Treatment Name: R-DHAP (Rituximab + Dexamethasone + Cytarabine + Cisplatin)

R-DHAP (Rituximab + Dexamethasone + Cytarabine + Cisplatin) is a Chemotherapy Regimen for Lymphoma, Mantle Cell

How does R-DHAP work?

Rituximab is an antibody that is designed to target and bind to a protein on the surface of cancerous b-cells. When rituximab binds to this protein, it helps your immune system destroy the cancer cell. Dexamethasone, cytarabine, and cisplatin are designed to kill rapidly dividing cells such as cancerous lymphocyte cells.

R – Rituximab (Rituxan®)
D – Dexamethasone (Decadron®)
HA – High-dose Ara-C (Cytarabine)
P - CisPlatin

Goals of therapy:

R-DHAP is given to shrink lymph nodes and decrease symptoms from lymphoma such as enlarged lymph nodes and spleen. It is commonly given with the goal of cure, but may require a bone marrow transplant.

Schedule

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How is R-DHAP therapy for mantle cell lymphoma given?

  • Rituximab intravenous (I.V.) infusion on Day 1. The time of infusion varies depending on tolerability
  • Dexamethasone 40 mg (ten 4 mg oral tablets) by mouth once daily on Days 1, 2, 3, and 4
  • Cytarabine I.V. infusion over 2 hours every 12 hours for 2 total doses on Day 2
  • Cisplatin I.V. infusion over 24 hours on Day 1

Click here for the common R-DHAP starting doses.

R-DHAP usually requires a 2 to 3 day stay in a hospital. In some cases, rituximab may be given in an outpatient infusion center prior to hospital admission while cytarabine, dexamethasone, and cisplatin are given in the hospital. Dexamethasone may be taken at home on Days 3 and 4 if you are no longer admitted to the hospital.

R-DHAP is repeated every 21 days. This is known as one Cycle. Each cycle may be repeated up to six times, depending upon the stage of the disease. Duration of therapy may last up to 5 months, depending upon response, tolerability, and number of cycles prescribed.

Side Effects

What are the most common side effects from R-DHAP for mantle cell lymphoma?

In a multi-drug regimen, each medication has unique side effects. When these medicines are given together, drug-related side effects reported in clinical studies give the best estimate of what to expect. In clinical studies, the most commonly reported side effects of R-DHAP are shown here.

Importantly, not all people who experience a side effect from R-DHAP will experience it in the same way. It may be mild in some or severe in others, depending upon the individual. Everybody is different. Additionally, side effects may vary over time. For some, side effects may be a reason to delay or switch treatment, reduce the dose, or avoid treatment with a certain medication altogether.

Side effects may be treatable when they occur or preventable by taking certain medications before they happen. When medications are taken to prevent a problem, this is known as prophylaxis, or "prophy" for short.

After starting treatment with R-DHAP, be sure to come back and watch all of the side effect videos shown below. Each of these videos contain valuable information about side effect management that will hopefully help you to both feel better and stay out of the hospital.

Watch videos on common R-DHAP therapy side effects below

Side effect videos Side Effect Videos
Nausea and VomitingNausea and VomitingDiarrheaDiarrheaBleedingBleedingNeutropenic FeverNeutropenic Fever

Monitoring

How often is monitoring needed?

Labs (blood tests) may be checked before each treatment and in between treatments at the discretion of your doctor. Labs often include: Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), uric acid, plus any others your doctor may order. Prior to getting rituximab, you may be checked for hepatitis B and HIV.

How often is imaging needed?

Imaging may be checked before treatment, at the completion of treatment to assess response, or if there are any concerns for certain side effects. Imaging may include: X-rays, magnetic resonance imaging (MRI), computerized tomography (CT) scans, or positron emission tomography (PET) scans.

How might blood test results/imaging affect treatment?

Depending upon the results, your doctor may advise to continue R-DHAP as planned, reduce the dose of future treatments, delay the next dose until the side effect goes away, or switch therapy.

Questions to Ask Your...

A better understanding of your treatments will allow you to ask more questions of your healthcare team. We then hope that with the answers, you will get better results and have greater satisfaction with your care. Because we know it's not always easy to know what questions to ask, we've tried to make it easy for you!

Choose any healthcare provider below to see common questions that you may want to ask of this person. Then, either print each list to bring to your clinic visits, or copy the questions and send them as a message to your healthcare team through your electronic medical record.

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Questions to ask your DoctorNursePharmacist

