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This information is about two similar chemotherapy treatments for lymphoma, called DHAP and R-DHAP. If you have any questions you can ask your doctor or nurse at the hospital where you are having your treatment, or speak to one of our cancer support service nurses.
DHAP is named after the drugs that are used in the treatment. This includes dexamethasone, which is a steroid, and the chemotherapy drugs:
R-DHAP also includes the monoclonal antibody drug rituximab (Mabthera®).
Rituximab is a monoclonal antibody. It is used to treat several different types of B-cell non-Hodgkin lymphoma. Monoclonal antibodies are used to try to destroy some types of cancer cells while causing little harm to normal cells. They are designed to recognise certain proteins that are found on the surface of some cancer cells. The monoclonal antibody recognises the protein and locks onto it (like a key in a lock). This may then trigger the body’s immune system to attack the cancer cells and can sometimes cause the cells to destroy themselves.
Rituximab locks onto a protein called CD20, which is found on the surface of one of the main types of normal white blood cells (B-cell lymphocytes). It is also present on the surface of most of the abnormal B-cell lymphocytes that occur in some types of non-Hodgkin lymphoma. Rituximab acts by attacking both abnormal (malignant) and normal B-cell lymphocytes. However, the body can quite quickly replace any normal white blood cells that are damaged.
DHAP or R-DHAP treatment is usually given to you during a short stay in hospital. You will need to have a blood test before you start treatment – either on the same day, or a few days beforehand. You will also be seen by a doctor, specialist nurse or pharmacist. If the results of your blood test are normal, the pharmacy will prepare your chemotherapy drugs. All of this may take a couple of hours.
The nurse will then put a thin, flexible tube (cannula) into a vein in your hand or arm. You may find this uncomfortable or a little painful but it should not take long. Some people have their chemotherapy given through a thin, plastic tube, which is inserted under the skin and into a vein near the collarbone (central line), or passed through a vein in the arm (PICC line). Your doctor or nurse will explain more about this to you.
You will be given some anti-sickness (anti-emetic) drugs. These are usually given by injection through the cannula, central line or PICC line, which is connected to a drip (infusion). Some anti-sickness medicines are given as tablets.
The steroid and chemotherapy drugs are then given separately:
While having DHAP or R-DHAP you will also be given plenty of fluid through your drip to help keep your kidneys working normally. This is sometimes known as hydration. You may also be given a drug called mannitol, which is given as an infusion with the cisplatin. Mannitol increases the amount of urine that your kidneys produce.
Your doctor may use the word 'regimen' (eg the DHAP regimen) when talking about your chemotherapy. This means the whole plan, or schedule, of the particular treatment that you are receiving.
On the first day of your treatment you will start the first of four days of dexamethasone tablets or infusions. You will also start a 24-hour infusion of cisplatin. If you are having R-DHAP you will be given an infusion of rituximab before the cisplatin.
On the second day of your treatment you will be given more dexamethasone tablets, or another infusion. You will also be given two infusions of cytarabine, which are given 12 hours apart.
If you are taking dexamethasone tablets you can go home when the chemotherapy and hydration have finished. You will be given some dexamethasone tablets to take at home over the next two days (days 3 and 4 of your treatment). If you have been having dexamethasone infusions, you will need to stay in hospital for the infusions to be given on the third and fourth day. Before going home you will be given some steroid eye drops to take for the next 5–7 days.
When you go home you will be given a supply of anti-sickness tablets to take with you. It is important to take these as directed, even if you are not feeling sick. This is because some anti-sickness drugs are much better at preventing sickness than at stopping it once it has started.
You will then have a rest period with no chemotherapy, which completes one cycle of your chemotherapy treatment. Each cycle lasts 21 or 28 days.
You will begin your next cycle of treatment after the rest period, which will be either three or four weeks after your first infusion.
