Daratumumab, lenalidomide, dexamethasone (DRd)

You usually have daratumumab at a chemotherapy day unit or clinic as an outpatient. Lenalidomide and dexamethasone are capsules or tablets that you take at home.

During your course of treatment, you will meet someone from your cancer team, such as a:

• blood cancer doctor (haematologist)
• chemotherapy nurse or specialist nurse
• specialist pharmacist.

This is who we mean when we mention doctor, nurse or pharmacist in this information.

Before or on the day of each treatment, you will have a blood test. This is to check that it is safe for you to have treatment.

You will meet with a doctor, nurse or pharmacist before you have treatment. They will talk to you about your blood results and ask how you have been feeling. If your blood results are okay, the pharmacy team will prepare your cancer drugs.

You usually have a course of several cycles of DRd over a few months. Each cycle lasts 28 days (4 weeks).

You will have daratumumab once every week for the first 2 cycles. Then once every 2 weeks for the next 4 cycles. Then every 4 weeks.

You take lenalidomide once a day on day 1 to 21 of each 4 week cycle.

You take dexamethasone once or twice a week.

You usually keep having this treatment as long as it is effective and any side effects can be managed. Your cancer team will discuss your treatment plan with you. They may give you a copy of the plan to take home.

Daratumumab can be given as a drip into a vein (intravenous). But for this combination, you usually have daratumumab as an injection under the skin (subcutaneous). Your nurse will give the injection into your tummy area (abdomen). They will give it over 3 to 5 minutes. The nurse will give it in different areas of the tummy each time. This can help stop your skin from becoming sore.

You will have medicines before and after each injection to reduce the chance of an allergic reaction. After the first treatment, you may be asked to wait in the hospital for 4 to 6 hours after the injection. This is to check for any signs of a reaction to the treatment.

These drugs come in capsules or tablets. This means you can take them at home.

Your doctor, nurse or pharmacist will explain when and how to take each drug. You may be given capsules or tablets of different strengths. Make sure you understand which days you should take each drug and what dose you should take.

They may also give you anti-sickness drugs and other medicines to take home. Take all your capsules or tablets exactly as they have been explained to you.

Swallow the lenalidomide and dexamethasone whole with a glass of water. Do not chew, open, break or crush the capsules or tablets.

You can take lenalidomide with or without food. This drug can make you sleepy so you may want to take it in the evening.

You should take dexamethasone after food, or with plenty of water. This drug can cause difficulty sleeping so it is best to take with breakfast or lunch.

If you forget to take dexamethasone, take the missed dose as soon as possible.

If you forget to take lenalidomide and there is less than 12 hours until your next dose, do not take the missed dose. Take the next dose at the usual time and tell your doctor, nurse or pharmacist. Do not take a double dose.

Other things to remember about your capsules or tablets:

• If you are sick (vomit) just after taking them, do not take an extra dose. Take your next dose at the usual time.
• Keep them in the original package and at room temperature, away from moisture, heat and direct sunlight.
• Keep them safe, where children cannot see or reach them.
• Do not throw away unused capsules or tablets. Return them to your cancer team at the hospital.

We explain the most common side effects of this treatment here. We also include some that are less common.

You may get some of the side effects we mention, but you are unlikely to get all of them. And you may have some side effects, including rarer ones, that we have not listed here. 

Always tell your doctor, nurse or pharmacist about any side effects you have. They can give you: 

• drugs to help control some side effects
• advice about managing side effects. 

It is important to take any drugs exactly as explained. This means they will be more likely to work for you. 

Some cancer treatments can cause serious side effects. Sometimes, these may be life-threatening. Your doctor, nurse or pharmacist can explain the risk of these side effects to you.

Your doctor, nurse or pharmacist will give you 24-hour contact numbers for the hospital. If you feel unwell or need advice, you can call at any time of the day or night. Save these numbers in your phone or keep them somewhere safe.

This treatment can reduce the number of white blood cells in your blood. These cells fight infection. If your white blood cell count is low, you may be more likely to get an infection. A low white blood cell count is 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. If you have any of the following symptoms, contact the hospital straight away on the 24-hour number:

• a temperature above 37.5°C  
• a temperature below 36°C 
• you feel unwell, even with a normal temperature
• you have symptoms of an infection.

Symptoms of an infection include:

• feeling shivery and shaking
• a sore throat
• a cough 
• breathlessness
• diarrhoea
• needing to pass urine (pee) often, or discomfort when you pass urine.

It is important to follow any specific advice your cancer treatment team gives you.

Your white blood cell count 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.

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:

• nosebleeds
• bleeding gums
• heavy periods
• blood in your urine (pee) or stools (poo)
• tiny red, brown or purple spots that may look like a rash – these spots can be harder to see if you have black or brown skin. 