What does my caregiver need to know before I start therapy? Caregivers
Caregivers will benefit from knowing the treatment you are receiving and what side effects they can expect. Caregivers may also benefit from knowing what "as needed" medications you have to treat common side effects of chemotherapy. It is important that they know the treatment schedule in case they need to take time off of work to bring you to the infusion center or doctor appointments. Use our Treatment Tracker to help you plan for treatment, doctor appointments, lab draws, and send all of these reminders to your smartphone. Work with your doctor and ask questions early and often before small problems become big ones. Knowing who to call during business hours as well as after hours is also extremely important. Reference
Am I able to be the primary caregiver when my loved one is receiving cancer treatment? Caregivers
Caregiving can be very difficult, especially if you live in a remote location and do not have access to resources, have little money, are elderly yourself, or are caring for someone who requires a complicated treatment regimen (Reference). Ask your doctor if they think you are able to care for your loved one based upon the treatment they are receiving and the condition they are in. When possible, reach out to other family members for help and seek assistance from friends. Many people will want to help, but may not know how unless you tell them! Take good notes during appointments and ask your doctor what might make things easier for you as a caregiver. For example, by connecting with a social worker, together you may locate resources such as grants, or temporary housing to make it easier for you to care for your family or friend. For example, you may qualify for free house cleaning.
What is a clinical trial and am I eligible to participate in one now? Clinical Trials
A clinical trial is a type of study in which people are assigned to groups that either receive a new treatment intervention or standard treatment. In clinical trials with patients with cancer, it is sometimes unethical to give no treatment or a placebo. The type of treatment received by the patient is determined by the study protocol. Ask your doctor if they have any clinical trials that are enrolling patients or know if any at treatment centers nearby. You may also visit the website clinicaltrials.gov to see what clinical trials might be available for all cancer types and where these clinical trial medications are being offered.
Is it possible to participate in a clinical trial even if I live far away? Clinical Trials
It is possible, but it will depend upon the clinical trial requirements and whether you are willing to travel periodically for monitoring. Some, but not all, clinical trials require daily laboratory work as part of the monitoring requirements. Usually monitoring is more frequent at the start of the trial and decreases as time goes on. Most clinical trials cover the cost of the experimental medication and some help to cover travel costs as well as scans when needed. If you cannot afford a standard treatment, a clinical trial may be a way to receive treatment while minimizing out-of-pocket costs.
What are the best ways to minimize costs of treatment? Cost
One way to minimize costs associated with cancer treatment is to ask your doctor what types of tests they are ordering. If they are expensive, ask if they are covered by insurance before getting the test. If you are concerned about costs, you can also ask your doctor to only order tests that are absolutely necessary and to minimize the ones that are unlikely to change the plan. Some anti-cancer and supportive care medications are now available as generic formulations and preferred by insurance companies. If these medications are still expensive, ask your doctor to work with your pharmacist to find cheaper alternatives. Some drugs have co-pay cards or patient assistance programs that can help reduce the cost.
How do I prepare for a bone marrow biopsy? Diagnosis
A bone marrow biopsy is a relatively simple procedure that can be done outpatient and does not require hospitalization. You may request sedative medications prior to the procedure if you have anxiety. You should arrange to have someone drive you home if you take anxiety medications or receive pain medications prior to the procedure. You may have discomfort around the biopsy area and experience soreness for a few days afterwards. If you take anticoagulation (blood thinners) for a blood clot or atrial fibrillation, ask your doctor if you should skip a dose to decrease or prevent bleeding with the biopsy.
​If I don't fully understand what type of cancer I am dealing with, how do I learn more about it? Diagnosis
There are many reputable online resources to learn more about specific types of cancer, such as the American Cancer Society. Once a final diagnosis is made by your doctor, they can share this information with you and point you to other resources they know as well.
What is the exact cancer diagnosis? Diagnosis
An exact cancer diagnosis helps to narrow down potential treatment options that have the highest chance of working against the cancer. Your doctor will work with other specialized doctors, specifically pathologists, who analyze cancer cells and determine what type they are. From there, additional testing may be ordered by your doctor to further guide the decision towards the most targeted treatments. 

