Page 1 CARFILZOMIB/RITUXIMAB/DEXAMETHASONE (CaRD) INTRAVENOUS CANCER TREATMENT EDUCATION CARFILZOMIB/RITUXIMAB/DEXAMETHASONE (CaRD) Name of the regimen and cancer drugs Your care team may refer to your treatment as CaRD. CaRD consists of 3 different anti-cancer therapies. • Carfilzomib (kar FILZ oh mib): Kyprolis • Rituximab (ri TUK si mab): Rituxan, Ruxience, Truxima, or Riabni • Dexamethasone (deks a METH a sone): Decadron Common uses Your regimen is used to treat Waldenström macroglobulinemia or Lymphoplasmacytic lymphoma, but may be used for other treatments. Treatment schedule (Induction Phase) 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 CaRD treatment is repeated every 21 days (3 weeks). 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. You will receive carfilzomib/rituximab/dexamethasone for 6 cycles (21-day cycles) during the induction phase of treatment. o Carfilzomib: Days 1, 2, 8, 9. Carfilzomib is a solution given as an IV infusion over 20 minutes on each treatment day during cycle 1, and over 30 minutes for cycles 2 and beyond. o Rituximab: Days 2 and 9. Rituximab is a solution given as an IV infusion on each treatment day. It may be administered more slowly during the first dose to prevent infusion reactions. o Dexamethasone: Days 1, 2, 8, 9. The Dexamethasone infusion is given IV infusion over 20 minutes or less on each treatment day. Drug Cycle 1 Day 1 2 3 4 5 6 7 8 9 10 ... Cycle 2 Day 1 Carfilzomib Rituximab Dexamethasone Page 2 CARFILZOMIB/RITUXIMAB/DEXAMETHASONE (CaRD) INTRAVENOUS CANCER TREATMENT EDUCATION Treatment schedule (Maintenance Phase) 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 CaRD treatment is repeated every 21 days (3 weeks). 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. You will then receive carfilzomib/rituximab/dexamethasone for 8 cycles (8-week cycles) during the maintenance phase of treatment. o Carfilzomib: Days 1 and 2. Carfilzomib is a solution given as an IV infusion over 30 minutes. o Rituximab: Day 2. Rituximab is a solution given as an IV infusion on each treatment day. o Dexamethasone: Days 1 and 2. The Dexamethasone infusion is given IV infusion over 20 minutes or less on each treatment day. Drug Cycle 1 Day 1 2 3 4 5 6 7 8 9 10 ... Cycle 2 Day 1 Carfilzomib Rituximab Dexamethasone Page 3 CARFILZOMIB/RITUXIMAB/DEXAMETHASONE (CaRD) INTRAVENOUS CANCER TREATMENT EDUCATION Possible drug interactions o Carfilzomib/rituximab/dexamethasone 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. Instructions: Anti-nausea medication other medications You will receive medications to prevent nausea and other side effects just before your chemotherapy. You may get prescriptions for other medications to take at home, as below: Infection prevention There is a risk of serious infections during treatment. You may get prescriptions for medciations to take at home for infection prevention, as below: Other medications Other medications may be ordered for you to prevent or treat certain side effects. These include: Page 4 CARFILZOMIB/RITUXIMAB/DEXAMETHASONE (CaRD) INTRAVENOUS CANCER TREATMENT EDUCATION Common Side Effects Common side effects that have been known to happen in patients receiving carfilzomib/rituximab/dexamethasone 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 in-fection. 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. Infusion Reactions Rituximab can cause infusion reactions. During your treatments, let the nurse know right away if any of these symptoms happen: chills or shaking, dizziness, fever, itchiness or rash, flushing, difficulty breathing, wheezing, sudden back pain, or feeling faint. Continued on the next page Page 5 CARFILZOMIB/RITUXIMAB/DEXAMETHASONE (CaRD) INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Changes in electrolyte levels and other laboratory values: High glucose levels High lipase levels High amylase leves 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 or confusion • Swelling of your legs or feet • Red or brown colored urine Changes in liver function Your liver function will be checked every so often by a simple blood test. Contact your care team if you notice any of the following. • Yellowing of the skin or whites of your eyes • Dark or brown urine • Bleeding or bruising Rash or itchy skin • Keep your skin moisturized with creams and moisturizing lotions to decrease the risk of rash or itchiness and wear loose fitting clothing. • Avoid using perfumes and cologne as these products may increase rash symptoms. • Avoid being in the heat for long periods of time. • Your provider may recommend an over-the-counter antihistamine or a topical cream. • Sunlight can make symptoms worse • Avoid sun exposure as much as possible to decrease the risk of sunburn. The highest exposure to UV (ultra-violet) radiation occurs between the hours of 10am and 4pm. • Wear long-sleeved clothing, with UV protection if possible. • Wear broad-brimmed hats. • Apply broad-spectrum sunscreen (UVA/UVB) with at least SPF 30 as often as directed on the bottle. • Use lip balm with at least SPF 30 If your rash or itching continues to worsen, contact your care team. 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 6 CARFILZOMIB/RITUXIMAB/DEXAMETHASONE (CaRD) INTRAVENOUS CANCER TREATMENT EDUCATION Rare but serious side effects Tell your care provider if you experience any symptoms of these problems: o Carfilzomib may affect your heart’s ability to pump blood. Tell your healthcare provider right away if you experience new or worsening shortness of breath, chest pain, irregular heartbeat, or swelling of your ankles or legs. o You may have a mild to moderate rise in blood pressure while taking carfilzomib. Take your blood pressure on a regular basis and let your doctor know of any big increases in blood pressure. o You may be at a higher risk of bleeding while taking carfilzomib. Be sure to seek medical attention right away if you have any major bleeding. Also be sure to check for any signs of bleeding in your stool. o Carfilzomib may result in serious and fatal lung toxicity. If you start to experience shortness of breath, fatigue, breathlessness, or discomfort/worsening of symptoms while lying on your back, please immediately contact your prescriber. o Rituximab 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 These medications may be harmful to your kidneys. Speak to your care team to know when you need to have laboratory tests done to monitor your kidneys. o These medications may cause tumor lysis syndrome when starting treatment. Your care team may do blood tests to check for this side effect. o Call your care team right away if you have headaches, seizures, confusion or changes in vision, as this may be a severe side effect of the treatment. o Before getting any vaccines while taking rituximab, talk to your care team. If you experience ANY new, worsening, or uncontrolled side effects, call your care team immediately. Page 7 CARFILZOMIB/RITUXIMAB/DEXAMETHASONE (CaRD) 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 carfilzomib/rituximab/dexamethasone, follow the instructions below for at least two 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. Page 8 CARFILZOMIB/RITUXIMAB/DEXAMETHASONE (CaRD) INTRAVENOUS CANCER TREATMENT EDUCATION 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 carfilzomib/rituximab/dexamethasone. 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. Additional resources Carfilzomib (Kyprolis): https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/202714lbl.pdf Rituximab (Rituxan): https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/103705s5311lbl.pdf Rituximab-pvvr (Ruxience): https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/761103s000lbl.pdf Rituximab-abbs (Truxima): https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/761088s000lbl.pdf Rituximab-arrx (Riabni): https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/761140s000lbl.pdf Dexamethasone (Decadron): https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/084916s066lbl.pdf Updated – January 14, 2022 Additional instructions 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 © 2021 by NCODA. All rights reserved.