CTD comes from the initials of the drugs used:
- C – cyclophosphamide (a chemotherapy drug)
- T – thalidomide (an immunotherapy drug)
- D – dexamethasone (a steroid)
Your doctor will talk to you about this treatment and its possible side effects before you agree (consent) to have treatment.
During treatment you usually see a cancer doctor, a chemotherapy nurse or a specialist nurse, and a specialist pharmacist. This is who we mean when we mention doctor, nurse or pharmacist in this information.
Before or on the day of treatment, a nurse or person trained to take blood (phlebotomist) will take a blood sample from you. This is to check that your blood cells are at a safe level for you to have treatment.
You will see a doctor or nurse before you have treatment. They will ask you how you have been feeling. If your blood results are okay, the pharmacist will prepare your treatment. Your nurse will tell you when your treatment is likely to be ready.
Your course of CTD
CTD comes in capsules and tablets. You can take it at home.
Cancer treatment is usually given as a course of several cycles of treatment over a few months. A cycle of CTD is usually given over 21 days (3 weeks) or 28 days (4 weeks). Your nurse or doctor will tell you which cycle you are going to have.
You take thalidomide each day for 21 days.
You take cyclophosphamide once a week, on days 1, 8 and 15.
You take dexamethasone on days 1 to 4 and 12 to 15.
You take thalidomide each day for 28 days.
You take cyclophosphamide once a week, on days 1, 8, 15, and 22.
You take dexamethasone on days 1 to 4 and 15 to 18.
Your nurse or doctor will discuss your treatment plan with you. They may give you a copy of the treatment plan to take home with you.
The nurse or pharmacist will give you the capsules and tablets to take home. You may be given capsules and tablets of different strengths.
Your nurse or pharmacist may also give you anti-sickness drugs and other medicines to take home. Take all your capsules and tablets exactly the way you have been told to. This is im-portant to make sure they work as well as possible for you.
Taking CTD tablets and capsules
You should swallow all the tablets and capsules whole with a glass of water. They should not be chewed, opened or crushed. Take them at the same time every day.
Always take them exactly as explained. This is important to make sure they work as well as possible for you.
It is important to
- take dexamethasone with or just after breakfast
- take thalidomide at bedtime, as it can make you feel sleepy
- avoid grapefruit and grapefruit juice when you take cyclophosphamide, because it can affect how cyclophosphamide works.
If you forget to take the cyclophosphamide or dexamethasone you should take the missed dose as soon as possible within the same day. If it has been a full day, tell your doctor or nurse.
If you forget to take the thalidomide and less than 12 hours have passed, take your capsules straight away. If more than 12 hours have passed, do not take your missed dose. Just take your usual dose at the usual time the next day. Tell your doctor or nurse if you have missed a dose.
Do not take a double dose unless your doctor tells you to.
Other things to remember about your capsules and tablets:
- Wash your hands after taking your tablets and capsules.
- Other people should avoid direct contact with the chemotherapy drugs.
- Keep them in the original package and at room temperature, away from heat and direct sunlight.
- Keep them safe and out of sight and reach of children.
- If you are sick (vomit) just after taking the capsules or tablets, contact the hospital. Do not take another dose.
- If your treatment is stopped, return any unused capsules or tablets to the pharmacist.
We explain the most common side effects of this treatment here. We also include some less common side effects.
You may get some of the side effects we mention, but you are unlikely to get all of them. If you are also having treatment with other cancer drugs, you may have some side effects that we have not listed here. Always tell your doctor, nurse or pharmacist about any side effects you have.
Your doctor can give you drugs to help control some side effects. It is important to take them exactly as your nurse or pharmacist explains. This means they will be more likely to work for you. Your nurse will give you advice about managing your side effects. After your treatment is over, most side effects start to improve.
Serious and life-threatening side effects
Some cancer treatments can cause severe side effects. Rarely, these may be life-threatening. Your cancer doctor or nurse can explain the risk of these side effects to you.
Contact the hospital
Your nurse will give you telephone numbers for the hospital. If you feel unwell or need advice, you can call them at any time of the day or night. Save these numbers in your phone or keep them somewhere safe.