Cancer type: ___________________________________________, Sub-type: ___________________________________________
What if I'm worried that the treatment won't work? Mindset
Our mindsets describe for us what is right, what is possible, and what is natural. Changing our mindset often requires a combination of education and communication with others. In general, mindsets can be shaped by our education and experiences, people we trust, the media, social networks, culture, or religion. When it comes to treatment, it is okay to be uncertain. Your doctor wants to do what is right and will only offer treatment they think will help. Try to change your mindset by talking with your doctor. The belief that treatment will help you meet your goals is powerful and may actually lead to beneficial physiologic changes in your body.(Reference)
What do I need to know regarding my blood tests, which are sometimes referred to as "labs"? Monitoring
Unless you have access to them via your electronic chart, we recommend that you always ask for a copy of your labs. There are hundreds, if not thousands, of different blood tests available for your doctor to order. Some are common and some are not. Have your team explain to you what blood tests they have ordered and what the results mean when you do not understand. This way you will have a better understanding if the treatment is working or not. Plus, doctors may prescribe medications when your lab work is abnormal. When your lab work returns to normal you may be able to stop taking these medications, or reduce the dose.
Is it helpful and safe to exercise before treatment? Physical Activity
Physical exercise before, during, and after treatment has been shown to decrease the number of side effects and increase survival for patients with certain cancer types. You may not feel like exercising before treatment, but once you start feeling better ask your doctor about recommendations on the best way to start moving your body again in a way that is safe and beneficial. Importantly, you may have certain physical limitations now that may prevent you from doing certain exercises that may get better with treatment and time.
Will this treatment cause fatigue and if so, what can I do about it? Supportive Care
According to one large study, fatigue is reported by roughly 6 out of 10 people receiving treatment for cancer (Ref: Roila F, et al. Support Care Cancer. 2019). It is commonly described as the hardest side effect to deal with when receiving cancer treatment. In about half of these people, fatigue lasted for more than 4 months. The investigators also found that the most important factors related to the development of fatigue were decreased physical activity, poor sleep quality, pain, anxiety, anemia, and depression (Ref: Roila F, et al. Support Care Cancer. 2019). Fatigue may impact your relationship with others, and ability to work or have fun. It is often under-treated and importantly, medications are not always needed to make it better. If fatigue is an expected side effect of your treatment, or you feel it already, work with your doctor now on ways to prevent fatigue or to decrease its impact on your lifestyle.
What is a consent form and do I need to sign it before treatment? Treatment
A consent form contains information about your treatment, including possible risks and expected benefits. Signing the consent means that you understand and agree that the possible benefits outweigh risks and that you are willing to move forward with treatment. Not all treatments require a consent form. Your doctor will tell you if a consent is needed.
If possible, should I change how I do my job in order to balance treatment-related side effects? Work
While not always possible, some people are able to change what they do at their jobs to reduce some of the stress or physical demands on their body while undergoing treatment for cancer. Many people do not want to stop working and this might be one way to keep working until you are feeling back to your normal self. 
What if my job as a caregiver is getting harder? Caregivers
Caregivers can be partners, children, parents, siblings, friends, or colleagues. Importantly, the needs of the person receiving treatment may first grow and not decrease until that person feels better. As a result, the primary caregiver may take on more tasks, such as cooking, laundry, house cleaning, or child care. Although being a caregiver can be both rewarding through improved self-worth, and relationship enhancement, it can become overwhelming at times too (Reference). Tell your doctor what has become most difficult for you to manage. And remember, it's okay to ask other potential caregivers for help with tasks to make your job as a primary caregiver a little easier.
What should I do if I receive a bill for something that I thought would be covered by insurance? Cost
On occasion, items may be submitted and denied by insurance for a variety of reasons. Sometimes the medication or procedure is not covered, but sometimes claims are submitted with too little information to be approved by insurance or sometimes claims are submitted with the wrong information (example: miscoded). A denial letter from the insurance company, when issued, usually helps to explain the situation. If you receive an unexpected bill, ask your doctor if there is a financial counselor or someone you can speak with to help you.
What if I do not feel like eating during treatment or if foods taste different to me now due to treatment? Healthy Diet
Some treatments are well-known to change the way foods taste. Some experts recommend avoiding your favorite food if it tastes different during treatment so that when you are finished with treatment, you will still enjoy eating it. In addition, if food makes you nauseated, try to avoid foods that produce a lot of aroma, or leave them uncovered so that they do not produce overwhelming smells when you take the lid off. If you are unintentionally losing weight, ask your doctor if you can meet with a dietician who can recommend specific foods that will help prevent further weight loss.
​What foods should I avoid while receiving treatment? Healthy Diet
Be sure to check with your doctor and pharmacist about foods that may interact with your treatment because certain medications may be affected. For example, grapefruit and grapefruit juice commonly interacts with certain anti-cancer pills.
What foods should I eat during treatment? Healthy Diet
Ask if a dietician is available to speak with you. In general, most experts recommend that you consume a diet that has enough protein to ensure you maintain your muscle mass. Some experts recommend plant-based protein whenever possible. If you have had antibiotics recently, dairy products may be more difficult to digest and cause abdominal pain. It may take time to re-populate the good bacteria in your gut once antibiotics are stopped. Some experts also do not recommend probiotics and would advise you talk with your doctor and pharmacist before taking a probiotic supplement while receiving cancer treatment. In general, it is best to avoid highly processed foods, and those that have a lot of sugar. Ask your doctor or clinical pharmacist if raw fruits and vegetables are safe to eat with your treatment as these are often the best source of necessary vitamins and nutrients your body needs to stay healthy.
Could persistent fatigue after treatment be related to what I eat? Healthy Diet
It has been shown in a clinical study of cancer survivors that a diet high in vegetables (particularly green leafy vegetables), nuts and seeds, whole grains, and fish was associated with a lower chance of having fatigue as well as lessening the severity of fatigue. In addition, it may improve the quality of your sleep. Just like exercise, sticking to a diet takes a certain amount of discipline, but it is worth it! Know that it may take time to feel the full benefits of incorporating more of these foods into your diet. If your diet could use improvement and feeling better matters to you, then give it your best effort to make these changes. You may lose weight and over time be able to lower the dose of, or even stop medications for high blood pressure or cholesterol if you take these as well.
What if I'm still experiencing anxiety after treatment? Mindset
Anxiety after treatment is natural and may come and go. If it is physically affecting you or your ability to sleep or socialize with others, talk with your doctor about it, and consider speaking with someone such as a social worker. Talking with someone can be very therapeutic, and may be better than taking medications for anxiety that may have side effects, such as fatigue.
What can I do if I'm having a hard time exercising? Physical Activity
Your beliefs about what you can do and your expectations regarding how your body will benefit likely have a strong impact upon whether you start exercising, and whether you stick with it. Some experts find that the most successful people make physical activity a part of their routine, just like you do with brushing your teeth. Over time, you will find that daily physical activity will lead to many health benefits for both your body and your mind. To avoid hurting yourself, consider starting out slow. Every little bit counts, especially when it becomes a regular practice. Ask your doctor about the best way to begin a physical activity program and whether they think seeing a physical therapist would help as well. Physical therapists can teach you new exercises and ensure the ones you are doing now are safe and beneficial.
What can I do if my treatment is over and I am still having side effects? Side Effects
It is not always easy to predict if side effects from treatment will go away or when. When speaking with your doctor, try to describe what is troubling to you and how it limits the things you want to do. By setting goals, you can tell if the interventions you make to reduce the side effect are helping you get closer to goal. For example, chemo brain (cancer-related cognitive dysfunction), may limit your short-term memory. Your doctor may be able to recommend treatments, including those that do not have more medications. (Chung NC et al. Oncology. 2018)
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Questions to ask your NurseDoctorPharmacist

