Page 1 R-EPOCH INTRAVENOUS CANCER TREATMENT EDUCATION R-EPOCH Name of the regimen and cancer drugs Your care team may refer to your treatment as R-EPOCH or EPOCH-R. This regimen consists of 6 different anti-cancer therapies. • R: Rituximab (rih-TUK-sih-mab): Rituxan®, Ruxience®, Truxima®, Riabni™ • E: Etoposide (ee-toh-POH-side), also called VP-16: Toposar® • P: Prednisone (PRED-nih-sone) • O: Vincristine (vin-KRIS-teen): Oncovin® • C: Cyclophosphamide (SY-kloh-FOS-fuh-mide): Cytoxan® • H: Doxorubicin (DOK-soh-ROO-bih-sin), also called Hydroxydaunorubicin: Adriamycin® Common uses R-EPOCH is most commonly used for lymphoma but may be used for other diagnoses. Treatment schedule Your treatment will be given into your vein through an intravenous (IV) line. This may be into a short, flexible temporary catheter in your arm, or through a central venous catheter. A central venous catheter, or central line is a long, flexible IV tube that empties into a very large vein next to the heart. Talk with your care team to see which will be best for you and your treatment. Each R-EPOCH treatment is repeated every 21 days. This is known as one cycle. Your treatment may be given for a set number of cycles, or it will keep going until the drug, or drugs, stop working or you have side effects which stop you from continuing treatment. o Rituximab IV once per cycle o Etoposide continuous IV infusion over 96 hours starting on Day 1 and ending on Day 5 o Prednisone taken once daily by mouth on Days 1 thru 5 of each cycle. Your provider will prescribe this medication for you. Take prednisone with food to avoid stomach upset. Tell your provider if you develop heartburn or acid reflux. Avoid evening/ bedtime administration as prednisone may cause trouble sleeping. o Vincristine continuous IV infusion over 96 hours starting on Day 1 and ending on Day 5 o Cyclophosphamide IV on Day 5 o Doxorubicin continuous IV infusion over 96 hours starting on Day 1 and ending on Day 5 Drug Cycle 1 Day 1 2 3 4 5 6 7 8 ... 21 Cycle 2 Day 1 Rituximab Etoposide Prednisone Vincristine Cyclophosphamide Doxorubicin Page 2 R-EPOCH INTRAVENOUS CANCER TREATMENT EDUCATION Other medications Other medications may be ordered for you to prevent or treat certain side effects. These include: Instructions: Growth Factors Growth factors, like filgrastim, pegfilgrastim, and others, are medications used to treat neutropenia and prevent infections. Neutropenia is a condition where there are lower-than-normal white blood cells caused by some type of chemotherapy. Growth factors help the bone marrow to make more white blood cells. Anti-nausea medications You will receive medications to prevent nausea just before your cancer treatment. You may also get prescriptions for other medications to take at home, as below: Medications to prevent side effects You will receive your medications to prevent side effects just before your cancer treatment. You may get prescriptions for other medications to take at home, as below: Medications to prevent allergic reactions You will receive medications to prevent infusion related reactions prior to starting your cancer treatment. Infection prevention There is a risk of serious infections during treatment. You may receive medications to prevent infection in the hospital, and may also get prescriptions for medications to take at home for infection prevention, as below: Page 3 R-EPOCH INTRAVENOUS CANCER TREATMENT EDUCATION Common Side Effects Common side effects that have been known to happen in patients receiving R-EPOCH are listed in the left side of this table. In some instances, the side effects may be reported less often but are still important to discuss. This table does not list all the known side effects for this therapy, only the ones that are experienced most often. Not every patient experiences every known side effect of a drug; even if you are taking the same drug as another patient, you may experience different side effects. Options to help manage any side effects that do occur are included on the right side of this table. These should be discussed with your care provider. If you experience any side effect you cannot manage or that is not listed here, contact your care provider. Possible Side Effect Management Decreased white blood cells (WBCs) and increased risk for infection Your WBCs should be monitored by a simple blood test. When your WBCs are low, you are at a greater risk of having an infection. Take the following precautions to protect yourself from infection. • Wash your hands often, especially before eating and after using the bathroom. • Avoid crowds and people with fevers, flu, or other infection. • Bathe often for good personal hygiene. Contact your care team if you experience any signs or symp-toms of an infection such as: • Fever (temperature more than 100.4°F or 38°C) • Chills • Sore throat • Burning when peeing • Tiredness that is worse than normal • A sore that becomes red, is draining, or does not heal. Check with your care team before taking any medicine for a fever or chills. Continued on the next page Possible drug interactions o R-EPOCH may interact with other drugs you are taking. Please inform your care providers of all prescription medicine, over-the-counter medications, vitamins, and herbal products that you take. o Talk with your care provider or pharmacist before taking new medications, supplements, or receiving any vaccines. o Grapefruit or grapefruit juice may interact with prednisone, doxorubicin, and