We cannot list every side effect for this treatment. There are some rare side effects that are not listed. You can visit the electronic Medicines Compendium (eMC) for more detailed information.
Risk of infection
This treatment can reduce the number of white blood cells in your blood. These cells fight infection. If the number of white blood cells is low, you are more likely to get an infection. A low white blood cell count is sometimes called neutropenia.
An infection can be very serious when the number of white blood cells is low. It is important to get any infection treated as soon as possible. Contact the hospital straight away on the 24-hour contact number you have been given if:
- your temperature goes over 37.5°C (99.5°F)
- you suddenly feel unwell, even with a normal temperature
- you have symptoms of an infection
- your temperature goes below 36°C (96.8°F).
Symptoms of an infection include:
- feeling shivery and shaking
- a sore throat
- a cough
- needing to pass urine (pee) a lot, or discomfort when you pass urine.
It is important to follow any specific advice your cancer treatment team gives you.
The number of white blood cells will usually return to normal before your next treatment. You will have a blood test before having more treatment. If your white blood cell count is low, your doctor may delay your treatment for a short time, until your cell count increases.
Bruising and bleeding
This treatment can reduce the number of platelets in your blood. Platelets are cells that help the blood to clot.
If the number of platelets is low, you may bruise or bleed easily. You may have:
- bleeding gums
- heavy periods
- blood in your urine (pee) or stools (poo)
- tiny red or purple spots on the skin that may look like a rash.
Tell your doctor if you have any unexplained bruising or bleeding. You may need a drip to give you extra platelets. This is called a platelet transfusion.
Anaemia (low number of red blood cells)
This treatment can reduce the number of red blood cells in your blood. Red blood cells carry oxygen around the body. If the number of red blood cells is low, this is called anaemia. You may have symptoms such as:
- pale skin
- lack of energy
- feeling breathless
- feeling dizzy and light-headed.
Tell your doctor or nurse if you have these symptoms.
If you are very anaemic, you may need a drip to give you extra red blood cells. This is called a blood transfusion.
Blood clot risk
Cancer and some cancer treatments can increase the risk of a blood clot. Symptoms of a blood clot include:
- throbbing pain, redness or swelling in a leg or arm
- suddenly feeling breathless or coughing
- sharp chest pain, which may be worse when you cough or take a deep breath.
If you have any of these symptoms, contact the hospital straight away on the 24-hour contact number you have been given. If you cannot get through to your doctor, call the NHS urgent advice number on 111.
A blood clot is serious, but it can be treated with drugs that thin the blood (anticoagulants). Your doctor or nurse can give you more information.
You can help reduce the risk of developing a blood clot by:
- staying active during treatment
- drinking plenty of fluids, especially water.
You may be given anticoagulants to help prevent a clot.
Your doctor will give you anti-sickness drugs to help prevent or control sickness during your treatment. Take the drugs exactly as your nurse or pharmacist tells you. It is easier to prevent sickness than to treat it after it has started.If you feel sick, take small sips of fluids often and eat small amounts regularly. It is important to drink enough fluids. If you continue to feel sick, or are sick (vomit) more than once in 24 hours, contact the hospital as soon as possible. They will give you advice. Your doctor or nurse may change the anti-sickness drug to one that works better for you.
Sore mouth and throat
This treatment may cause a sore mouth and throat. You may also get mouth ulcers. This can make you more likely to get a mouth or throat infection. Use a soft toothbrush to clean your teeth or dentures in the morning, at night and after meals.
If your mouth or throat is sore:
- tell your nurse or doctor – they can give you a mouthwash or medicines to help
- try to drink plenty of fluids
- avoid alcohol, tobacco, and foods that irritate your mouth and throat.
Sucking ice chips may sometimes help relieve mouth or throat pain. But if you are having radiotherapy to the head or neck, do not suck on ice. It can cause damage.
This treatment can cause constipation. Constipation means that you are not able to pass stools (poo) as often as you normally do. It can become difficult or painful. Here are some tips that may help:
- Drink at least 2 litres (3½ pints) of fluids each day.
- Eat high-fibre foods, such as fruit, vegetables and wholemeal bread.