Who should I consider to have as my caregiver during cancer treatment? Caregivers
Your primary caregiver should be a trusted spouse, partner, parent, or adult child. You can also consider close friends, co-workers, or neighbors to assist.
What can my caregiver expect to experience emotionally? Caregivers
Being a caregiver can hold a lot of meaning and personal satisfaction, but it is important to be aware that caregivers experience emotional pain, sadness, and frustration as well. They may experience caregiver fatigue and, if so, might look for a local or online support group to assist with navigating the ups and downs. Ask you nurse if there are specific things that they think might help your caregiver as well.
What tasks might be required of my caregiver? Caregivers
If you are not feeling well, your caregiver may need to be available to drive you to and from your clinic appointments, lab draws, and infusion visits. If the treatment you are receiving increases the risk of serious side effects, you may need to have someone available around-the-clock in case you need urgent help or deciding if you need transportation to the ER. At some or all stages of your treatment, you may need a caregiver in home 24 hours a day to help you with eating and bathing until your are feeling better. Caregivers often play an important role in helping you keep track of your scheduled medications throughout treatment. Ask your nurse what other ways your caregiver may be able to help.
Are there any programs that I can use to help minimize the cost of my treatment? Cost
If your cancer treatment is going to be costly, there may be financial or patient assistance programs available to you to help lessen out-of-pocket costs. Ask your nurse if any of these are available and if someone such as a financial counselor can help you. You may qualify for financial or patient assistance programs, or supplemental insurance. If you do not know your pharmacist, your nurse may be able to connect you with one that may help reduce the cost of medications.
Is a bone marrow biopsy painful and will I be sedated for the procedure? Diagnosis
Bone marrow biopsies may produce some minor discomfort and have been described by some as similar to having a tooth pulled at the dentist. A local numbing agent, such as lidocaine, is used to numb the biopsy site. Most bone marrow biopsies are done in the clinic or at bedside in the hospital, but may alternatively be done with radiology guidance. You can ask your nurse how bone marrow biopsies are typically done at their practice site and whether sedatives are offered prior to the procedure.
What kinds of foods should I eat to prepare for treatment? Healthy Diet
Before treatment, ask your nurse if the specific treatment you are receiving is likely to change the way food tastes or if you are likely to lose weight. Now might be a good time to reevaluate what you eat on a daily basis. If you eat a lot of sugary or fatty foods, it would be good to eat more wholesome foods such as vegetables and fruits. Remember, it is not always what you are eating, it is what you are NOT eating that matters as well. Fruits and vegetables may contain valuable cancer-fighting compounds that may help you heal faster. If your healthcare team advises that you avoid vegetables, ask them for the written information that supports this recommendation.
What resources can I use to help me make better choices regarding my diet as I begin cancer treatment? Healthy Diet
Many oncology clinics have a dietician available to help you make positive changes in your diet. If one is not available, your nurse may be able to give you appropriate resources to help you make safe and positive dietary changes.
If I have to spend a long time at the infusion center, should I bring food with me? Healthy Diet
Some cancer treatments take several hours to complete causing you to spend a significant part of your day in the infusion center. In some cases, you may be at the infusion center when it is time to eat. Ask your nurse if food is typically provided to patients in the infusions center and if not, what the policy is for patients who want to bring food with them. A tablet or computer, or a good book often helps the time go by faster as well.
What should I do if I'm not a person who likes to ask for help? Mindset
Your nurse wants to make your life easier, but won't be able to unless you tell him or her what you are struggling with. Know that most health care professionals genuinely want to help you and the questions you ask now will save both you and them time by preventing problems down the road. If you can change your mindset and begin asking for assistance early, it will help them and it will help you. Problems may be able to be prevented and everyone wins!
If I need a stem cell transplant, what are the closest facilities that perform stem cell transplants? Stem Cell Transplant
Stem cell transplantation is a very specialized treatment that only certain centers are able to perform. It is possible that there may not be a center in your hometown that performs stem cell transplants. If you are told that you need a stem cell transplant, be sure to ask your nurse what facilities you could possibly go to in order to receive this treatment.
If I have an issue after normal clinic hours, what phone number do I call? Supportive Care
Serious issues can arise anytime of the day or in the middle of the night. Ask your nurse what on-call phone number you need to speak to a doctor or other healthcare professional after hours.
If I'm afraid to start treatment, who is the best person to talk with? Treatment
Your nurse may have experience helping other patients who have received the same treatment recommended to you. If they do not have experience, ask your nurse to schedule another appointment with your Doctor to answer questions. You can also ask your nurse if a social worker is available to talk to. They may be able to help you navigate through many of the fears of starting treatment and help you take the proper steps in addressing them.
What type of intravenous (I.V.) access is best for this treatment? Treatment
There are many ways to infuse treatment, including a peripheral I.V. line, a port, a PICC line (pronounced 'pick'), a tunneled catheter, and others. Your doctor, nurse, and sometimes pharmacist will work together to determine what is best for you.
What should I look for to know if my caregiver is experiencing caregiver fatigue? Caregivers
If your caregiver begins appearing irritable, withdrawn, depressed, stressed, etc. they may be experiencing burnout. Changes in their sleep pattern and/or eating habits may also be a sign. Your nurse may know of other signs to look out for as well.
What if my caregiver is not available? Caregivers
It is important to have a designated back-up during the times your primary caregiver is unavailable or to have a plan in place for the times that they are not around. If you know you will have difficulty making it to certain appointments, ask your nurse if they might be able to reschedule for a time or day that works for you. If you need transportation to a health-related appointment, your social worker may be able to assist, but will need plenty of time to make arrangements for you. In the case of an emergency, never hesitate to call 911.
What can I do to support my caregiver? Caregivers
Encourage your caregiver to schedule rest and relaxation, have other friends or family members take "shifts" being the caregiver, allow friends or loved ones to cook meals, or find local or online support groups when time permits. It is important your caregiver continue to engage in activities that bring them joy, even though they may feel guilty stepping away from their role. Remind them they can't take care of you unless they take care of themselves first! Your nurse may have more specific ideas for you as well.
How can I ensure I am getting adequate nutrition when I have no appetite during cancer treatment? Healthy Diet
When food becomes unappealing, focus on protein shakes, smoothies, electrolyte replenishing drinks, and broth. Ask your nurse to connect you with a dietician to help you with making food choices that agree with you. When all else fails, eat what you can! Most experts agree that a small snack that sounds delicious and stays down is better than nothing at all.
What should I eat if I am experiencing diarrhea during cancer treatment? Healthy Diet
In some cases, diarrhea can be caused by an infection. Be sure to speak to your nurse and care team before attempting to manage diarrhea at home. You should then consider trying the B.R.A.T. diet (banana, rice, applesauce, toast, oatmeal, or crackers) or bland foods. If you like dairy products, know that they may cause cramping in some people during treatment. If your stomach is bothering you, and you are having diarrhea, eat dairy in small amounts until you know you can tolerate a full serving.
If I am admitted to the hospital, do I need to bring my home medications with me? Home Medications
It is always helpful to bring your medications so that your healthcare team can see exactly what you are taking and determine if you need any refills before you go home. Importantly, most if not all, medications will be supplied by the hospital. However, some medications such as oral anti-cancer medication or chemotherapy pills may not be routinely stocked and may not be readily available to the hospital's pharmacy. If this is the case, and your doctor wants you to continue to take your oral anti-cancer medication, you may ask the hospital if their policy permits you to use your own medication so that you do not miss doses. If you do bring your medications, and they allow you to use your own supply, it is important to know that hospital staff often require that they oversee the administration of these medicines so that they know exactly what you are taking in order to keep you safe. If they do hold onto your medications, make sure you ask for your them back before you leave since it is common for people to forget. Your nurse may be able to help answer more specific questions about medications brought into the hospital.
Can I come in a day or two early to have labs drawn to decrease the amount of time I wait to receive treatment? Monitoring
In some instances, labs have to be drawn on certain days. In other instances, labs can be drawn a day or two before treatment. If interested, ask your nurse if you need to have labs drawn on the day of treatment or if you can get them done earlier to lessen the time you spend waiting at the infusion center.
Who can help me stay active when I am feeling weak? Physical Activity
In order to maintain activity in a safe manner, ask your nurse to put you in contact with a physical therapist. They can assess your strength level and give you individualized exercises to maintain and build muscle safely. An example is to get up every hour during the day for a short walk in the house to maintain endurance. It might not be easy, but try to stick with it because it may greatly benefit you in the long run.
What side effects should I contact the clinic about if they happen? Side Effects
Ask your nurse which side effects should prompt a phone call and which side effects can be managed on your own. While certain side effects can wait until normal clinic hours to be reported to the clinic staff, some should not wait and need to be reported right away as they may be very serious or life threatening. Ask your nurse what side effects should be reported right away and should not wait.
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    Questions to ask your PharmacistDoctorNurse

