grade 2)

Eating much less than usual, or vomiting 1 to 3 times in a day.

Severe (grade 3 or 4)

Vomiting more than 3 times in 24 hours, or cannot keep down water or medicines, or feeling dizzy.

• Take your anti-sickness tablets on time for the days advised, even if you feel well.
• Eat small, plain meals often: idli, toast, rice, biscuits. Avoid oily, spicy food and strong smells.
• Sip fluids through the day: water, ORS, lemon water, coconut water.
• Ginger tea or lemon may help.
• Sit up for 30 minutes after eating.

• Ondansetron or granisetron, aprepitant, dexamethasone, olanzapine and metoclopramide.
• If you still feel sick, tell us: the medicines can be changed or added for the next cycle.

Mild (grade 1)

Harder stools, or a day without passing stools.

Moderate (grade 2)

No stools for 2 to 3 days, otherwise well, or needing laxatives every day.

Severe (grade 3 or 4)

No stools for 3 days with vomiting, or a swollen and painful tummy.

• Drink 2 to 3 litres of fluid a day.
• Eat fibre: fruit (papaya, banana), vegetables, whole grains, isabgol.
• Walk every day.
• Take laxatives early; do not wait for several days.

• Lactulose, polyethylene glycol, senna or bisacodyl.
• Always take a laxative with morphine-type pain medicines.

Mild (grade 1)

Soreness or redness; eating normally.

Moderate (grade 2)

Painful ulcers; you can eat soft food only.

Severe (grade 3 or 4)

Cannot eat or drink, or cannot swallow saliva.

• Rinse 4 to 6 times a day with salt water or soda bicarbonate water (half a teaspoon in a glass of water).
• Use a soft toothbrush; avoid alcohol-based mouthwash.
• Eat soft, cool, mild food: curd rice, dal, khichdi, ice cream. Avoid spicy, sour and very hot food.
• Keep lips moist.

• Pain-relieving gels and mouthwashes; antifungal medicine if there are white patches (thrush).

Mild (grade 1)

Tired, but better with rest.

Moderate (grade 2)

Not better with rest; you cannot do housework, shopping or work as usual.

Severe (grade 3 or 4)

Cannot get out of bed or walk, fainting, dizziness on standing, or tiredness with breathlessness or confusion.

• Gentle exercise, such as a 20 to 30 minute walk most days, helps more than resting all day.
• Plan important things for your better days; accept help with chores.
• Short naps (under 30 minutes), regular sleep times.
• Eat well and drink enough.

• Treating the cause: a blood transfusion or iron for low haemoglobin, thyroid tablets, or help with sleep or low mood.

• Cut hair short before it starts; use a soft brush and mild shampoo.
• Use a scarf, cap or wig; protect the scalp from sun and cold.
• It is normal to feel upset. Talking about it helps.

Mild (grade 1)

Dry skin, mild rash or redness, without pain.

Moderate (grade 2)

Painful redness or peeling of the hands or feet, or a rash over a large area, that affects daily work.

Severe (grade 3 or 4)

Blisters, skin peeling off, a rash with fever, a rash in the mouth or eyes, or a red, hot, swollen area with pus.

• Moisturise twice a day with a fragrance-free cream; urea cream for hands and feet.
• Use sunscreen and cover up in the sun.
• Bathe with lukewarm water and mild soap.
• Avoid tight shoes, hot water and long walks if hands and feet are sore.
• Keep nails short; wear gloves for housework.

• Antibiotic tablets and creams for EGFR rash; steroid creams; a short break or dose change for sore hands and feet.

Mild (grade 1)

Tingling or numbness that does not affect daily tasks.

Moderate (grade 2)

Difficulty with buttons, writing, holding things, or walking feels unsteady.

Severe (grade 3 or 4)

Cannot dress or walk safely, or falls. Or sudden weakness of the legs, numbness around the bottom, or trouble passing urine or stools (this can be pressure on the spinal cord).

• Protect hands and feet: check feet daily for cuts, wear well-fitting footwear, test bath water with your elbow.
• Take care on stairs and in the dark.
• Gentle exercise and physiotherapy help.

• The dose can be lowered or the medicine changed. Medicines such as duloxetine or pregabalin help painful tingling.

From: Rituximab

Rituximab and some others can wake up hepatitis B lying hidden in the liver.

When: During and for months after treatment.

What helps:

• A hepatitis B blood test is done before starting; antiviral tablets prevent it if needed.

From: Cyclophosphamide

Some medicines can stop periods or lower fertility in women and men.

When: Discuss before starting.

What helps:

• Talk to us before starting about storing eggs, embryos or sperm.
• Use contraception during treatment; pregnancy must be avoided.

From: Doxorubicin

Some medicines can weaken the heart muscle or affect its rhythm.

When: Can happen during or after treatment.

What helps:

• A heart scan (2D echo) or ECG is done before and during treatment.
• Most changes are found early on the echo and recover when the medicine is paused.