- Do regular gentle exercise, like going for short walks.
If you have constipation, contact the hospital for advice. Your doctor can give you drugs called laxatives to help.
This treatment may cause diarrhoea. Diarrhoea means passing more stools (poo) than is usual for you, or having watery or loose stools. If you have a stoma, it will be more active than usual.
If you have diarrhoea:
- try to drink at least 2 litres (3½ pints) of fluids each day
- avoid alcohol, caffeine, milk products, high-fat foods and high-fibre foods
- contact the hospital for advice.
Your hair will get thinner. Or you may lose all the hair from your head. You may also lose your eyelashes and eyebrows, as well as other body hair. Hair loss usually starts after your first or second treatment.
Your nurse can talk to you about ways to cope with hair loss. There are ways to cover up hair loss if you want to. Your scalp may be sensitive. It is important to cover your head to protect your skin when you are out in the sun.
Hair loss is almost always temporary. Your hair will usually grow back after treatment finishes.
Tummy pain and indigestion
Steroids can irritate the stomach lining. Let your nurse or doctor know if you have pain in your tummy or indigestion. They can give you drugs to help. Taking steroids with food can help to protect your stomach.
Steroids can make you feel more hungry than usual and you may gain weight. Your appetite will go back to normal when you stop taking them. If you are worried about gaining weight, talk to your doctor or nurse.
Raised blood sugar levels
Steroids can raise your blood sugar levels. Your nurse will check your blood regularly for this. They may also test your urine for sugar. Symptoms of raised blood sugar include:
- feeling thirsty
- needing to pass urine more often
- feeling tired.
Tell your doctor or nurse if you have these symptoms.
If you have diabetes, your blood sugar levels may be higher than usual. Your doctor will talk to you about how to manage this. You may need to adjust your insulin or tablet dose.
Mood and behaviour changes
Steroids can affect your mood. You may:
- feel anxious or restless
- have mood swings
- have problems sleeping.
Taking your steroids in the morning may help you sleep better at night.
Tell your doctor or nurse if you have any of these side effects. They may make some changes to your treatment if the side effects become a problem.
Feeling tired is a common side effect of this treatment. It is often worse towards the end of treatment and for some weeks after it has finished. Try to pace yourself and plan your day so you have time to rest. Gentle exercise, like short walks, can give you more energy.
If you feel sleepy, do not drive or use machinery.
Dizziness, blurred vision or feeling drowsy
Thalidomide can cause dizziness, blurred vision or make you feel sleepy (drowsy). Do not drink alcohol while you are taking thalidomide. This is because alcohol can make you sleepy and tha-lidomide can make you even sleepier. Steroids can also cause blurred vision.
Do not drive or operate machinery if you have these side effects. Talk to your doctor or nurse if you notice any of these effects.
CTD may affect your skin. Your doctor or nurse can tell you what to expect. If your skin feels dry, try using an unperfumed moisturising cream every day. CTD can cause a rash, which may be itchy.
Sometimes, thalidomide can cause a more serious skin rash that blisters. Let your doctor know straight away if this happens.
Always tell your doctor or nurse about any skin changes. They can give you advice and may give you creams or medicines to help. Any changes to your skin are usually temporary and improve when treatment finishes.
Numb or tingling hands or feet (peripheral neuropathy)
This treatment may affect the nerves, which can cause numb, tingling or painful hands or feet. You may find it hard to fasten buttons or do other fiddly tasks.
Tell your doctor if you have these symptoms. They sometimes need to lower the dose of the drug. The symptoms usually improve slowly after treatment finishes. But for some people they may never go away. Talk to your doctor if you are worried about this.
Build-up of fluid
This treatment may cause your ankles and legs to swell. This is due to fluid building up. Tell your doctor or nurse if this happens, as there are medicines that can help. If the swelling is uncomfortable, they may give you support stockings to wear. The swelling gets better after your treatment ends.
Cyclophosphamide may irritate your bladder and cause discomfort when you pass urine (pee). Drink plenty of fluids, at least 2 litres (3 ½ pints) during the first 24 hours after chemotherapy. It is also important to empty your bladder regularly and to try to pass urine as soon as you feel you need to. Contact the hospital straight away if you find it difficult to pass urine. Or contact the hospital if you feel any discomfort or stinging when you pass urine. If you notice any blood in your urine tell your doctor straight away.