    Is my caregiver allowed to pick up my prescriptions? Caregivers
    In most cases, a caregiver should be allowed to pick up your prescriptions from the pharmacy for you. Sometimes, a driver's license, government-issued I.D., or other additional information may be needed before a caregiver can pick up certain medications. Ask your pharmacist if any steps need to be taken before your caregiver goes to the pharmacy.
    What foods or drinks, if any, should I be avoiding as I start treatment for cancer? Healthy Diet
    There may be certain foods and/or drinks that interact with your treatment or may increase your risk of certain side effects. Your pharmacist can check for possible drug-food interactions to help you avoid certain foods or drinks that might cause problems when taken with your current medication regimen and cancer treatment.
    Am I able to safely continue over-the-counter and herbal supplements while receiving this treatment? Home Medications
    Some over-the-counter and herbal supplements may increase the risk of side effects of therapy, or cause the treatment to not work as well. Be sure to tell your doctor and pharmacist everything that you are taking, including prescription and non-prescription medications. This includes eye drops, inhalers, topical medications such as creams or patches, implants or injections, which are sometimes forgotten but are all medications too! Consider visiting this website from Memorial Sloan Kettering Cancer Center to learn more about herbal products. When you visit this website, scroll to the bottom of the page to find the herbal medication you are interested in learning more about.
    What if the cancer treatment prescribed by my doctor is denied by my insurance company? Treatment
    If your insurance denies your medication, or prior authorization, your doctor may write an appeal letter, sometimes referred to as a "Letter of Medical Necessity" on your behalf. This describes the importance of the medication they have prescribed and why other treatments are either less likely to work or more likely to cause significant side effects that you may not tolerate. If the letter does not work and the cancer treatment is still denied by insurance, some drug manufacturers are able to offer free medication to individuals who qualify for their free drug programs. You may access these programs by calling the manufacturer, going to their website, or asking your clinical oncology pharmacist for help with this process. Not all manufacturers have free drug programs, so ask your pharmacist if they can help you determine if one is available.
    How will I know if my cancer medications are working? Monitoring
    Your pharmacist may help you manage side effects allowing you to avoid cancer treatment dose delays or dose reductions. This will hopefully help you get rid of or control the cancer. Your doctor may determine if the medications are working by performing a physical exam during each clinic visit, asking you to get scans of certain body parts (examples may include X-ray, M.R.I. scan, or C.T. scan), or ordering blood tests to help understand if the cancer medications are working. Ask your doctor or clinical pharmacist to explain the results of these tests to you if you are interested.
    Who would I talk to about drug cost if I need other treatments? Cost
    If you are now in remission, or between treatments, you may want to start with the person who helped you get approval for the first medication. Alternatively, if this was not a pharmacist, know that "clinical oncology pharmacists" are often excellent resources for help with co-pay assistance, grant assistance, or drug manufacturer assistance programs for cancer medications as well as most other medications as well.
    Where do I dispose of unused chemotherapy or other medications? Treatment
    If medications are not expired, ask your pharmacist if there might be any chance of needing them again in the future before you throw them away. If not, they may know of programs that accept unused medications in their original container that are not expired. If there are no programs located nearby that can recycle your unused medications, call your local police or fire department to see if they accept and destroy medications. Alternatively, if you have unused medications and are concerned about someone else taking them, mix them with old coffee grounds or other food scraps before throwing them away. This may also be the most environmentally friendly way of disposing of them. Before flushing medication down the sink/toilet, first ask your pharmacist to advise you on the best way is to dispose of it. For more information, visit this FDA website on unused medication disposal.
    How long after completion of treatment can I resume a full work schedule? Work
    A pharmacist may be able to give you information about how long certain side effects are likely to last after the last dose is taken. Your doctor can assess your overall health status and provide advice regarding when they feel like you are ready to return to work based upon their assessment of your physical and mental health, as well as their experience with other patients who have taken the same treatment.

