Bortezomib, thalidomide and dexamethasone (VTD)

Bortezomib, thalidomide, and dexamethasone (VTD) is a cancer drug combination for the treatment of myeloma. 

What is VTD?

VTD is the name of a cancer drug combination that includes:

• V - bortezomib (Velcade)
• T - thalidomide
• D - dexamethasone (a steroid)

It is a treatment for myeloma. 

How does VTD work?

Bortezomib is a type of targeted cancer drug called a proteasome inhibitor.

Proteasomes are in cells. They help to break down proteins that the cell doesn't need. Bortezomib blocks the proteasomes so the proteins build up inside the cell. The cell then dies.

Thalidomide works in different ways. It: 

• stops cancer cells developing
• stops cancers making their own blood vessels, that they need to be able to grow
• stimulates some of the immune system cells to attack myeloma cells

Dexamethasone helps bortezomib and thalidomide to work better and kills myeloma cells.

How do you have VTD?

You have bortezomib as an injection under your skin. You take thalidomide as capsules and dexamethasone as tablets.

You usually take your thalidomide capsules at bedtime. This helps you to feel less sleepy at other times of the day.

Injection just under the skin

You usually have injections under the skin (subcutaneous injection) into the stomach or thigh.

You might have stinging or a dull ache for a short time after this type of injection but they don't usually hurt much. The skin in the area may go red and itchy for a while.

Taking your tablets or capsules

You should take the right dose, not more or less.

Talk to your healthcare team before you stop taking a cancer drug, or if you have missed a dose.

You should take dexamethasone tablets after a meal or with milk as they can irritate your stomach. Taking them in the morning might help to stop difficulty in sleeping (insomnia).

How often do you have VTD?

You have VTD as cycles of treatment. You usually have up to 6 cycles of VTD. The number of cycles you have will depend on your individual situation.

You might have VTD over 3 weeks (21 days) or 4 weeks (28 days). The number of days you have this treatment for will depend on your individual situation. 

Talk to your treatment team about how often you will have treatment.

Tests

You have blood tests before and during your treatment. They check your levels of blood cells and other substances in the blood. They also check how well your liver and kidneys are working.

What are the side effects of VTD?

Side effects can vary from person to person. They also depend on what other treatments you're having. 

When to contact your team

Your doctor, nurse or pharmacist will go through the possible side effects. They will monitor you during treatment and check how you are at your appointments. Contact your advice line as soon as possible if:

• you have severe side effects 

• your side effects aren’t getting any better

• your side effects are getting worse

Early treatment can help manage side effects better. 

We haven't listed all the side effects here. Remember it is very unlikely that you will have all of these side effects. But you might have some of them at the same time.

Common side effects

These side effects happen in more than 10 in 100 people (more than 10%). You might have one or more of them. They include:

Numbness or tingling in fingers or toes

Numbness or tingling in fingers or toes is often temporary and can improve after you finish treatment. Tell your doctor if you're finding it difficult to walk or complete fiddly tasks such as doing up buttons. 

You might also have less feeling or strange sensations such as pins and needles or tingling.

Pain in different parts of your body

You might feel pain from different parts of your body such as your muscles, joints and nerves (neuralgia). 

Nerve pain can happen when the nerves get irritated or damaged. It can feel like a stabbing, burning, or sharp shooting pain. This can be severe.

Rarely, you might get pain in your groin, or at the injection site.

Speak to your doctor or nurse about what painkillers you can take to help with this.

High temperature (fever) 

If you get a high temperature, let your healthcare team know straight away. Ask them if you can take paracetamol to help lower your temperature.

Constipation 

Constipation is easier to sort out if you treat it early. Drink plenty of fluids and eat as much fresh fruit and vegetables as you can. Try to take gentle exercise, such as walking. Tell your healthcare team if you think you are constipated. They can prescribe a laxative.

Diarrhoea 

Contact your advice line if you have diarrhoea. For example, 2 or more extra loose bowel movements than usual each day. If you have a stoma, you might have more output than normal. Your doctor may give you anti diarrhoea medicine to take home with you after treatment.

Try to eat small meals and snacks regularly. It’s best to try to have a healthy balanced diet if you can. You don’t necessarily need to stop eating foods that contain fibre. But if your diet is normally very high in fibre, it might help to cut back on high fibre foods such as beans, nuts, seeds, dried fruit, bran and raw vegetables. 

