Polatuzumab vedotin, bendamustine and rituximab (Pola-BR)

Polatuzumab vedotin (Polivy), bendamustine (Levact) and rituximab (Mabthera) is a cancer drug combination for diffuse large B cell lymphoma (DLBCL).

It is a treatment for DLBCL that has come back or did not get better after at least one other anti-cancer treatment, and you are unable to have a stem cell transplant.

How does polatuzumab vedotin, bendamustine and rituximab (Pola-BR) work?

Polatuzumab is a type of monoclonal antibody with a chemotherapy drug attached to it. Monoclonal antibodies (MABs) are copies of a single antibody. They are made in the laboratory. Monoclonal antibodies seek out cancer cells by targeting particular proteins on the cell surface. 

Polatuzumab targets a protein called CD79b that is found on the surface of B cells. Polatuzumab sticks to the CD79b protein and delivers the chemotherapy drug into the cell. The drug then kills the cell. 

Rituximab is a type of monoclonal antibody. Rituximab targets a protein known as CD20. CD20 is found on B cells. 

Bendamustine is a type of chemotherapy drug called an alkylating agent. 

These drugs work by interfering with the DNA in cancer cells. The cells can’t divide into 2 new cells so the cancer can’t grow. 

How do you have polatuzumab vedotin, bendamustine and rituximab (Pola-BR)?

You have these drugs into your bloodstream (intravenously).

You might have treatment through a long plastic tube that goes into a large vein in your chest. The tube stays in place throughout the course of treatment. This can be a:
•    central line
•    PICC line
•    portacath

If you don't have a central line

You might have treatment through a thin short tube (a cannula) that goes into a vein in your arm each time you have treatment.

How often do you have polatuzumab vedotin, bendamustine and rituximab (Pola-BR)?

You have polatuzumab vedotin, bendamustine and rituximab as cycles of treatment. This means that you have the drugs and then a rest to allow your body to recover.

Each cycle of treatment lasts 21 days (3 weeks). You might have up to 6 cycles. 

Some hospitals vary in the way that they give cycle 1. So check with the team looking after you. 

You might have each cycle of treatment in the following way:

Cycle 1

Cycles 2 to 6

Some people have an allergic reaction to polatuzumab or rituximab. This can cause flu-like symptoms such as fever and sickness. To prevent an allergic reaction you usually have the first dose slowly over a few hours. You may also have paracetamol, steroids and an antihistamine drug before the treatment. 

You might need to stay in hospital while you have your treatment. Check with the team looking after you. 

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.

Side effects

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:

Increased risk of 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. 

Lung infection 

You might develop a cough or breathing problems. This could be due to infection, such as pneumonia or inflammation of the lungs (pneumonitis). 

Breathlessness and looking pale

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

Bruising and bleeding

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).

Less commonly this can lead to severe bleeding. 

Allergic reaction 

A reaction may happen during the infusion. Symptoms can include a skin rash, itching, swelling of the lips, face or throat, breathing difficulties, fever and chills. Your nurse will give you medicines beforehand to try to prevent a reaction. 

Rarely you might have a severe allergic reaction called anaphylaxis. 

Low levels of potassium in your blood 

Low levels of potassium in the blood is called hypokalaemia. Regular blood tests will check for this. 

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.

Numbness or tingling in fingers or toes  (peripheral neuropathy) 

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

Tiredness (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.

Decreased appetite and weight loss 

You might not feel like eating and may lose weight. Eating several small meals and snacks throughout the day can be easier to manage. You can talk to a dietitian if you are concerned about your appetite or weight loss. 

Dizziness

You might feel drowsy or dizzy. Don’t drive or operate machinery if you have this.

Sore mouth and ulcers 

Mouth sores and ulcers can be painful. It helps to keep your mouth and teeth clean, drink plenty of fluids and avoid acidic foods such as lemons. Chewing gum can help to keep your mouth moist. Tell your doctor or nurse if you have ulcers.

Diarrhoea or constipation 

Tell your healthcare team if you have diarrhoea or constipation. They can give you medicine to help. 

Tummy (abdominal) pain 

Tell your treatment team if you have this. They can check the cause and give you medicine to help. 

Headaches 

Tell your healthcare team if you keep getting headaches. They can give you painkillers to help.

Skin problems

Skin problems include a skin rash, dry skin and itching. This usually goes back to normal when your treatment finishes. Your healthcare team can tell you what products you can use on your skin to help.

Kidney changes

You may have changes in levels of certain minerals in your blood, which can affect your kidneys. You have regular blood tests during treatment to check this.

Hair loss

You could lose all your hair. This includes your eyelashes, eyebrows, underarms, legs and sometimes pubic hair. Your hair will usually grow back once treatment has finished but it is likely to be softer. It may grow back a different colour or be curlier than before. 

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:

• changes to your blood pressure
• high blood sugar levels
• low levels of calcium in your body
• pain in your chest, muscles, joints, back and neck
• high levels of chemicals in your blood due to the breakdown of cancer cells (tumour lysis syndrome) - you have regular blood tests to check for this
• heart problems such as an abnormal heart rhythm or a heart attack
• difficulty sleeping (insomnia)
• difficulty walking (problems with your gait)
• blurred vision
• eye problems such as inflammation of the eyes (conjunctivitis)
• swelling (oedema) in your arms, legs and face
• restlessness and anxiety
• difficulty swallowing
• indigestion or heartburn
• periods stopping (amenorrhoea)
• hearing changes such as ringing or buzzing in the ear (tinnitus) and ear pain
• swelling in the nasal passages (rhinitis)
• sweating or night sweats
• pain at the site of the tumour
• increase or decrease of levels of certain enzymes and proteins in the blood
• dehydration

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 way your blood clots
• low mood (depression)
• taste changes
• a hole in your stomach or bowel (perforation)
• swollen tummy (abdomen)
• inflammation of the lungs (asthma)
• a severe skin reaction that may start as tender red patches which leads to peeling or blistering of the skin. You might also feel feverish and your eyes may be more sensitive to light. This is serious and could be life threatening
• pain at the site of injection
• a second cancer (acute myeloid leukaemia or myelodysplastic syndrome)
• fluid around the heart (pericardial effusion)
• sleepiness (somnolence) - do not drive or operate machinery if you are drowsy
• problems with your speech
• low oxygen levels in the blood (hypoxia)

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 drinks 

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.

Loss of fertility

You may not be able to become pregnant or get someone pregnant after treatment with these drugs. Talk to your doctor before starting treatment if you think you may want to have a baby in the future.

Men might be able to store sperm before starting treatment. And women might be able to store eggs or ovarian tissue. But these services are not available in every hospital, so you would need to ask your doctor about this.    

Pregnancy and contraception 

This treatment might harm a baby developing in the womb. It is important not to become pregnant or get someone pregnant while you're having treatment and for a few months afterwards.

Talk to your doctor or nurse about effective contraception before starting treatment. Let them know straight away if you or your partner become pregnant while having treatment.

Breastfeeding 

Don’t breastfeed during this treatment. This is because the drugs may come through in your breast milk.

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.