Treating Non-Hodgkin Lymphoma

Antibiotics and anti-virals

Some chemotherapy drugs (fludarabine and other purine analogs) as well as the antibody drug alemtuzumab (Campath, Lemtrada) can put you at high risk of certain types of infections, including:

• CMV (a virus)
• Pneumocystis pneumonia (PCP), which is caused by the fungus Pneumocystis jirovecii

These infections are mainly seen in people with impaired immune systems.

An anti-viral medicine like acyclovir is often given to try to prevent CMV infections. To help prevent PCP, a sulfa antibiotic such as trimethoprim with sulfamethoxazole (Septra or Bactrim) is often given. Other treatments are available for people who are allergic to sulfa medicines.

If you do get an infection, you might need antibiotics and anti-viral medicines to treat it. You might need higher doses or different medicines than the ones used to prevent infection.

Intravenous immunoglobulin (IVIG)

Some people with NHL have low levels of antibodies (immunoglobulins). Antibodies are immune system proteins that fight infections. If you have a low level of antibodies, this can lead to lung and sinus infections that keep coming back.

Low antibody levels can be caused by the lymphoma itself or by some treatments, including rituximab and similar drugs, CAR T-cell therapy, and bispecific antibodies.

The level of antibodies in your blood can be checked with a blood test. If the level is low, antibodies from donors can be put into a vein (IV) to help prevent infections. This is called intravenous immunoglobulin (IVIG). IVIG is often given once a month at first, but it may be given less often based on blood tests of antibody levels.

For more information on infections, see Infections in People with Cancer.

Chemotherapy (chemo) and some other lymphoma treatments can affect your bone marrow, where new blood cells are made. This can lead to low levels of some types of blood cells.

Low white blood cell count

Your body needs white blood cells to fight infection, especially certain white blood cells called neutrophils. Having too few neutrophils (neutropenia) can lead to serious or even life-threatening infections.

If your chemo is likely to cause neutropenia, you might get shots of a white blood cell growth factor to help keep your neutrophil count up. You might also get these shots if your count is already low. This can lower your risk of serious infection and help keep your chemo on schedule.

Examples of white blood cell growth factors include:

• Filgrastim (Neupogen) and similar drugs, which are given as a shot every day for several days.
• Pegfilgrastim (Neulasta) and similar drugs, which are given once each chemo cycle. They can be given as a shot or with a small device worn on the skin that gives the dose automatically.

These are not given on the same day as chemo, because giving them too close to chemo can make neutropenia worse. They are usually started at least one day after chemo ends.

If you have neutropenia and get a fever or other signs of infection, call your care team right away. You'll need treatment with antibiotics.

Low platelet count

Platelets help blood to clot, which stops bleeding. If your platelet count gets very low, it can lead to serious bleeding. Platelet transfusions can often help prevent this.

If you have NHL, your platelet count can also become low. This can happen when your platelets are destroyed by abnormal antibodies. It is called immune thrombocytopenia (ITP). Before diagnosing this, your healthcare team will often need to check your bone marrow to make sure there isn’t another cause for the low platelet counts.

Platelet transfusions don’t usually help to treat ITP, because the antibodies just destroy the new platelets, too. Instead, ITP can be treated in a few other ways:

• With medicines that affect the immune system, like corticosteroids and intravenous immunoglobulin (IVIG).
• By removing your spleen, because after the antibodies stick to the platelets, they are destroyed in the spleen.
• With thrombopoietin receptor agonists (TPO-RAs) such as eltrombopag (Promacta) or romiplostim (Nplate). These can help your body make more platelets.

Low red blood cell count

Some people develop low red blood cell counts (anemia) from NHL or its treatment. This can lead to feeling tired, lightheaded, or short of breath.

Anemia that is causing symptoms can be treated with red blood cell transfusions.

Medicines such as epoetin alfa (Epogen, Procrit) or darbepoetin alfa (Aranesp) may also be used. These medicines help your body make more red blood cells. However, they can raise the risk of blood clots and may lead to worse cancer outcomes. They are generally only used for people who decline blood transfusions, and with close monitoring.

In some people with NHL, abnormal antibodies can also lower red blood cell counts. This is called autoimmune hemolytic anemia (AIHA).

It can be treated with medicines that affect the immune system, such as corticosteroids and intravenous immunoglobulin (IVIG). Removing the spleen is also an option. If you are being treated with the chemo drug fludarabine (Fludara) when the AIHA develops, the drug itself may be the cause. In this case, your cancer care team may stop your fludarabine.

Sometimes, the treatments you get to control your symptoms are similar to the treatments used to treat cancer. For example:

• When lymph nodes become enlarged, they may press on nerves and cause pain. Radiation therapy to these areas may help relieve the pain.
• You might also be given pain medicines, ranging from ibuprofen and similar drugs to more potent medicines such as opioids (like morphine).
• Nausea and loss of appetite can be treated with medicines and high-calorie food supplements.
• If the lymphoma has spread to your lungs, you might get short of breath. Oxygen may be used to help treat this.