    ChemoExperts Tips

    • Premedications such as diphenhydramine (Benadryl®), acetaminophen (Tylenol®), and hydrocortisone (Solu-Cortef®) may be given before rituximab to help avoid infusion related reactions.
    • The first dose of rituximab is often the hardest. It may lead to fever, shaking, and chills even if medications are given beforehand to help prevent these side effects. Side effects generally go away when the rituximab is stopped. It may then be restarted at a slower rate. Most patients are able to receive the entire dose, although it may take longer. In most cases, after the first dose is well tolerated, rituximab can be given over 90 minutes.
    • Because severe neutropenia and neutropenic fever may occur after R-DHAP, growth factor therapy known as G-CSF (examples: filgrastim or pegfilgrastim) is recommended. G-CSF helps keep the good white blood cells, known as neutrophils, from dropping too low. This in turn, helps to prevent serious infections that could result in hospitalization or even death.
    • Intravenous (I.V.) fluids may be given while receiving cisplatin to maintain good hydration and protect against kidney damage. These fluids may contain electrolytes such as potassium and magnesium.
    • Corticosteroid eye drops, such as prednisolone, are often started before the first dose of cytarabine to prevent eye irritation known as conjunctivitis. Eye drops may be continued at home for up to 72 hours after the last dose of cytarabine.
    • Short term difficulty with writing, walking, or talking may occur but is rare and usually reversible. To prevent these problems, various neurological exercises are done prior to each dose of cytarabine, to test for early signs of toxicity. Examples of these tests include: follow an object with your eyes, repeat various phrases, sign your name, or walk a straight line.
    • A pharmacist should ALWAYS review your medication list to ensure that drug interactions are prevented or managed appropriately.
    • Clinical trials may exist for mantle cell lymphoma. Ask your doctor if any studies are currently enrolling in your area. If not, go to clinicaltrials.gov to search for other centers offering study medications.

    Patient Assistance & Co-payment Coverage

    Patients under the age of 65 years, or those with private insurance plans:
    If you have insurance and are looking for patient assistance or copay assistance for R-DHAP (Rituximab + Dexamethasone + Cytarabine + Cisplatin), we have provided links that may help.

    Visit our Patient Assistance page and click the links to various patient assistance programs for help paying for R-DHAP (Rituximab + Dexamethasone + Cytarabine + Cisplatin). Depending upon your income, they may be able to help cover the cost of:

    • Rituximab
    • Dexamethasone
    • Cytarabine
    • Cisplatin

    For Branded medications (may be available for generic medications too), check with the manufacturer to determine if a co-pay card is offered and if it could reduce your monthly copay.

    • If you are uninsured, check with the manufacturer to determine if you are eligible to receive medication at no cost.

    Medicare and Medicaid patients (Patients 65 years or older):
    The clinic providing treatment will likely pre-authorize medications and immune therapies such as R-DHAP (Rituximab + Dexamethasone + Cytarabine + Cisplatin) and are the best source to help you understand drug cost.

    • Ask to speak with a patient assistance technician or financial counselor at the clinic or hospital administering this therapy.

    Emotional Wellness

    What is Emotional Wellness?
    Emotional wellness is having a positive outlook balanced with a realistic understanding of current life events. This requires both an awareness and acceptance of your emotions. It is with this knowledge that you can develop a plan to take the necessary actions to positively impact your life.

    Emotional wellness uses an ongoing process to continually reflect on the stressors of life in a constructive manner to move forward and create happiness.