Low blood pressure
Thalidomide can cause a temporary fall in your blood pressure. This can make you feel dizzy for a few moments if you stand up quickly. It can help to move slowly from lying to sitting and from sitting to standing.
Tell your doctor or nurse if you have ever had problems with your blood pressure.
Effects on the heart
Sometimes thalidomide can affect your heart. It may feel like your heart is beating too slowly. If you notice this, tell your doctor straight away. They can check your heart rate.
It is also important to contact a doctor straight away if you:
- have pain or tightness in your chest
- feel breathless
- feel your heart is beating too fast.
Other conditions can cause these symptoms, but it is important to get them checked by a doctor.
Effects on the lungs
This treatment can cause changes to the lungs. Tell your doctor if you develop:
- a cough
You should also tell them if any existing breathing problems get worse. You may have tests to check your lungs.
Effects on the kidneys and liver
This treatment can affect how your kidneys and liver work. This is usually mild and goes back to normal after treatment. You will have blood tests before chemotherapy to check how well your kidneys and liver are working.
Hepatitis B reactivation
If you have had hepatitis B (a liver infection) in the past, this treatment can make it active again. Your doctor or nurse will talk to you about this. They will also test you for hepatitis B before you have this treatment.
Changes in hearing
Thalidomide may cause hearing changes, including some hearing loss. Tell your doctor if you notice any changes in your hearing.
You must take part in a pregnancy prevention programme while taking thalidomide. Your doctor will give you information about not becoming pregnant or making someone pregnant during and after treatment with thalidomide. This is because thalidomide can cause birth defects in developing babies. Both men and women taking thalidomide can pass this risk on to an unborn child.
Your doctor or specialist nurse will give you some written information about the risks of thalidomide and the best ways to prevent pregnancy. They will ask you to sign a consent form once you have read the information.
Women taking thalidomide
If you have not yet had your menopause you will have a pregnancy test before starting treatment with thalidomide. This will be repeated every 4 weeks during treatment. You will also have a pregnancy test 4 weeks after treatment finishes.
You must use an effective form of contraception, such as:
- an implant
- or a progesterone-only oral pill.
The combined oral contraceptive pill is not recommended because it increases your risk of developing blood clots.
You must use contraception for 4 weeks before treatment, during treatment, and for 4 weeks after treatment finishes. If you think you may be pregnant at any time during your treatment, contact your doctor or specialist nurse straight away.
Men taking thalidomide
You must use a condom during sex while taking thalidomide and for 1 week after treatment finishes. This is to protect your partner from thalidomide, which can pass into your semen.
If your partner thinks they might be pregnant during your treatment, contact your doctor or specialist nurse straight away.
Some cancer drugs can affect whether you can get pregnant or make someone pregnant.
If you are a woman, your periods may become irregular or stop. This may be temporary, but for some women it is permanent. Your menopause may start sooner than it would have done.
You are advised not to breastfeed while having this treatment, or for some time after treatment finishes. This is because the drugs could be passed to the baby through breast milk.
Your doctor or nurse can give you more information.
Do not drive if you feel dizzy or tired, or if your vision is affected. Talk to your doctor if you are not sure whether it is safe for you to drive.
Some medicines can affect how this treatment works or be harmful when you are having it. Always tell your cancer doctor about any drugs you are taking or planning to take, such as:
- medicines you have been prescribed
- medicines you buy in a shop or chemist
- vitamins, herbal drugs and complementary therapies.
Tell other doctors, pharmacists or dentists who prescribe or give you medicines that you are having this cancer treatment.
You can visit the electronic Medicines Compendium (eMC) for more detailed information about your treatment.
Medical and dental treatment
If you need medical treatment for any reason other than cancer, always tell the doctors and nurses you are having cancer treatment. Give them the contact details for your cancer doctor so they can ask for advice.
If you think you need dental treatment, talk to your cancer doctor or nurse. Always tell your dentist you are having cancer treatment.