Drink plenty to try and replace the fluid lost. Aim for 8 to 10 glasses per day.

Loss of appetite 

You might lose your appetite for various reasons while having cancer treatment. Sickness, taste changes or tiredness can put you off food and drinks.

Feeling or being sick

Feeling or being sick is usually well controlled with anti sickness medicines. It might help to avoid fatty or fried foods, eat small meals and snacks and take regular sips of water. Relaxation techniques might also help.

It is important to take anti sickness medicines as prescribed even if you don’t feel sick. It is easier to prevent sickness rather than treat it once it has started.

Tiredness and weakness (fatigue)

Tiredness and weakness (fatigue) can happen during and after treatment. Doing gentle exercises each day can keep your energy up. Don't push yourself, rest when you start to feel tired and ask others for help.

Breathlessness and looking pale 

You might be breathless and look pale due to a drop in red blood cells. This is called anaemia.

Bruising, bleeding gums or nosebleeds 

This is due to a drop in the number of platelets in your blood. These blood cells help the blood to clot when we cut ourselves. You may have nosebleeds or bleeding gums after brushing your teeth. Or you may have lots of tiny red spots or bruises on your arms or legs (known as petechiae).

Rarely, you might have bleeding from other parts of the body. Tell your healthcare team if you notice this.

Increased risk of getting an infection 

Increased risk of getting an infection is due to a drop in white blood cells. Symptoms include a change in temperature, aching muscles, headaches, feeling cold and shivery and generally unwell. You might have other symptoms depending on where the infection is.

Infections can sometimes be life threatening. You should contact your advice line urgently if you think you have an infection. 

Feeling very sleepy (drowsy) 

You should not drive or operate machinery if you feel drowsy. 

If you are very sleepy or are finding it hard to keep awake, contact your doctor straight away.

Tremor

This treatment can make you tremble or shake (tremor). Talk to your team if you have notice this happening.

Fluid build up

A build up of fluid may cause swelling in your arms, hands, ankles, legs, face and other parts of the body. Contact your doctor if this happens to you.

Dizziness

This drug might make you feel dizzy. Don’t drive or operate machinery if you have this.

Changes in blood sugar levels 

You have regular blood and urine tests to check this. If you have diabetes you may need to check your blood sugar levels more often than usual. 

Weight changes 

Talk to your team if you are gaining weight.

Occasional side effects

These side effects happen in between 1 and 10 out of every 100 people (between 1 and 10%). You might have one or more of them. They include:

• breathlessness and cough that could be due to infection such as pneumonia or it might be due to changes in the lung tissue making it less flexible
• blood pressure changes – you might feel light headed or dizzy
• eye problems such as swelling, eyesight changes and infection. Rarer problems include blurred or double vision, pain, dry eye or leaking fluid (discharge). Let your team know if this happens.
• kidney problems causing them not to work as well. Other problems might include going to the toilet more or less often, and you may not empty your bladder properly, but this is rare. You have regular blood tests to check for any kidney changes.
• taste changes
• weight loss, rarely you might gain weight
• indigestion, symptoms include heartburn, bloating and burping
• difficulty in sleeping (insomnia)
• mood changes such as feeling very low (depressed) or confused. Much less commonly you may have memory problems, feel anxious or agitated
• lack of fluid in the body (dehydration)
• mouth sores and ulcers that can be painful. Your mouth might also get dry or you may get throat pain
• blood in your poo (stool) due to bleeding from your stomach or bowel
• liver changes – you will have regular blood tests to check for this
• hearing changes such as ringing in the ears, hearing loss, unable to hear as clearly, discomfort or pain
• changes in your coordination
• cramps, twitching and weakness of the muscles
• headaches. Less often you might get migraines.
• temporary loss of consciousness (fainting)
• changes in levels of minerals and salts in your body - you will have regular blood tests to check for this
• swelling of the tummy (abdomen)
• skin changes such as a dry, red, itchy rash
• fits (seizures)
• heart problems such as a changes in heart rhythm and how well your heart pumps blood around the body. Rarely, you might get chest pain, heart attack, or fluid around the heart.
• blood clots that can be life threatening; signs are pain, redness and swelling where the clot is. Feeling breathless can be a sign of a blood clot in the lung. Contact your advice line or doctor straight away if you have any of these symptoms
• a second cancer some years after treatment ends
• feeling generally unwell (malaise)
• wind (flatulence)
• chills
• feeling giddy or unbalanced (vertigo)