    Because emotional wellness is deeply connected with physical, social, and spiritual wellness, pursuing it often becomes particularly difficult in times of major illness. Despite this difficulty, working toward emotional wellness has been connected to improved treatment outcomes and a higher likelihood of achieving goals of therapy.

    Learn more about pursuing emotional wellness while receiving treatment with R-DHAP (Rituximab + Dexamethasone + Cytarabine + Cisplatin)

    Individual Drug Label Information

    Rituximab (Rituxan®, Truxima®, Ruxience® Riabni®)

    • Rituximab is an intravenous infusion
    • Acetaminophen (Tylenol®) and antihistamines (e.g. diphenhydramine = Benadryl®) should be given prior to each dose
    • Patients should be screened for hepatitis B as rituximab can cause a re-activation of this infection
    • May cause vaccines to work less well for 6 - 12 months after the last dose of rituximab. It is advised that vaccines be given two to four weeks prior to rituximab if possible
    General Rituximab Side Effects
    • May cause an infusion reaction, which could include skin reaction, shaking, chills, fever, or shortness of breath. These reactions may be severe, but are very rarely life-threatening Infusion reactions does not usually happen after the first dose, but are possible
    • May increase the risk of infection. Your doctor may prescribe antibiotics to prevent certain infections associated with rituximab use
    • Click on the rituximab package insert below for reported side effects and potential drug Interactions

    Side Effect Videos
    Fatigue Fatigue

    See DailyMed package insert.

    Dexamethasone (Decadron®)

    • Dexamethasone is supplied as an oral tablet or oral liquid
    • Dexamethasone may increase the risk of infection. Depending upon how much dexamethasone is taken, antibiotics may be prescribed to help prevent infection
    • Should be taken with food and with a large glass of water to avoid stomach irritation or ulcers
    • Should be taken before 6 p.m. when possible, to avoid trouble falling asleep
    • May decrease the response to vaccines; vaccines may need to be repeated at a later date to obtain maximal response
    • If taken daily for several days or weeks, the dose of dexamethasone may need to be gradually decreased (tapered) to avoid withdrawal symptoms
    • If you miss a dose, take the next dose as soon as possible
    • Should be stored at room temperature
    General Dexamethasone (Decadron) Side Effects
    • May cause high blood sugar, weight gain, irritability, high blood pressure, difficulty sleeping, stomach ulcers, bone loss, muscle weakness
    • Click on the dexamethasone (Decadron) package insert below for reported side effects and potential drug Interactions
    See DailyMed package insert.

    Cytarabine (Ara-C)

    • Cytarabine is most commonly given as an intravenous infusion but may be given subcutaneously
    • FDA Black-Box Warnings for low white blood cells, low platelets, low red blood cells, nausea, vomiting, diarrhea, mouth sores, liver damage, and abdominal pain
    • Dosage adjustments may be required renal or liver function
    • May cause a series of symptoms known as Cytarabine (Ara-C) Syndrome within 6 to 12 hours after administration. Symptoms may include fever, rash, chest pain, muscle aches, bone pain, tiredness, and inflammation and redness of the eye
    General Cytarabine (Ara-C) Side Effects
    • Low red blood cells, white blood cells, or platelets
    • Nausea or vomiting
    • Liver dysfunction
    • Click on the cytarabine (Ara-C) package insert below for reported side effects and possible drug interactions

    Side Effect Videos
    Nausea and VomitingNausea and VomitingDiarrheaDiarrheaFatigue Fatigue BleedingBleedingPainPainAnemiaAnemiaNeutropenic FeverNeutropenic Fever

    See DailyMed package insert.

    Cisplatin (Platinol®)

    • Cisplatin is an intravenous (I.V.) infusion that is typically given over one to two hours
    • Cumulative toxicity to kidneys from cisplatin can be severe 
    • Other toxicities from multiple doses are:  low blood counts, nausea, vomiting, and hearing loss
    • Dosage adjustments may be required for poor kidney function or bone marrow toxicity (low blood counts) 
    • Cisplatin is hazardous to a human fetus; women should avoid pregnancy while on this drug 
    • Women should not breast-feed while on cisplatin; it has been reported to be in human milk 
    • Patients on anticonvulsant drugs may have decreased levels while on cisplatin 
    General Cisplatin (Platinol) Side Effects 
    • Kidney problems (nephrotoxicity), especially in elderly patients. 
    • Nausea and vomiting, both acute (within first 24 hours) and delayed (two to five days after infusion) 
    • Diarrhea 
    • Low blood cell counts (myelotoxicity, acute leukemia)
    • Hearing problems- ringing ears.  All patients should have a baseline hearing test done.  All children should have hearing test done before each dose and for several years after therapy is complete 
    • Low blood electrolytes:  magnesium, potassium, calcium, sodium, and phosphate
    • Nerve pain 
    • Vision problems; improvement and/or complete recovery usually occurs after stopping therapy 
    • Liver toxicity; recovery usually occurs after stopping therapy 
    • Click on the cisplatin (Platinol) package insert below for reported side effects and possible drug interactions

    Side Effect Videos
    Nausea and VomitingNausea and VomitingDiarrheaDiarrheaFatigue Fatigue PainPainAnemiaAnemiaNeutropenic FeverNeutropenic Fever

    See DailyMed package insert.

    References

    1) Velasquez WS, Cabanillas F, Salvador P, McLaughlin P, Fridrik M, Tucker S, Jagannath S, Hagemeister FB, Redman JR, Swan F, et al. Effective salvage therapy for lymphoma with cisplatin in combination with high-dose Ara-C and dexamethasone (DHAP). Blood 1988 Jan;71(1):117-22.

