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Treatment Name: RCHOP (Rituximab + Cyclophospha­mide + Doxorubicin + Vincristine + Prednisone)

RCHOP (Rituximab + Cyclophospha­mide + Doxorubicin + Vincristine + Prednisone) is a Chemotherapy Regimen for Lymphoma, B-cell

How does R-CHOP work?
Each of the medications in R-CHOP are designed to kill cancerous blood cells known as B-lymphocytes. 

R - Rituximab
C - Cyclophosphamide
H - Hydroxydaunorubicin (doxorubicin)
O - Oncovin® (vincristine)
P - Prednisone

Goals of therapy:
R-CHOP is given to shrink tumors and reduce symptoms from lymphoma. R-CHOP is commonly given with the goal of cure.

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Schedule

  • Rituximab I.V. infusion on Day 1. The time of infusion varies depending on tolerability
  • Cyclophosphamide I.V. infusion over 30 - 60 minutes on Day 1
  • Hydroxydaunorubicin (Doxorubicin) I.V. push over 2 - 3 minutes on Day 1
  • Oncovin® (Vincristine) I.V. push or I.V. infusion (generally over 30 minutes or less) on Day 1
  • Prednisone 100 mg (two 50 mg, or five 20 mg) oral tablets by mouth once daily on Days 1, 2, 3, 4, and 5

Estimated total infusion time for this treatment:

  • Up to 8 hours for Cycle 1, Day 1; as short as 3 hours for the first day thereafter, if well tolerated
  • Infusion times are based on clinical studies, but may vary depending on doctor preference or patient tolerability.  Pre-medications and intravenous (I.V.) fluids, such as hydration, may add more time

Click here for common starting doses.

R-CHOP is usually given in an outpatient infusion center allowing the person to go home afterwards. Prednisone tablets are usually taken at home all five days, for which the doctor will write a prescription to be filled at an outpatient pharmacy. R-CHOP may be given in the hospital if someone is too sick to go to an outpatient infusion center.

R-CHOP is repeated every 14 or 21 days. This is known as one Cycle. Each cycle may be repeated up to eight times, depending upon the stage of the disease and tolerability. Duration of therapy may last up to six months, depending upon tolerability and number of cycles prescribed.

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Side Effects

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 with R-CHOP are seen here. Side effects sometimes have percentage ranges [example: 17 – 55% get neutropenia] because they differed between clinical studies.

More than 90% of patients are able to receive the prescribed number of cycles without unacceptable toxicity.

Although not reported in the original clinic RCHOP studies, neutropenic fever may occur after receiving RCHOP chemotherapy

Side effect videos Side Effect Videos
AnemiaAnemiaBleedingBleedingNausea and VomitingNausea and VomitingConstipationConstipationHair LossHair LossPainPainFatigue Fatigue Neutropenic FeverNeutropenic Fever

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Monitoring

How often is monitoring needed?
Labs (blood tests) may be checked before treatment, and before each cycle thereafter. Labs for R-CHOP often include: Complete Blood Count (CBC), Hepatitis B screening, Human Immunodeficiency Virus (HIV) screening, a Comprehensive Metabolic Panel (CMP), Lactate Dehydrogenase (LDH), and Uric acid, plus any others your doctor may order.

How often is imaging needed?
Imaging may be checked before treatment, and periodically thereafter to determine how well the chemotherapy is working. Imaging may include chest X-rays, computerized tomography (CT) scans, or positron emission tomography (PET) scans, plus any others your doctor may order.

How might blood test results/imaging affect treatment? 
Depending upon the results, your doctor may advise to continue chemotherapy as planned, or delay or switch therapy if it is not working or if you are neutropenic on the day the next cycle is scheduled to begin.

