Hematologist
CION Cancer Clinics
Bendamustine-rituximab (BR) in follicular and slow-growing lymphoma | CION Cancer Clinics
Bendamustine-rituximab, or BR, is a common first treatment when follicular lymphoma needs treating. It is usually given as day-care drips on two days in a row, repeated about every four weeks for up to six cycles. Hair loss is uncommon, but immunity stays low for months. This page explains the schedule, the side effects, who it does not suit, and when to seek help urgently. At CION Cancer Clinics, our haematology team plans myeloma and lymphoma care with you, discussed at a tumour board and explained in plain words.
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Medically reviewed by Dr. Basudev PokhrelConsultant Haematologist · last reviewed September 2026, next review due September 2027
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The short answer
What is bendamustine-rituximab, and why is it used?
Bendamustine-rituximab, often written BR, is a common first treatment for follicular lymphoma and other slow-growing lymphomas that need treating. It pairs a chemotherapy drug, bendamustine, with an antibody, rituximab. Most people have it as day-care drips over several months.
How the two drugs work together
Bendamustine damages the DNA of dividing cells so lymphoma cells die. Rituximab sticks to a marker called CD20 on lymphoma cells and helps your immune system clear them. Together they usually shrink the lymphoma more deeply than rituximab alone.
Why it is chosen over other combinations
In trials, BR worked at least as well as R-CHOP for slow-growing lymphoma, with less hair loss, fewer nerve problems and less strain on the heart. That is why many haematologists offer it first. It does lower the immune defences for a long time, which needs planning.
Who it does not suit
BR is usually not chosen for grade 3B follicular lymphoma or lymphoma that has changed into a faster-growing type. Those need treatment planned for faster disease. It may also be unsuitable for people with poorly working kidneys or liver, uncontrolled infections, or serious frailty. Your team will check these first.
The schedule
What does a course of BR look like?
A typical pattern. Your own schedule may differ, and that does not mean it is wrong.
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Tests before starting
Blood counts, kidney and liver tests, and a hepatitis B test, because rituximab can wake up a hidden infection. Your team also reviews vaccines and any history of tuberculosis or shingles.
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Day one of each cycle
Rituximab and bendamustine are given as drips. The first rituximab drip is given slowly because reactions such as chills or fever are common that day. Later drips are usually quicker.
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Day two
You come back for a second bendamustine drip. Most people go home the same day on both days.
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Recovery weeks
The rest of the cycle lets your blood counts recover. Blood tests are checked before the next cycle, which may be delayed if counts are still low.
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End of the course
Cycles usually repeat about every four weeks, for up to six cycles. A scan then checks the response, and your team discusses whether maintenance rituximab should follow.
Not sure whether this applies to you?
Ask an oncologistWhat to expect
What side effects are common with BR?
Not everyone has all of these. Tell your team early, because most are easier to manage when caught soon.
Low blood counts
White cells, platelets and haemoglobin can drop between cycles. This raises the risk of infection, bruising and tiredness.
Watch for
- Fever or shivering
- Unusual bruising or bleeding
Drip reactions
Mostly with the first rituximab drip: chills, fever, rash, itching or breathlessness. Nurses slow or pause the drip and treat it.
Tiredness, sickness and skin
Tiredness builds through the course. Feeling sick is usually well controlled with medicines. Some people get a skin rash, which should be reported.
Long-lasting low immunity
Bendamustine lowers a type of white cell called CD4 cells for many months after treatment. This raises the chance of shingles and some chest infections.
Your team may prescribe preventive medicines. Take them exactly as advised.
!
One thing that cannot wait
A fever, shivering, or feeling suddenly very unwell during or after BR can mean a serious infection. Call your treating team straight away. If you cannot reach them, go to the nearest emergency department or call 108, and say the person is on chemotherapy. Do not wait for the morning, and do not wait at home to see whether it settles.
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On your treatment card
What do the words on your chart mean?
- Cycle
- One round of drips followed by rest weeks for your counts to recover.
- ANC or neutrophils
- The white cells that fight bacteria. A low count raises the risk of infection. Laboratory ranges differ, so your team reads the result.
- CD4 count
- A type of white cell that stays low for months after bendamustine.