vincristine. Avoid eating or drinking these during your treatment. Page 4 R-EPOCH INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Decreased hemoglobin, part of the red blood cells that carry iron and oxygen Your hemoglobin should be checked by a simple blood test. When your hemoglobin is low, you may notice that you get tired or fatigued more easily. • Try to get 7 to 8 hours of sleep per night • Avoid operating heavy machinery if you feel too tired • Find a balance between “work” and “rest” • Stay as active as possible, but know that it is okay to rest as needed, too • You might notice that you are more pale than usual Let your care team know right away if you have: • Shortness of breath • Dizziness • Fast or abnormal heartbeat Decreased platelet count and increased risk of bleeding Your platelets should be monitored by a simple blood test. When they are low, you may bruise or bleed more easily than usual. • Use caution to avoid bruises, cuts, or burns. • Blow your nose gently and do not pick your nose • Brush your teeth gently with a soft toothbrush and maintain good oral hygiene • When shaving use an electric razor instead of razor blades • Use a nail file instead of nail clippers Call your care team if you have bleeding that won’t stop. Examples include: • A bloody nose that bleeds for more than 5 minutes despite pressure • A cut that continues to ooze despite pressure • Gums that bleed a lot when you floss or brush Seek medical help right away if you have any severe headaches, blood in your urine or stool, coughing up blood, or bleeding that you cannot stop or lasts a long time. You may need to take a break or “hold” your medication for medical or dental procedures. Talk to your care team or dentist before any scheduled procedures. Continued on the next page Page 5 R-EPOCH INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Nausea or vomitting • Take all medications as prescribed to help prevent and lessen symptoms of nausea and vomiting • Eat and drink slowly • Drink 8-10 (8-ounce) glasses of water and/or fluid (soup or broth) each day unless your care team has instructed you to limit your fluid intake • Eat small, frequent meals throughout the day rather than a few large meals • Eat bland foods; avoid spicy, fried, and greasy foods • Avoid intense exercise immediately after eating • Don’t lay down right away after eating • Wear loose fitting clothing for comfort • Avoid strong odors. Consider getting fresh air and try deep breathing. Let your care team know if you have nausea or vomiting. Your care team may prescribe medication to help with the symptoms. Numbness or tingling in hands and feet Report changes in your sense of touch, such as a burning feeling, pain on the skin or weakness. Fatigue • You may be more tired than usual or have less energy • Stay as active as possible, but know it is okay to rest as needed • Try to do some type of moderate activity every day • Conserve your energy. Plan your activities and do them at a time of day when you feel a bit more energetic • Follow a healthy diet and stay hydrated • Accept help from family and friends • Find healthy ways to manage stress, such as meditation, journaling, yoga, and guided imagery • Develop good sleeping habits, limit napping during the day to help you sleep better at night • Avoid operating heavy machinery if you feel too tired • Contact your care team if you experience extreme fatigue that prevents you from doing your normal daily activities Continued on the next page Page 6 R-EPOCH INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Diarrhea (loose and/ or urgent bowel movements) Monitor how many bowel movements you have each day. • Drink 8-10 (8-ounce) glasses of water or fluid each day unless your care team has asked you to limit your fluid intake. • Eat small, frequent meals throughout the day rather than a few large meals. • Eat bland, low-fiber foods (such as bananas, applesauce, potatoes, chicken, rice, and toast). • Avoid high fiber foods, such as raw vegetables and fruits and whole grains. • Avoid foods that cause gas, such as broccoli and beans. • Avoid foods with lactose, such as yogurt and milk. • Avoid spicy, fried, and greasy foods. Contact your care team if: • The number of bowel movements you have in a day increases by 4 or more • You feel dizzy or lightheaded Your care team may recommend an over-the-counter medication or prescribe something to help manage your symptoms. Constipation Keep track of how many bowel movements you have each day. • Drink 8-10 (8-ounce) glasses of water or fluid each day unless your care team has asked you to limit your fluid intake. • Stay active and exercise, if possible. • Eat foods high in fiber like raw fruits and vegetables. Contact your care team if you have not had a bowel movement in 3 or more days. Your care team may recommend over-the-counter medications to help with constipation. A daily stool softener such as docusate (Colace®) and/or laxative such as senna (Senakot®) may be helpful. If these do not help within 48 hours, tell your care team. Mouth irritation or sores (stomatitis or mucositis) Practice good mouth care. • Rinse your mouth often • Brush your teeth with a soft toothbrush or cotton swab after meals • Use a mild non-alcohol mouth rinse at least 4 times a day (after eating and at bedtime). One example is a mixture of 1/8 teaspoon of salt and 1/4 teaspoon of baking soda in 8 ounces of warm (not hot) water • If you have sores in your mouth, avoid using tobacco