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ChemoExperts Tips

  • The first dose of Rituximab is often the hardest. It may lead to fever, shaking, and chills even when 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, Rituximab can be given over 90 minutes if there are no infusion reactions
  • Don't forget take your oral prednisone on Days 1 - 5 of each cycle!  Your doctor will give you a prescription to fill at your pharmacy
  • A pharmacist should ALWAYS review your medication list to ensure that drug interactions are prevented or managed appropriately
  • Clinical trials may exist for 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 RCHOP (Rituximab + Cyclophospha­mide + Doxorubicin + Vincristine + Prednisone), 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 RCHOP (Rituximab + Cyclophospha­mide + Doxorubicin + Vincristine + Prednisone). Depending upon your income, they may be able to help cover the cost of:

  • Rituximab
  • Cyclo­phospha­mide IV
  • Hydroxy­dauno­rubicin
  • Oncovin®
  • Pred­nisone

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 RCHOP (Rituximab + Cyclophospha­mide + Doxorubicin + Vincristine + Prednisone) 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 RCHOP (Rituximab + Cyclophospha­mide + Doxorubicin + Vincristine + Prednisone)

Individual Drug Label Information

Rituximab (Rituxan®)

  • Rituximab is an intravenous infusion
  • Acetaminophen (Tylenol®) and antihistamines (e.g. diphenhydramine = Benadryl®) should be given prior to each dosePatients should be screened for hepatitis B as rituximab can cause a re-activation of this infection
  • May cause vaccines to work less well. It is advised that vaccines be given two to four weeks prior to rituximab if possible
General Rituximab (Rituxan) 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 (Rituxan) package insert below for reported side effects and potential drug Interactions
See DailyMed package insert.

Cyclo­phospha­mide IV (Cytoxan®)

  • Cyclophosphamide is administered as an intravenous (I.V.) infusion
  • May decrease the ability to become pregnant. Fertility preservation is recommended in couples wishing to become pregnant.
  • A smaller dosage may be required for patients receiving hemodialysis
  • Has been linked to the development of other cancers in a small number of people
General Cyclophosphamide (Cytoxan) Side Effects
  • Low white blood cell count which can increase the risk of infection
  • Nausea or vomiting, which can be acute (first 24 hours) or delayed (Days 2 – 5)
  • Hair loss, which is usually reversible
  • Click on the cyclophosphamide (Cytoxan) package insert below for reported side effects and potential drug Interactions

Side Effect Videos
Nausea and VomitingNausea and VomitingHair LossHair LossNeutropenic FeverNeutropenic Fever

See DailyMed package insert.

Hydroxy­dauno­rubicin (Doxo­rubicin)

  • Hydroxydaunorubicin is administered as an intravenous infusion and is red in color
  • Can affect heart function. A heart study (echocardiogram) may be required before receiving the first dose
  • Dosage may be reduced in patients with poor liver function
  • Has been linked to the development of other cancers in a small number of people (1.5% chance at 10 years)
General Hydroxydaunorubicin (Doxorubicin) Side Effects
  • May cause nausea, vomiting, diarrhea, and mouth sores (stomatitis)
  • Leakage into skin or surrounding muscle may cause severe irritation (extravasation)
  • May temporarily turn urine orange
  • May cause hair loss, which is usually reversible
  • May increase the risk of infection due to decrease white blood cell count (neutropenia)
  • Click on the Hydroxydaunorubicin (Doxorubicin) package insert below for reported side effects and potential drug Interactions

Side Effect Videos
Nausea and VomitingNausea and VomitingDiarrheaDiarrheaHair LossHair LossFatigue Fatigue PainPainNeutropenic FeverNeutropenic Fever

See DailyMed package insert.

Oncovin® (Vincristine)

  • Vincristine MUST only be given by intravenous infusion. May NOT be administered any other way
  • Dosage may be reduced in patients with poor liver function
  • May interact with certain antifungal medications
  • Vincristine will cause death if administered into spinal fluid
General Oncovin (Vincristine) Side Effects
  • Nerve pain in hands or feet may increase after each dose. It is usually reversible if treatment is stopped or dose is adjusted
  • Hair loss is NOT common if this is given by itself
  • May cause constipation; preventative medicines may help decrease or avoid constipation
  • Leakage into skin or surrounding muscle may cause severe irritation (extravasation)
  • Click on the Oncovin (vincristine) package insert below for reported side effects and potential drug Interactions

Side Effect Videos
ConstipationConstipationPainPain

See DailyMed package insert.

