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Care During Chemotherapy and Beyond

Flu-like Syndrome

What Is Flu-Like Syndrome?

Other terms: flu, fever and chills

Flu-like syndrome is a side effect of many treatments used in cancer care. The exact process of how flu-like syndrome is caused is not fully understood. However, when the body is exposed to certain medications it is believed that these medications trigger normal inflammatory mechanisms of the immune system. This process is similar to the body's response when it is dealing with a "flu" virus.

Symptoms of Flu-Like Syndrome:

  • Fever (sudden onset, timing associated with the therapy causing the flu-like syndrome).
  • Chills (often come before the fever, usually involve upper body first).
  • Muscle/joint aches (myalgias/arthralgias), (generalized aches and pains, accompanied by sensation of weakness, may or may not be relieved by rest).
  • Headache (usually across forehead, accompanied by sensitivity to light, may include visual disturbances for example, blurring).
  • Poor appetite.
  • Nausea, vomiting
  • Diarrhea
  • Nasal stuffiness (runny nose usually clear, watery and persistent).
  • Cough (dry, hacking, and persistent, rarely productive).
  • Bone pain.
  • Fatigue (malaise) (accompanied by sense of apathy, lack of energy or motivation).

Cancer Therapies Associated with Flue-Like Syndrome:

  • Biologic therapies such as:
    • Interleukin-2, Interferons
    • Colony-stimulating factors (GM-CSF)
    • Monoclonal antibodies
  • Chemotherapy medications associated with flu-like syndrome:
    • bleomycin, cladribine, cytarabine, dacarbazine, fluorouracil, l-asparaginase, procarbazine, and trimetrexate.

With some of the medications the flu-like syndrome is dose related and not all of the symptoms of flu are present with each of the medications mentioned. The time frame for the flu-like syndrome also varies, as well as the severity of the flu-like symptoms. Another aspect to these symptoms of flu is they may be more severe at first but as the body "gets used" to the medication the experience of fever and chills, for example, will be less severe with subsequent doses. Symptoms may reappear or worsen if treatment is interrupted and then resumed or if the dose is increased. Flu-like symptoms resolve once treatment is stopped completely.

Management of Flu-Like Syndrome:

Things you can do for symptoms of flu:

General:

Ask your health care professional to explain the medications you will be taking to treat your cancer. Specifically, ask what type of side effects you can expect and what will be done to prevent or control the side effects.

Fever:

Things you can do for fever:

  • Take a lukewarm (tepid) bath if flu-like syndrome causes a fever. Also, you can use cold or ice packs on your body for comfort. Some patients find it comforting to have a cool, moist wash cloth on their foreheads or on the back of their necks.
  • When you have a fever, you lose water and can become dehydrated. Therefore, it is important to drink lots of (non-alcoholic and non-caffeinated) fluid during these times.
  • Take medication to control symptoms of fever as recommended.

Drugs that may be prescribed by your doctor for fever:

  • Anti-pyretic (anti-fever) medications such as acetaminophen (Tylenol®) are used to treat fever related to flu-like syndrome. This may be prescribed to be taken around the clock, or prior to when expected fever may occur. Do not take more than the recommended amount of acetaminophen in a 24 hour time frame. No more than 4 grams (gm) of acetaminophen should be taken. Higher doses may lead to toxicity to the liver. Check the bottle for the milligram dose (mg) of each pill, 1000mg = 1 gram. If you are taking medications that have acetaminophen as one of the ingredients, this needs to be taken into account of the total dose for the day. For example: Percocet® and Darvocet® each contain 325mg of acetaminophen per pill. It is important to review all of the medications you are taking with your health care professional.
  • If you have a bleeding disorder, you should avoid non-steroidal anti-inflammatory (NSAID) drugs, as well as aspirin, because these drugs may interfere with blood platelets, and prolong bleeding. Use of such drugs to treat fever symptoms should be discussed first with your healthcare professional.

Chills:

Things you can do for chills:

  • In contrast, if flu-like syndrome causes the chills, you should put on some warm clothes, blankets or take a warm bath. If you like to use hot packs or heating pads, use caution to avoid burning your skin.
Drugs that may be prescribed by your doctor for chills:
  • A narcotic may be prescribed such as meperidine or hydromorphone, to stop severe chills that may occur with some drugs.

Muscle and/or Joint Aches:

Things you can do for muscle and/or joint aches:

  • Some patients find the application of heat or cold to the joints and muscles helps in relieving some of the discomfort.
  • Rest when you feel achy and tired, however, there should be a balance between rest and exercise. Some exercise can actually boost your energy levels. Ask your doctor if exercise is right for you during flu-like syndrome.
  • Relaxation techniques.