- Irradiated blood
- Blood treated so its white cells cannot harm you. You may need it for any future transfusion. Carry the card your team gives you.
- Biosimilar
- A close copy of the original rituximab, tested to work the same way.
Commonly believed
What do families often get wrong about BR?
"No hair loss means it is a weak treatment."
Hair loss does not measure how well a treatment works. BR usually causes only mild thinning and still works strongly against slow-growing lymphoma.
"Once the course ends, the immune system is back to normal."
Immunity can stay low for many months. Keep reporting fevers, rashes that blister, or a cough that will not settle, even long after the last drip.
"We can skip a cycle if he feels tired."
Never skip or delay a cycle on your own. Tell the team how tired he feels. They may adjust the timing safely, but that decision belongs with them.
"Village tonics will build the blood back faster."
Herbal products can affect the liver, kidneys or blood counts and make results harder to read. Show your team anything you want to take before taking it.
Being straight with you
What can this page not tell you?
It cannot tell you whether BR is the right choice for you, how you personally will cope with it, or how long it will keep the lymphoma away. Those depend on your lymphoma, your health and how you respond.
Questions to ask your haematologist
Why BR rather than rituximab alone or another combination? How many cycles do you expect? Will I need preventive medicines, irradiated blood or vaccines? Who do I call at night with a fever? Will maintenance rituximab follow?
How care is organised at CION
The haematology team reviews your biopsy, scans and blood tests, discusses the case at a tumour board, and explains the plan to you and your family before the first cycle. Coverage under Aarogyasri, PM-JAY, CGHS, ECHS, EHS or cashless insurance depends on your scheme, and the rules change, so check the current rules.
Questions we are asked
Common questions about bendamustine-rituximab
Will I lose my hair on BR?
Most people do not lose their hair. Some notice mild thinning, which grows back after treatment. This is one reason many families find BR easier than R-CHOP. If hair loss matters a lot to you, mention it when the options are being discussed.
Can I work during BR?
Many people keep working, with the two drip days off and a lighter week afterwards. Tiredness often builds as the course goes on. Avoid crowded places when counts are low, and talk to your team if your job involves close contact with sick people.
Why do I need irradiated blood?
After bendamustine, white cells in donated blood could attack your body because your own defences are low. Irradiated blood prevents this. If you ever need a transfusion, even years later at another hospital, show the card and ask for irradiated blood.
Can I take vaccines during treatment?
Live vaccines are usually avoided during and for a long time after BR. Some other vaccines may be advised, though they may work less well. Always ask your haematologist before any vaccine, including for travel.
Is BR used for lymphomas other than follicular?
Yes. It is also used for some marginal zone lymphomas, Waldenstrom macroglobulinaemia, mantle cell lymphoma and chronic lymphocytic leukaemia in certain situations. The number of cycles and what follows may differ. Ask how the plan applies to your exact diagnosis.
What happens after the last cycle?
A scan checks how much the lymphoma has shrunk. Your team then discusses whether maintenance rituximab should follow or whether regular check-ups are enough. Keep reporting fevers, rashes and infections, because immunity stays low for a while.
Can BR be used again if the lymphoma returns?
Sometimes, especially if the lymphoma stayed away for a long time. If it returned soon after BR, a different treatment is more likely. Your team will look at how long the response lasted and your health at that point.
Does BR affect fertility?
It may. If you might want children in future, ask about fertility before the first cycle, because options such as storing sperm or eggs need to happen before treatment. Contraception is also needed during treatment, as the drugs can harm a developing baby.
Your Haematologist
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Dr. Basudev Pokhrel reviews blood counts, transfusion needs and blood disorders, and works with the CION tumour board on blood cancers.
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Sources
- National Cancer Institute — Bendamustine Hydrochloride
- Cancer Research UK — Follicular lymphoma
- National Cancer Institute — Rituximab
- American Cancer Society — Non-Hodgkin Lymphoma
This page is general information, not a prescription. Do not change or stop any treatment based on what you read here. If anything is worrying you, contact your own treating team — or call our helpline and we will help you reach the right specialist.
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Been offered BR and have questions?
Tell us what has been found so far. Our haematology team will go through the plan with you and help you reach the right specialist.