Pred­nisone

  • Prednisone is an oral medication, usually supplied as a white tablet
  • Prednisone may increase the risk of infection. Depending upon how much prednisone is taken, antibiotics may be prescribed to help prevent infections during treatment with prednisone
  • 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 prednisone may need to be gradually decreased to avoid withdrawal symptoms
  • If you miss a dose, take the next dose as soon as possible
  • Should be stored at room temperature
General Prednisone Side Effects
  • May cause high blood sugar, weight gain, irritability, high blood pressure, difficulty sleeping, stomach ulcers, bone loss, muscle weakness
  • Click on the Prednisone package insert below for reported side effects and potential drug Interactions
See DailyMed package insert.

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References

1. Coiffier B, L epage E, Briere J, et al. CHOP chemotherapy plus rituximab compared with CHOP alone in elderly patients with diffuse large-B-cell lymphoma. N Engl J Med. 2002;346:235-242.

2. Habermann TM, Weller EA, Morrison VA, et al. Rituximab-CHOP versus CHOP alone or with maintenance rituximab in older patients with diffuse large B-cell lymphoma. J Clin Oncol. 2006;24:3121-3127.

3. Flinn IW, van der Jagt R, Kahl BS, et al. Randomized trial of bendamustine-rituximab or R-CHOP/R-C VP in first-line treatment of indolent NH L or MCL : the BRIGHT study. Blood. 2014;123:2944-2952.

4. Pfreundschuh M1, Müller C, Zeynalova S et al. Suboptimal dosing of rituximab in male and female patients with DLBCL. Blood. 2014;123:640-646.

Created: June 27, 2015 Updated: August 13, 2018

What is Lymphoma, B-cell?

B-cell Lymphoma is a disease of the white blood cells known as B-lymphocytes which are normally found in lymph nodes, blood, and throughout the body. There are many different types of lymphoma, most of which are rare. Known causes of lymphoma may include immunosuppressive medications, infections such as HIV, while some causes are still unknown. The stage of lymphoma can vary at diagnosis and throughout treatment. The effectiveness of the treatment may depend upon the sub-type of lymphoma and 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.

Clinical Studies

If you are interested in reading the clinical trials results, please click on references below:

1. Coiffier B, L epage E, Briere J, et al. CHOP chemotherapy plus rituximab compared with CHOP alone in elderly patients with diffuse large-B-cell lymphoma. N Engl J Med. 2002;346:235-242.

2. Habermann TM, Weller EA, Morrison VA, et al. Rituximab-CHOP versus CHOP alone or with maintenance rituximab in older patients with diffuse large B-cell lymphoma. J Clin Oncol. 2006;24:3121-3127.

3. Flinn IW, van der Jagt R, Kahl BS, et al. Randomized trial of bendamustine-rituximab or R-CHOP/R-C VP in first-line treatment of indolent NH L or MCL:the BRIGHT study. Blood. 2014;123:2944-2952.

4. Pfreundschuh M1, Müller C, Zeynalova S et al. Suboptimal dosing of rituximab in male and female patients with DLBCL. Blood. 2014; 123:640-646.

Common Starting Doses

  • Rituximab 375 mg/m2 IV infusion on Day 1. The time of infusion varies depending on tolerability
  • Cyclophosphamide 750 mg/m2 IV infusion over 30 - 60 minutes on Day 1
  • Doxorubicin 50 mg/m2 IV push over 2 - 3 minutes on Day 1
  • Vincristine 1.4 mg/m2 (max dose = 2 mg) IV push or IV infusion (over 30 minutes or less) on Day 1
  • Prednisone 100 mg (two 50 mg, or five 20 mg) oral tablets by mouth once daily on Days 1, 2, 3, 4, and 5

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 status2) 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

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 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, doctors use 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.

What is an I.V. Push?

An intravenous medication that is usually prepared in a syringe and infused by vein over a short period of time, such as 15 minutes or less

What does "being neutropenic" or neutropenia mean?

This occurs when there is an abnormally low amount of a certain type of white blood cells, called neutrophils, in the blood. These neutrophils help the body body fight infections caused by bacteria and viruses. Many chemotherapy drugs temporarily damage bone marrow where white blood cells are created, resulting in neutropenia. Please watch our video on neutropenic fever to learn more.