Drugs that may be recommended by your doctor for muscle and/or joint aches:

  • Analgesics (pain medication) such as acetaminophen. Do not take more than the recommended amount of acetaminophen in a 24 hour time frame. No more than 4 grams (gm) of acetaminophen should be taken. Higher doses may lead to toxicity to the liver. Check the bottle for the milligram dose (mg) of each pill, 1000mg = 1gram. If you are taking medications that have acetaminophen as one of the ingredients, this needs to be taken into account of the total dose for the day. For example: Percocet® and Darvocet® each contain 325mg of acetaminophen per pill. It is important to review all of the medications you are taking with your health care professional.
  • If you have a bleeding disorder, you should avoid non-steroidal anti-inflammatory (NSAID) drugs, as well as aspirin, because these drugs may interfere with blood platelets, and prolong bleeding. Use of such drugs to treat headache should be discussed first with your healthcare professional.

Headache:

Things you can do for headache:

  • Rest in a quiet, dimly lit room. Perhaps, relaxing music would help soothe your headache.
  • Cool cloth on the forehead.
  • Headaches that may be due to sinus congestion may be helped by warmth and steam.
  • Headaches originating in the back of the head or neck may be related to muscle tension - heat and/or massage may help.

Drugs that may be recommended by your doctor for headache:

  • Analgesics (pain medication) such as acetaminophen. Do not take more than the recommended amount of acetaminophen in a 24 hour time frame. No more than 4 grams (gm) of acetaminophen should be taken. Higher doses may lead to toxicity to the liver. Check the bottle for the milligram dose (mg) of each pill, 1000mg = 1gram. If you are taking medications that have acetaminophen as one of the ingredients, this needs to be taken into account of the total dose for the day. For example: Percocet® and Darvocet® each contain 325mg of acetaminophen per pill. It is important to review all of the medications you are taking with your health care professional.
  • If you have a bleeding disorder, you should avoid non-steroidal anti-inflammatory (NSAID) drugs, as well as aspirin, because these drugs may interfere with blood platelets, and prolong bleeding. Use of such drugs to treat headache associated with flu-like syndrome should be discussed first with your healthcare professional.

Poor Appetite

Things you can do for poor appetite: Food preparation:

  • Try to eat small meals or snacks, every two to three hours, instead of three large meals a day (become a grazer). Don't expect to eat regular size meals when you suffer from flu-like syndrome.
  • Foods that are high in protein or calories are good snacks to have handy. Examples include; milk shakes, cheese, fruits, peanut butter, nuts, crackers and juices.
  • Eat foods that are rich in calories and nutrients. Avoid low-calorie foods that fill you up, such as lettuce, broth and diet soda.
  • When choosing beverages, select nutrient-dense fluids such as milk, milk shakes, juice and punch-type drinks.
  • Avoid heavy meals, greasy/fried foods, and foods that cause gas. Examples of gas-producing foods include: beans, cauliflower, broccoli, cabbage, and carbonated drinks.
  • Prepare food that is colorful and appealing to the eye.

Surroundings:

  • Try to eat with friends or family. Make eating a social event. Often times, people will eat more when they are socializing.
  • Try changing the time, place, and surroundings of meals. Watch your favorite TV program while you eat.
  • Use a plate that is larger than needed and put small portions on the plate. That way the amount of food that you need to eat does not look so overwhelming.
  • Avoid smells that are obnoxious or bothersome to you while you are eating.

Taste changes:

  • If you are not eating much during flu-like syndrome because you have lost your sense of taste from chemotherapy, you may want to try adding different seasonings to your foods.
  • If you have a bad taste in your mouth, try sucking on hard candies/mints or chewing gum. Also, keep your mouth clean by brushing at least two times per day and rinsing your mouth out with water between meals/snacks.

Dry mouth:

  • If you aren't eating much because flu-like symptoms cause your mouth to be dry, try increasing your non-alcoholic fluid intake to at least two liters per day; just make sure it is okay with your doctor to drink this much fluid. Also limit the amount of food you drink with meals. Liquids make you feel full. Save the liquids for between meals.
  • Avoid toothpaste and mouthwashes that contain alcohol as this can cause further drying of your mouth. To stimulate saliva, or to make your mouth moist, try sucking on ice cubes, candies, or gum.

Mouth sores:

  • If you are not eating because your flu-like symptoms include having sores in your mouth, use a soft bristle toothbrush. You can also rinse your mouth with a mixture of 1/2 to 1 teaspoon of baking soda or 1/2 to 1 teaspoon of salt in 8 ounces of water about four or five times a day. Check with your doctor if it is okay to use acetaminophen (Tylenol®) or ibuprofen for the discomfort.