products, alcohol, and mouthwashes that contain alcohol Call your care team if you experience pain or sores in your mouth or throat. Continued on the next page Page 7 R-EPOCH INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Renal/bladder toxicity Cyclophosphamide may be harmful to your kidneys and bladder. Speak to your care team to know when you need to have laboratory tests done to monitor them. Increase fluid intake to at least 2 Liters per day on day of treatment with Cyclophosphamide and for 2 days afterwards. Changes in body fluid color Doxorubicin may cause tears, sweat, saliva, and urine to have a reddish tint for a few days after treatment. Hair loss (alopecia) • Hair will likely grow back after treatment is completed, although the color and/or texture may be different. • It may take 3 to 6 months after therapy is completed to resume normal hair growth. • Some people choose to wear scarves, caps, or wigs. A short haircut prior to treatment may help with stress of hair loss. • Partial or complete hair loss is likely, usually 1-2 weeks after start of therapy. This hair loss can be all body hair. • Be sure to keep your head covered to protect it from the sun during the summer and cold during the winter. • If not covering your scalp during the summer months, be sure to use sunscreen when spending time outdoors. Changes in electrolyte levels and other laboratory values: • High glucose levels Changes in some lab values may occur and will be monitored by a simple blood test. • You may not feel any symptoms if the changes are mild and they usually are not a sign of a serious problem. • More severe changes may occur, which can be a sign of a serious problem. Notify your care team if you have any of the following: • Shortness of breath • Chest discomfort • Weakness or fatigue • New aches and pains • Headaches • Dizziness • Swelling of your legs or feet • Red or brown colored urine Reactivation of Hepatitis B Virus (HBV) This medication can cause hepatitis B virus (HBV) reactivation in patients previously infected with HBV. • You may be tested for HBV prior to beginning treatment with this medication. • Be sure your healthcare provider is aware of any previous HBV diagnosis and treatment, if known. • Patients with past HBV infection may need preventative antiviral medication while receiving and for months after completing this medication. • Additional routine monitoring of HBV levels may be needed in patients who were previously infected with HBV. Page 8 R-EPOCH INTRAVENOUS CANCER TREATMENT EDUCATION Rare but serious side effects Tell your care provider if you experience any symptoms of these problems: o Infusion reactions: Rituximab can rarely cause an infusion reaction. During your treatment, let the nurse know right away if any of these symptoms happen: chills or shaking, dizziness, fever, itchiness or rash, flashing, difficulty breathing, wheezing, sudden back pain, or feeling faint. o Hemorrhagic cystitis (bladder irritation): Cyclophosphamide can cause irritation of the bladder walls, leading to blood in the urine. It can be prevented by drinking plenty of fluids (8-10 eight ounce) glasses per day and emptying bladder frequently, especially before bed. Hepatic Toxicity: Doxorubicin, cyclophosphamide, vincristine may be harmful to your liver. Speak to your care team to know when you need to have blood tests done to monitor your liver function. If you get this side effect, your doctor may change your dose or stop treatment for some time. o Cardiomyopathy: Doxorubicin, cyclophosphamide, and rituximab can make your heart work harder to pump blood to the rest of your body. Tell your care team if you are having shortness of breath, sudden fluid retention, or chest pain. o Intestinal obstruction: rituximab and vincristine can cause blockages to form in the large or small intestine. Seek medical attention if you develop severe abdominal pain or other symptoms of intestinal obstruction. o R-EPOCH may rarely cause a secondary cancer called myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML). Your care team will monitor your blood cell counts during treatment and after treatment is complete. o Doxorubicin and vincristine are vesicants. If it leaks outside of the IV, it can cause severe damage to your skin. Notify your nurse right away if you feel any pain, aching, burning, itching, swelling, or redness at the site of your IV. o Etoposide may irritate your veins as it is infused. Notify your nurse right away if you notice any pain, aching, burning, itching, swelling, or redness at the site of your IV. o R-EPOCH cause a condition called tumor lysis syndrome when starting treatment. This results from the rapid destruction of cancer cells in the body during the initial cycles of treatment. Your care team may do blood tests to check for this side effect. o Live Vaccinations: Talk to your care team before getting any vaccines while taking rituximab. If you experience ANY new, worsening, or uncontrolled side effects, call your care team immediately. Page 9 R-EPOCH INTRAVENOUS CANCER TREATMENT EDUCATION Handling body fluids and waste Some of the drugs you receive may be present in urine, stool, sweat, or vomit for many days after treatment. Many cancer drugs are toxic, your bodily waste may also be toxic and can be dangerous to come into contact with. Once you have started R-EPOCH, follow the instructions below for at least five days after your treatment. This is to keep you, your loved ones, and the environment