Each person's reaction to chemotherapy is different. Some people have very few side effects, while others may experience more. The side effects described below will not affect everyone who is having DHAP or R-DHAP chemotherapy. We have outlined the most common side effects, so that you can be aware of them if they occur. However, we have not included those that are rare and therefore unlikely to affect you. If you notice any effects that you think may be due to the drug, but which are not listed in this information, please let your doctor or nurse know.
Feeling sick (nausea) and being sick (vomiting) Your doctor can prescribe very effective anti-sickness (anti-emetic) medicines to prevent or reduce nausea and vomiting. If the sickness is not controlled, or if it continues, tell your doctor. They can prescribe other anti-sickness medicines which may be more effective. Some anti-sickness medicines may cause constipation. Let your doctor or nurse know if this is a problem.
Lowered resistance to infection The chemotherapy will reduce the production of white blood cells by the bone marrow, making you more prone to infection. This effect can begin seven days after treatment has been given, with your resistance to infection usually reaching its lowest point 10–14 days after chemotherapy. Your blood cells will then increase steadily and will usually have returned to normal levels before your next cycle of chemotherapy is due. You may be given antibiotics to take as a preventative measure (known as prophylactic antibiotics).
Contact your doctor or the hospital straightaway if:
You will have a blood test before having more chemotherapy to make sure that your number of white blood cells has returned to normal. Occasionally, it may be necessary to delay treatment if your number of blood cells (blood count) is still low.
You may be given injections of a drug called G-CSF (granulocyte-colony stimulating factor), which is a protein that can help boost the number of white blood cells that your bone marrow produces. It is given as an injection under the skin (subcutaneously).
Bruising or bleeding DHAP and R-DHAP can reduce the production of platelets (which help the blood to clot). Let your doctor know if you have any unexplained bruising or bleeding, such as nosebleeds, blood spots or rashes on the skin, or bleeding gums.
Anaemia (low number of red blood cells) While having treatment with these drugs you may become anaemic. This may make you feel tired and breathless. Let your doctor or nurse know if these are a problem.
Your kidney function may be affected Usually this does not cause any symptoms, and the effect on the kidneys is generally mild. Rarely, it may cause permanent damage to the kidneys unless the treatment is stopped. Before each treatment you will have a blood test to check how well your kidneys are working.
You will be asked to drink more than normal during the day after treatment. It is important to tell your doctor or chemotherapy nurse if you are not able to drink enough. Let your doctor or nurse know if you are not passing as much urine as normal.
Allergic reaction It is not unusual to have a slight allergic reaction to rituximab. Signs of this include: skin rashes and itching; a feeling of swelling of the tongue or throat; irritation of the nasal passages; wheezing; coughing and breathlessness. You will be monitored closely during your treatment, but let your nurse or doctor know if you have any of these effects. To reduce the chance of developing an allergic reaction, certain drugs (chlorpheniramine and paracetamol) can be given. The rituximab infusion can also be slowed-down or stopped until the reaction is over.
Flu-like symptoms Some people find that rituximab can cause headaches, aching joints and muscles, a temperature, lethargy (feeling of having no energy) and chills. These can occur while the drug is being given, but do not usually last long.
Low blood pressure This may happen during the infusion of rituximab, so your blood pressure will usually be regularly checked. People who normally take drugs to lower their blood pressure may be advised by their doctor to take these at least 12 hours before rituximab is given. It is important not to alter your blood pressure medication without first discussing it with your doctor.
Sore mouth and ulcers Your mouth may become sore, or you may notice small ulcers during this treatment. Drinking plenty of fluids, and cleaning your teeth regularly and gently with a soft toothbrush, can help to reduce the risk of this happening. You will be given mouthwashes to help keep your mouth clean and prevent infection. Your nurse will show you how to use these. Let your doctor know if you develop any problems, as you may need to have painkillers or antibiotics if your mouth becomes sore and infected.
Tiredness and feeling weak Many people feel very tired (fatigued) during chemotherapy, particularly towards the end of treatment. This is a very common side effect and it is important to try to get as much rest as you need.