    Created: May 17, 2021 Updated: May 17, 2021

    What is Lymphoma, Mantle Cell?

    Mantle Cell lymphoma (MCL) is one of about 30 sub-types of Non-Hodgkin Lymphoma. MCL represents up to 8% of all diagnosed lymphomas. It is a cancer of the B-lymphocyte. Most patients who have MCL are 60 years old or greater and more commonly male than female. Many patients are diagnosed with swollen lymph nodes in the neck, armpit, or groin, or an enlarged spleen, which may cause fullness under the left rib cage or abdominal pain.

    The cause(s) of MCL are unknown. The stage of MCL can vary at diagnosis and throughout treatment. Stages of MCL include stage I, II, III, or IV. Although therapies are usually given with curative intent, many times the lymphoma returns within 1 – 2 years. Stem cell transplant and combined, multi-drug therapies are usually more effective than single medications.

    Medications for MCL may include intravenous infusions, oral tablets or capsules, or a combination of IV and oral medications. Patients may be diagnosed with MCL without having any symptoms. Others may go to their doctor with symptoms of swollen lymph nodes, a large spleen, or decreased appetite. The effectiveness of the treatment may depend upon the stage at diagnosis.

    NOTE: Treatment Options listed below are not all-inclusive. Other treatments may be available. ChemoExperts provides drug information and does not recommend any one treatment over another. Only your Doctor can choose which therapy is appropriate for you.

    What does Cure mean?

    The word “cure” means there are no cancer cells left in the body and cancer will never come back. Depending on the cancer type and stage, this may be the true goal of therapy. However, it is very difficult to prove all cancer cells are gone. Even though images, like X-rays and MRI’s, and blood tests may not show any signs of cancer, there can be a small amount of cancer cells still left in the body. Because of this, the word “remission” is used more often. This means there are no signs or symptoms of cancer. Patients in remission are followed closely for any signs of cancer returning. Sometimes, more chemotherapy may be given while in remission to prevent the cancer from coming back.

    Doctors usually do not consider a patient “cured” until the chance of cancer returning is extremely low. If cancer does return, it usually happens within 5 years of having a remission. Because of this, doctors do not consider a patient cured unless the cancer has not come back within 5 years of remission. The five-year cutoff does not apply to all cancers.

    Common Starting Doses

    • Rituximab 375 mg/m2 I.V. infusion on Day 1. The time of infusion varies depending on tolerability
    • Dexamethasone 40 mg by mouth daily on Days 1, 2, 3, and 4
    • Cytarabine 2000 mg/m2 I.V. infusion over 2 hours every 12 hours for 2 total doses on Day 2
    • Cisplatin 100 mg/m2 I.V. infusion over 24 hours on Day 1

    Note: Individual doses may vary based upon your Doctor's recommendation, or drug availability.

    What is an Antibody?

    An antibody is a small protein shaped like a “Y” that can attach to specific things in the blood, such as a cancer cell.
    • Once an antibody binds to something, your immune system may attempt to get rid of it.
    • Antibodies may also work by binding to the cancer cell surface and prevent other things from binding to the cancer cell that help it survive. Without the ability to bind growth factors, cancer cells may be forced to die"

    What is Tumor Lysis Syndrome (TLS)?

    Tumor lysis syndrome, or TLS, occurs when many cancer cells die quickly and release their contents into the bloodstream. Many times the body has the ability to flush these substances out through the kidneys or metabolize them via the liver. However, sometimes the body needs medicines to help eliminate these substances and to prevent organ damage.

    What is a CBC?

    A Complete Blood Count (CBC) is a frequently ordered blood test that tells clinicians the status of your: 1) White blood cell count, 2) Hemoglobin, and 3) Platelet count at the time the test was taken.

    Common uses:
    1) White blood cell count (WBC): is used to determine infection risk, or response to chemotherapy. Certain chemotherapy agents may harm our good infection-fighting cells. Sometimes chemotherapy may need to be delayed to allow these cells to recover.

    2) Hemoglobin: is used to determine if someone is anemic. Anytime the hemoglobin is below 12 g/dL, the person is said to be anemic. Red blood cell transfusions, and sometimes iron can be given to restore the hemoglobin level, but anemia treatment should always aim at treating the underlying cause or condition.

    3) Platelet count: is used to determine if the risk of bleeding is increased or if a platelet transfusion is required to prevent bleeding. Certain medications that increase bleeding risk, such as: aspirin, certain chemotherapy agents, and blood thinners, may need to be stopped temporarily until the platelet count is within a safe range.

    What is a CMP?

    A Comprehensive Metabolic Panel (CMP) is a frequently ordered blood test that tells clinicians the status of your: 1) Electrolytes & Acid/Base status, 2) Kidney function, 3) Liver function, 4) Blood sugar, and 5) Calcium at the time the test was taken. It is commonly used to monitor liver and kidney function when beginning new medications such as chemotherapy. A total of 14 tests are run simultaneously and are shown below.

    Electrolytes & Acid/Base status:
    1) Sodium, 2) Potassium, 3) Carbon dioxide, 4) Chloride

    Kidney Function:
    5) BUN (blood urea nitrogen), 6) Serum creatinine (Scr)

    Liver Function:
    7) AST, 8) ALT, 9) Total bilirubin, 10) Alk Phos, 11) Albumin, 12) Total protein

    Blood sugar:
    13) Serum glucose

    Calcium:
    14) Serum calcium