Rare side effects

These side effects happen in fewer than 1 in 100 people (less than 1%). You might have one or more of them. They include: 

• changes to the levels of chemicals in the blood due to breakdown of cancer cells (tumour lysis syndrome) – you have regular blood tests to check for this
• hiccups
• stroke
• difficulty concentrating
• high levels of thyroid hormones (hyperthyroidism)- you might feel irritable, tired or sensitive to heat
• hair changes such as loss or change in how your hair feels
• runny nose
• episodes of feeling warm and reddening of the skin (flushing)
• an allergic reaction that can cause a rash, shortness of breath, redness or swelling of the face and dizziness - some allergic reactions can be life threatening, alert your nurse or doctor if notice any of these symptoms
• difficulty swallowing
• night sweats
• digestive system problems such as a hole or blockage in the bowel, inflammation of different parts so of the digestive system. Other problems include the nerves and muscle not working properly to pass food through.
• inflammation of your pancreas – symptoms include severe tummy pain, feeling or being sick, a high temperature or you may have loose poo
• inflammation of your blood vessels. Symptoms can vary depending on which blood vessels are affected. General symptoms include feeling very tired, loss of appetite, weight loss, a high temperature, and aches and pains (vasculitis).
• a rare disorder of the nerves causing headache, fits, confusion and changes in vision - contact your health team straight away. This condition is reversible.
• voice changes could include you sounding more horse, rough or raspy

Coping with side effects

We have more information about side effects and tips on how to cope with them.

What else do I need to know?

Other medicines, foods and drink

Cancer drugs can interact with some other medicines and herbal products. Tell your doctor or pharmacist about any medicines you are taking. This includes vitamins, herbal supplements and over the counter remedies.

Alcohol

Do not drink alcohol while you are taking thalidomide. This is because alcohol can make you sleepy and thalidomide can make you even sleepier.

Pregnancy and contraception

This treatment might harm a baby developing in the womb. It is important not to become pregnant or father a child while you're having treatment and for 3 months afterwards. Talk to your doctor or nurse about effective contraception before starting treatment.

Women need to use effective contraception for 4 weeks before starting treatment.

Loss of fertility

It is not known whether this treatment affects fertility in people. Talk to your doctor before starting treatment if you think you may want to have a baby in the future.

Breastfeeding

It is not known whether these drugs come through into the breast milk. Doctors usually advise that you don’t breastfeed during this treatment.

Treatment for other conditions 

If you are having tests or treatment for anything else, always mention your cancer treatment. For example, if you are visiting your dentist.

Immunisations

Don’t have immunisations with live vaccines while you’re having treatment and for up to 12 months afterwards. The length of time depends on the treatment you are having. Ask your doctor or pharmacist how long you should avoid live vaccinations.

In the UK, live vaccines include rubella, mumps, measles, BCG, yellow fever and one of the shingles vaccines called Zostavax.

You can have:

• other vaccines, but they might not give you as much protection as usual
• the flu vaccine (as an injection)
• the coronavirus (COVID-19) vaccine - talk to your doctor or pharmacist about the best time to have it in relation to your cancer treatment

Members of your household who are aged 5 years or over are also able to have the COVID-19 vaccine. This is to help lower your risk of getting COVID-19 while having cancer treatment and until your immune system recovers from treatment.

Contact with others who have had immunisations - You can be in contact with other people who have had live vaccines as injections. Avoid close contact with people who have recently had live vaccines taken by mouth (oral vaccines) such as the oral typhoid vaccine. Sometimes people who have had the live shingles vaccine can get a shingles type rash. If this happens they should keep the area covered.

If your immune system is severely weakened, you should avoid contact with children who have had the flu vaccine as a nasal spray as this is a live vaccine. This is for 2 weeks following their vaccination.

Babies have the live rotavirus vaccine. The virus is in the baby’s poo for about 2 weeks and could make you ill if your immunity is low. Get someone else to change their nappies during this time if you can. If this isn't possible, wash your hands well after changing their nappy.

More information about this treatment

For further information about this treatment and possible side effects go to the electronic Medicines Compendium (eMC) website. You can find the patient information leaflet on this website.

You can report any side effect you have to the Medicines Health and Regulatory Authority (MHRA) as part of their Yellow Card Scheme.