as safe as possible. o Pregnant women should avoid touching anything that may be soiled with body fluids from the patient. o Toilet and septic systems • You may use the same toilet, septic tank, and/or sewer that you usually use. If you have a low-flow toilet, close the lid and flush twice to ensure that all waste has been discarded. o If the toilet or toilet seat becomes soiled with urine, stool, or vomit, clean the surface after every use before other people use the toliet. o Wash hands with soap and water after using the toilet for at least 20 seconds. o If you need a bedpan, be sure your caregiver knows to wear gloves to assist with cleanup and to wash the bedpan with soap and water every day. o If you do not have good control of bladder or bowels, use a disposable pad with a plastic back, a diaper, or a sheet to absorb body waste. o Wash any skin that has been exposed to body waste with soap and water. o Linens or clothing that are soiled with body fluids or body waste should be washed separately from other linens and clothing. If you do not have a washer, place the soiled linens in a plastic bag until they can be washed. o Wash hands with soap and water after touching linens or clothing that may be soiled with body fluids. Intimacy, sexual activity, contraception, and fertility This treatment may cause changes that can affect intimacy and sexuality, including desire and body image. Maintaining physical closeness and/or intimacy with loved ones can be continued during treatment. Holding hands, hugging, and kissing can be done safely. It is recommended that you talk to your care team about any restrictions or questions you may have. Some treatments can influence the ability to have children, also known as fertility. If you’re interested in preserving fertility, talk to your care team before treatment. Ask your healthcare provider to determine when it is safe to become pregnant after your treatment. Patients of reproductive ability should not become pregnant or get their partners pregnant while receiving R-EPOCH. Some of the drugs you receive may be present in semen and vaginal secretion for many days after treatment. You should use barrier devices, such as condoms, during sexual activity to limit exposure to body fluids. o Talk to your care team about birth control. Not all options may be right for your treatment or cancer. Effective contraception could include one or more of the following: barrier methods (e.g. condoms), hormone methods (e.g. birth control pills), or surgery. o Tell your care team if you become pregnant or plan to breastfeed. Page 10 R-EPOCH INTRAVENOUS CANCER TREATMENT EDUCATION Additional resources Prescribing information link Etoposide (Toposar®): https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/020457s016lbl.pdf Prednisone: https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/202020s000lbl.pdf Vincristine (Oncovin®): https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/071484s042lbl.pdf Cyclophosphamide (Cytoxan®): https://www.accessdata.fda.gov/drugsatfda_docs/ label/2013/012141s090,012142s112lbl.pdf Doxorubicin (Adriamycin®): https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/062921s022lbl.pdf Rituximab (Rituxan®) (This drug is offered in several different brands. To find out what you’re using, talk to your care team): https://www.gene.com/download/pdf/rituxan_prescribing.pdf Additional instructions Updated – July 5, 2023 Important notice: The Association of Community Cancer Centers (ACCC), Hematology/Oncology Pharmacy Association (HOPA), National Community Oncology Dispensing Association, Inc. (NCODA), and Oncology Nursing Society (ONS) have collaborated in gathering information for and developing this patient education guide. This guide represents a brief summary of the therapy derived from information provided by the drug manufacturer and other resources. This guide does not cover all existing information related to the possible uses, directions, doses, precautions, warnings, interactions, adverse effects, or risks associated with this therapy and should not substitute for the advice of a qualified healthcare professional. Provision of this guide is for informational purposes only and does not constitute or imply endorsement, recommendation, or favoring of this therapy by ACCC, HOPA, NCODA, or ONS, who assume no liability for and cannot ensure the accuracy of the information presented. The collaborators are not making any representations with respect to the medications whatsoever, and any and all decisions, with respect to such medications, are at the sole risk of the individual receiving therapy. All decisions related to receiving this therapy should be made with the guidance and under the direction of a qualified healthcare professional. Permission: Intravenous Cancer Treatment Education (IVE) sheets are provided as a free educational resource for patients with cancer in need of concise, easy-to-understand information about intravenous cancer therapy. Healthcare providers are permitted to copy and distribute the sheets to patients as well as direct patients to the OCE website for information. However, commercial reproduction or reuse, as well as rebranding or reposting of any type, are strictly prohibited without permission of the copyright holder. Please email permission requests and licensing inquiries to This email address is being protected from spambots. You need JavaScript enabled to view it.. Copyright © 2023 by NCODA. All rights reserved.