If you have any unexplained bruising or bleeding, contact the hospital straight away on the 24-hour number. You may need a drip to give you extra platelets. This is called a platelet transfusion.

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 feel:

• very low in energy
• breathless 
• dizzy and light-headed. 

If you have these symptoms, contact the hospital straight away on the 24-hour number. You may need treatment for anaemia. If you are very anaemic, you may need a drip to give you extra red blood cells. This is called a blood transfusion.

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 ends. Try to pace yourself and plan your day so you have time to rest. Gentle exercise, like short walks, can help you feel less tired. 

If you feel sleepy, do not drive or use machinery.

You may feel sick. This is usually mild, but your doctor, nurse or pharmacist can prescribe anti-sickness drugs to help. Tell them if you still feel sick or it gets worse. They can give you advice or a different anti-sickness drug to try.

This treatment may cause diarrhoea. Diarrhoea means passing more stools (poo) than is normal for you, or having watery or loose stools. You may also have stomach cramps. If you have a stoma, it may be more active than usual. 

If you are passing loose stools 3 or more times a day and this is not normal for you, contact the hospital as soon as possible on the 24-hour number. Follow the advice they give you about:

• taking anti-diarrhoea medicines 
• drinking enough fluids to keep you hydrated and to replace lost salts and minerals
• any changes to your diet that might help. 

They might also ask you for a specimen of your stool to check for infection.

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 on the 24-hour number for advice. They can give you drugs called laxatives to help. 

If you have not been able to pass stools for over 2 days and are being sick, contact the 24-hour number straight away. 

This treatment can cause a build-up of fluid in the body. This will slowly get better after treatment ends. Contact the hospital on the 24-hour number if you:

• are gaining weight 
• have swelling in your face, legs or ankles.

They can give you advice and treatment to help.

This treatment may affect the nerves in your fingers and toes. This can cause numbness, tingling or pain in your hands or feet. This is called peripheral neuropathy. You might find it hard to do fiddly tasks such as fastening buttons or tying shoelaces.

If you have these symptoms, always tell your doctor, nurse or pharmacist. They sometimes need to change the drug or the dose of the drug. The symptoms usually improve slowly after treatment ends. But for some people they continue and are a long-term side effect of treatment.

This treatment can affect your appetite. Don’t worry if you do not eat much for 1 or 2 days. But if your appetite does not come back after a few days, or if you are losing weight, tell your doctor, nurse or pharmacist. They can give you advice. They may give you food or drink supplements. Or they may suggest changes to your diet or eating habits to help.

This treatment can affect your mood and behaviour. It can cause:

• feelings of anxiety or restlessness
• mood swings (moods that go up and down)
• low mood or depression.

Sometimes, when taken in higher doses, dexamethasone can cause confusion or changes in thinking. This can include having strange or frightening thoughts.

If you notice any changes in your mood or behaviour, tell your doctor, nurse or pharmacist. They may make some changes to your treatment if the side effects are causing you problems.

This treatment can affect your skin. It might feel dry. You may develop a rash, which may be itchy. Always tell your doctor, nurse or pharmacist about any skin changes. They can give you advice or prescribe creams or medicines to help.

If your skin feels dry, try using soap-free cleansers and unperfumed moisturising cream every day.

Rarely, this treatment can cause a serious skin reaction that needs to be treated immediately in hospital.

Do not take any more of this treatment and contact the hospital straight away on the 24-hour number if you have any of these symptoms:

• a skin rash that is spreading
• blistering or peeling skin
• flu-like symptoms, such as a high temperature and joint pain
• sores on your lips or in your mouth.

This treatment can cause muscle spasms. They are usually mild. Or you may get pain in your muscles or joints. If this happens, tell your doctor, nurse or pharmacist. They can give you painkillers and advice. They can also tell you if any of the painkillers you usually take are suitable.

Tell them if the pain does not get better. Having warm baths and resting regularly may help.

This treatment may raise your blood sugar levels and increase the risk of diabetes. 

You will have regular blood tests to check this. 

Signs of raised blood sugar include:

• feeling thirsty
• needing to pass urine (pee) more often than usual
• feeling more tired than usual.

Contact the hospital on the 24-hour number if you have these symptoms during treatment or after it ends.

If you already have diabetes, your blood sugar levels may be higher than usual. You may need advice and support from your GP or diabetes team about managing this.

Some foods may taste different or have no taste. Try different foods to find out what tastes best to you. You may also get a bitter or metallic taste in your mouth. Your doctor, nurse or pharmacist can give you advice. It might help to try:

• sucking sugar-free sour or boiled sweets
• eating cold foods
• eating sharp-tasting fresh fruit.

Taste changes usually get better after treatment ends. We have more information about coping with changes to taste.

This treatment may affect your blood pressure. Tell your nurse, doctor or pharmacist if you have headaches or feel dizzy. These can be signs of blood pressure changes.