Exercise:

  • After getting approval from your doctor, try to do some daily, mild exercise during flu-like symptoms. Sometimes some daily activity, like twenty minutes of walking or yoga, will help stimulate your appetite, relieve stress, improve your mood, and help you sleep better at night.

Drugs that may be prescribed by your doctor to increase your appetite during flu-like symptoms:
*Note: These drugs are not usually prescribed for temporary or short-term appetite problems, and may not be appropriate in combination with certain treatment protocols.

  • Megestrol acetate (Megace®) comes in a pill and liquid form.
  • Metoclopramide (Reglan®) comes in tablets (pill) and in liquid form.
  • Dronabinol (Marinol®) comes in a capsule (pill) form.
  • Steroids like prednisone or dexamethasone (Decadron®) can increase your appetite and sense of well-being. These also come in tablets and liquid form.
  • Alcohol, one glass of wine or beer, can help stimulate your appetite and add some calories to your meal.

Nausea and Vomiting:

Things you can do for nausea and vomiting:

Eating hints:

  • Eat small amounts of food throughout the day.
  • Eat before you get too hungry.
  • Eat dry foods such as dry cereal, toast, or crackers without liquids especially first thing in the morning.
  • Avoid heavy, high fat and greasy meals right before chemotherapy.
  • Do not eat your favorite foods during flu-like syndrome. They will no longer be favorite foods if you begin to associate them with nausea and vomiting episodes.

Surroundings:

  • Avoid strong odors.
  • Don't lay flat for at least two hours after eating. Rest by sitting up or reclining with your head elevated.
  • Fresh air and loose clothing may be helpful after eating.
  • Exercising after eating may slow down digestion and increase discomfort.

Distraction:

  • Relax and try to keep your mind off the chemotherapy when flu-like symptoms are present. Bring soothing music, relaxation tapes, or CDs, with you to chemo. Perhaps you would like to bring a funny movie to watch during chemotherapy and/or a friend or family member to keep you company.

Other:

  • If you are vomiting due to flu-like symptoms, stop eating. Once you stop vomiting, start back on food slowly. Start with small amounts of clear liquids, such as broth, juice soda, sports drinks, or water. Then, advance to light, mild foods like jello, bananas, rice, or toast. Soon, you will be back to solid foods.
  • Avoid caffeine and smoking.
  • Suck on hard candy, popsicles, or ice during chemotherapy.
  • Take the medications for nausea and vomiting as prescribed by your doctor for flu-like symptoms. If you are running low, ask for a refill.
  • Notify your nurse or doctor if you feel nauseated during chemotherapy.

Drugs that may be prescribed by your doctor for nausea and vomiting:
*Note: Your doctor may not prescribe any anti-nausea drugs because not all chemotherapy causes nausea and vomiting. However, if the chemotherapy is likely to cause nausea and vomiting, your doctor may prescribe one or more of the following common anti-nausea medications:

  • dolasetron (Anzemet®) 
  • granisetron (Kytril®) 
  • ondansetron (Zofran®) 
  • proclorperazine (Compazine®)
  • promethazine (Phenergan® , Anergan®)
  • lorazepam (Ativan®)
  • metoclopramide (Reglan®)
  • dexamethasone (Decadron®)

These can be prescribed for you to take before, during, and/or after chemotherapy. As you can see there are many different medications that your doctor can prescribe to control these symptoms of flu. It may take trying a couple different medications before finding the right match for your flu-like syndrome.

Diarrhea:

Things you can do for diarrhea:

Dietary:

  • Drink plenty of clear fluids (8-10 glasses per day). Examples: Gatorade, broth, jello, water, etc.
  • Eat small amounts of soft bland low fiber foods frequently. Examples: banana, rice, noodles, white bread, skinned chicken, turkey or mild white fish.
  • Avoid foods such as:
    • Greasy, fatty, or fried foods.
    • Raw vegetables or fruits.
    • Strong spices.
    • Whole grains breads and cereals, nuts, and popcorn.
    • Gas forming foods & beverages (beans, cabbage, carbonated beverages).
    • Lactose-containing products, supplements, or alcohol.
    • Limit foods and beverages with caffeine and beverages extremely hot or cold.

Medication: (Available over-the-counter - please read label and check with your health care professional to make sure you can take this medication with your flu-like symptoms):

  • Loperamide (Imodium®) 
  • Kaopectate II caplets
  • Maalox® anti-diarrheal caplets
  • Pepto Diarrhea Control® (follow instructions on container)
  • Avoid: herbal supplements (milk thistle, cayenne, ginseng, saw palmetto, and others).