Gritty and sore eyes (conjunctivitis) This can happen because cytarabine can cause inflammation of the conjunctiva (the membrane that covers the whites of the eyes and lines the eyelids). You will be given steroid eye drops to help prevent this side effect occurring. It is important to follow the instructions you are given.
The levels of sugar in your blood may change While you are having steroids as part of the DHAP regimen, your blood sugar levels may be checked with blood tests. You may be asked to test your urine for sugar. You will be shown how to do this.
People with diabetes should be more careful than usual when checking their blood sugar levels. You should contact your doctor if there is any problem controlling your diabetes. Tell your doctor if you get thirsty or if you are passing more urine than usual.
Irritation of stomach lining Dexamethasone can reduce the production of protective stomach mucus. This can irritate the lining of your stomach and may cause or aggravate an ulcer. To help reduce this effect the tablets should always be taken with food or a drink of milk. Tell your doctor if you have any indigestion, stomach pains or abdominal discomfort.
Diarrhoea This can usually be easily controlled with medicine but tell your doctor if it is severe or if it continues. It is important to drink plenty of fluids if you have diarrhoea. If you have any change in bowel habit, tell your doctor.
Constipation This may occur and can usually be relieved by drinking plenty of fluids, eating a high-fibre diet and taking gentle exercise. Sometimes you may need to take medicines to stimulate your bowel. These can be prescribed by your doctor.
Hair loss Although you may notice that a small amount of your hair falls out during treatment, noticeable hair loss is rare with this type of chemotherapy.
Ringing in your ears and hearing loss Cisplatin can cause ringing in the ears (tinnitus). It can also cause some loss of ability to hear high-pitched sounds. This usually improves when the treatment is over. Tell your doctor if you notice any loss of hearing or ringing in your ears.
Numbness or tingling in hands or feet This is due to the effect of cisplatin on nerves and is known as peripheral neuropathy. Tell your doctor if you notice these symptoms. The problem usually improves slowly a few months after treatment ends.
Temporary taste alterations You may notice that your food tastes different. Your normal sense of taste will come back after the treatment finishes. A dietitian or specialist nurse at your hospital can give you advice.
Loss of appetite A dietitian or specialist nurse at your hospital can give advice on boosting your appetite, coping with eating difficulties and maintaining weight.
Behavioural changes You may experience mood swings, difficulty with sleeping, and perhaps anxiety or irritability. These effects can happen because of the steroids you are taking. Tell your doctor about any changes that are worrying you. Difficulty with sleeping may be helped by taking the steroids in the early part of the day, but discuss this with your doctor first.
Skin changes You may develop an itchy rash. Your doctor can prescribe medicine to help with this. Rarely, your skin may darken. If it does, it usually goes back to normal a few months after treatment is finished.
During treatment, and for several months afterwards, you will be more sensitive to the sun and your skin may burn more easily. You can still go out in the sun, but always wear a high protection-factor suncream and cover up with clothes.
Risk of blood clots Cancer can increase your risk of developing a blood clot (thrombosis), and having chemotherapy may increase this risk further. A blood clot may cause symptoms such as pain, redness and swelling in a leg, or breathlessness and chest pain. Blood clots can be very serious, so it is important to tell your doctor straightaway if you have any of these symptoms. However, most clots can usually be successfully treated by using drugs which thin the blood. Your doctor or nurse can give you more information.
Other medicines Some medicines can be harmful to take when you are having chemotherapy. Always tell your doctor about any medicine you are taking. This includes any that you may have bought from a pharmacy or supermarket, as well as any herbal or complementary therapies.
Fertility Your ability to become pregnant or father a child may be affected by this treatment. It is important to discuss fertility with your doctor before starting treatment.
Contraception It is not advisable to become pregnant or father a child while taking this treatment, as it may harm the developing foetus. It is important to use effective contraception whilst taking this drug, and for some time afterwards. Again, discuss this with your doctor.
This section is based upon our DHAP and R-DHAP chemotherapy factsheet which has been compiled using information from a number of reliable sources, including:
For further references, please see the general bibliography.
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