This treatment can affect your eyesight. Tell your doctor, nurse or pharmacist if you notice any change in your vision.

Dexamethasone can irritate the stomach lining. If you have indigestion or pain in your tummy, tell your doctor, nurse or pharmacist. They can prescribe drugs to help reduce stomach irritation.

To help protect your stomach, you should take the dexamethasone with food.

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.

Contact the hospital straight away on the 24-hour number, if:

• a sore mouth or throat affects how much you can drink or eat 
• your mouth, tongue, throat or lips have any blisters, ulcers or white patches. 

They can give you advice, and mouthwash or medicines to help with the pain or to treat any infection. Follow their advice and make sure you:

• drink plenty of fluids
• avoid alcohol and tobacco
• avoid food or drinks that irritate your mouth and throat.

This treatment can affect how your kidneys or liver work. This is usually mild and goes back to normal after treatment ends. You will have blood tests to check how well your kidneys and liver are working. Contact the hospital on the 24-hour number if you:

• have blood in your urine (pee)
• are passing less urine or peeing less often than usual.

Drinking fluids also helps protect your kidneys. The advice is usually to try to drink at least 2 litres (3½ pints) of fluid each day. But follow any advice from your doctor, nurse or pharmacist about how much is right for you.

This treatment increases your risk of a blood clot. Your cancer team will give you drugs to take that help prevent blood clots.

Contact the hospital straight away on the 24-hour number if you have any of these symptoms during or after treatment:

• throbbing pain or swelling in a leg or arm
• reddening of the skin in the area – if you have black or brown skin, this can be harder to notice, but the skin might become darker
• suddenly feeling breathless or coughing.

Always call 999 if you have:

• chest pain
• difficulty breathing.

A blood clot is serious, but it can be treated with drugs called anticoagulants. These thin the blood. Your doctor, nurse or pharmacist can give you more information about preventing and treating blood clots.

Daratumumab can affect the result of a blood test called the indirect Coombs test. This is one of the tests that matches you to a donor’s blood before you have a blood transfusion.

Before you start daratumumab, you will have the blood tests you need for a blood transfusion. Your doctor may also give you a card to carry that explains the treatment you are having.

If you need a blood transfusion during treatment or for 6 months after, tell the person arranging it that you have had daratumumab. You can show them the card your doctor has given you.

Some viral infections can become active again while you are taking this treatment. These may need treatment with anti-viral drugs. This includes hepatitis B (a liver infection) and herpes zoster (shingles). Your doctor or nurse will talk to you about this. Before you start treatment you will have a blood test to check if you have had hepatitis B.

This treatment may affect your ability to drive. Do not drive if you have blurred vision, or if you feel dizzy, very tired or sleepy. Talk to your doctor, nurse or pharmacist if you are not sure whether it is safe for you to drive.

This treatment may contain lactose. If you have a lactose allergy or intolerance, ask your doctor, nurse or pharmacist for more information.

Some medicines can affect how this treatment works or be harmful while you are having it. Always tell your cancer doctor, nurse or pharmacist about any drugs you are taking or planning to take, such as: 

• medicines you have been prescribed
• medicines you buy in a shop, pharmacy or online
• vitamins or supplements 
• herbal drugs and complementary or homeopathic therapies
• recreational drugs – for example, cannabis.

Doctors usually recommend that people with cancer have vaccinations for flu and for coronavirus (covid). These help reduce your risk of serious illness from these infections. Most people can have these vaccines, including people with weak immune systems.

If your immune system is weak, you should not have live vaccinations. Live vaccines can make you unwell because they contain a very weak version of the illness they will protect you against. Live vaccines include Zostavax^®, which is a shingles vaccine, and the yellow fever vaccine.

It is important to ask your doctor, nurse or pharmacist for advice about having vaccinations. They can explain what vaccines are right for you and when it is best to have them.

Your doctor, nurse or pharmacist will advise you not to get pregnant or make someone pregnant while having this treatment and for some time afterwards. The drugs may harm a developing baby. It is important to use contraception to prevent pregnancy. Follow their advice about:

• what types of contraception to use 
• how long after treatment you should continue to use contraception. 

You are advised not to breastfeed while having this treatment, or for some time after treatment ends. This is because the drugs could be passed to the baby through breast milk. 

Your doctor, nurse or pharmacist can give you more information.

Some cancer drugs can affect whether you can get pregnant or make someone pregnant. If you are worried about this, it is important to talk with your doctor before you start treatment.

If you need medical treatment for any reason other than cancer, always tell the healthcare professional that you are having cancer treatment. Give them the contact details for your cancer doctor or cancer team so they can ask for advice.

If you have appointments with a dentist, always tell them you are having cancer treatment. Talk to your cancer team before you have any dental treatment.