What are the side effects of R-CHOP (Rituximab, Cyclophosphamide, Hydroxydaunorubicin, Oncovin, and Prednisone)?

From the Guidelines

R-CHOP chemotherapy is associated with several side effects, including bone marrow suppression, gastrointestinal issues, hair loss, infusion reactions, and increased risk of infection, as reported in a phase 3 open-label trial comparing R-CHOP with rituximab and bendamustine 1. The most common side effects of R-CHOP include:

• Bone marrow suppression leading to low blood counts (neutropenia, anemia, thrombocytopenia), which increases infection risk, fatigue, and bleeding
• Gastrointestinal issues like nausea, vomiting, diarrhea, and mouth sores
• Hair loss
• Infusion reactions, particularly with the first dose of rituximab, including fever, chills, and rarely more severe allergic responses
• Cyclophosphamide may cause bladder irritation and hemorrhagic cystitis, so adequate hydration is essential
• Doxorubicin carries a risk of heart damage, especially at higher cumulative doses
• Vincristine commonly causes peripheral neuropathy (numbness and tingling in hands and feet)
• Prednisone can cause mood changes, increased appetite, weight gain, insomnia, and elevated blood sugar Long-term concerns include increased infection risk, potential fertility issues, and a small risk of secondary malignancies, as noted in guidelines for non-Hodgkin's lymphomas 1. Rituximab, a component of R-CHOP, has been associated with additional side effects, including:
• Serum sickness
• Interstitial pneumonitis
• Reactivation of viral infections, such as progressive multifocal leukoencephalopathy
• Neutropenia and increased risk for infection with long-term therapy, especially in patients who have previously or concurrently received cytotoxic chemotherapy 1. Patients receiving R-CHOP should be closely monitored for these side effects and report any fever, unusual bleeding, severe nausea/vomiting, or new neurological symptoms immediately to their healthcare provider.

From the FDA Drug Label

In NHL Studies 7 (NCT00003150) and 8, [see Clinical Studies (14. 3)], the following adverse reactions, regardless of severity, were reported more frequently ( greater than or equal to 5%) in patients age greater than or equal to 60 years receiving R-CHOP as compared to CHOP alone: pyrexia (56% vs. 46%), lung disorder (31% vs. 24%), cardiac disorder (29% vs. 21%), and chills (13% vs. 4%) The following Grade 3 or 4 adverse reactions occurred more frequently among patients in the R-CHOP arm compared with those in the CHOP arm: thrombocytopenia (9% vs. 7%) and lung disorder (6% vs. 3%) Other Grade 3 or 4 adverse reactions occurring more frequently among patients receiving R-CHOP were viral infection (NHL Study 8), neutropenia (NHL Studies 8 and 9 (NCT00064116)), and anemia (NHL Study 9).

The side effects of R-CHOP include:

• Pyrexia (56% vs. 46% in CHOP alone)
• Lung disorder (31% vs. 24% in CHOP alone)
• Cardiac disorder (29% vs. 21% in CHOP alone)
• Chills (13% vs. 4% in CHOP alone)
• Thrombocytopenia (9% vs. 7% in CHOP alone)
• Lung disorder (6% vs. 3% in CHOP alone)
• Viral infection
• Neutropenia
• Anemia 2 2

From the Research

Side Effects of R-CHOP

The R-CHOP regimen, which consists of Rituximab, Cyclophosphamide, Hydroxydaunorubicin, Oncovin, and Prednisone, is a standard treatment for non-Hodgkin lymphoma. The side effects of R-CHOP can be significant and may include:

• Cardiovascular adverse events, such as heart failure, which can occur in up to 4.62% of patients 3
• Haematological adverse events, such as neutropenia, which can occur in up to 11.6% of patients 4
• Non-haematological adverse events, such as infections, which can occur in up to 10.7% of patients 4
• Grade III/IV adverse events, which can occur in up to 33.1% of patients 4

Comparison of R-CHOP to Other Regimens

Studies have compared the side effects of R-CHOP to other chemotherapy regimens, such as R-CVP (cyclophosphamide, vincristine, prednisone) and R-COMP (rituximab, cyclophosphamide, non-pegylated liposomal doxorubicin, vincristine, and prednisolone). These studies have found that:

• R-CVP may have a lower rate of grade III/IV adverse events compared to R-CHOP 4
• R-COMP may have a lower rate of cardiotoxicity compared to R-CHOP 5
• The addition of rituximab to chemotherapy regimens may increase the risk of adverse events, such as infections and neutropenia 6, 4

Risk Factors for Side Effects

Certain patient characteristics, such as age and performance status, may increase the risk of side effects from R-CHOP. For example:

• Older patients may be at higher risk of cardiovascular adverse events 3
• Patients with a history of cardiac disease may be at higher risk of cardiotoxicity 5