Skin Care:

  • Clean skin around anus gently with warm water and soft cloth then dry gently and completely.
  • May apply a barrier cream (such as Desitin®) to irritated skin.
  • Allow the irritated skin to be exposed to open air as much as possible.

Drugs that may be prescribed by your doctor for diarrhea:
(These drugs are available only by prescription):

  • Diphenoxylate - atropine sulfate (Lomotil®)
  • Tincture of opium

Runny Nose:

Things you can do for runny nose:

  • Use a vaporizer or a humidifier to moisten the air. Avoid dry air. This will help liquefy your mucus secretions when you are congested. Although you may have a runny nose due to flu-like syndrome, it is important that these secretions continue to drain, to prevent overgrowth of bacteria in your sinuses from congestion.
  • Drink 2 to 3 liters of fluid every 24 hours, unless you were told to restrict your fluid intake, and maintain good nutrition. Keeping well hydrated will prevent congestion, and also liquefy your secretions.

Drugs that may be prescribed by your doctor for runny nose:

  • Treatment of a runny nose during flu-like syndrome may include antibiotic therapy if an infection is present, decongestants, humidified air (such as a vaporizer or a steamy shower), and drinking lots of fluids.
  • Antihistamines: If you have a flu-like symptoms such as a runny nose, sneezing, watery eyes and itching, antihistamines may help to decrease your symptoms.
    • Non-prescription antihistamines include most commonly Diphenhydramine (Benadryl ®), and Chlorpheniramine (Chlor-Trimeton ®). However, these drugs may leave you drowsy, and with a dry mouth.
    • Newer prescription antihistamines without side effects of dry mouth, drowsiness or sedation, include Loratadine (Claritin ®), and Fexofenadine (Allegra ®). You can take one of these pills daily, every other day, or whenever you have these flu-like symptoms. These medications may be prescribed alone, or in combination with a decongestant (such as Loratadine/Pseudoephedrine -D ®)
  • Corticosteroids: Corticosteroids (steroids) work locally to decrease nasal irritation and inflammation, if given in the form of a nasal spray (topical). This is good, because you don't have to worry about bad long-term side effects of steroids from a short-term, local use. Only a small amount is distributed through your body. Common topical nasal steroids include Budesonide (Rhinocort ®), and Fluticasone propionate (Flonase ®).
  • Decongestants: May be helpful in a pill form, or as a nasal spray (topical), to relieve a blockage, or symptoms of a runny nose.&
    • The most commonly prescribed pill to treat congestion is Pseudoephedrine (Sudafed®).
    • A commonly used nasal spray decongestant is Azelastine (Astelin®).
    • Antihistamines, in combination with a decongestant, work well in some people, as the decongestant will enhance the effectiveness of the antihistamine. Be careful using decongestants, though, if you have a history of high blood pressure. Discuss this with your healthcare provider.

Cough:

Things you can do for cough:

  • Describe your cough the best you can to your doctor. Think about what kinds of things/activities aggravate or relieve your cough. Think about how long you have had your cough. Do you cough out mucous or blood with it? Do you have a fever? Have you been losing weight suddenly without explanation? Do you get short of breath?
  • Quit smoking and avoid environmental/occupational exposure to irritants.
  • You may try using a humidifier to keep your throat and nasal passages moist if you have a chronic, persistent dry cough.

Drugs that may be prescribed/recommended by your doctor for cough:

  • Antitussive: (cough suppressant). Benzonatate, codeine, and dextromethorphan are generic ingredients of various cough preparations.
  • Expectorant: (aides in coughing up phlegm or mucous). Guaifenesin - a generic ingredient of various cough preparations.
  • Decongestant / Alpha/Beta agonist: (acts on certain receptors of the lining of the lungs and airways causing constriction, and relaxation thus relieving congestion). Pseudoephedrine - a generic ingredient of various cough preparations.
  • Antihistamines: (competes with histamine for receptor sites on cells in the lining of the gastrointestinal tract, blood vessels, and nose, lung and airways, this helps to decrease flu-like symptoms of excessive secretions (ie. runny nose) particularly related to allergies). Brompheniramine, cetirizine, chlorpheniramine, diphenhydramine, fexofenadine, loratadine are generic ingredients of various cough preparations.

Fatigue (Malaise):

(For additional information, see symptom management - fatigue.)

Things you can do for fatigue:

  • Think of your personal energy stores as a "bank." Deposits and withdrawals have to be made over the course of the day or the week to ensure a balance between energy conservation, restoration and expenditure.
  • Keep a diary for one week to identify the time of day when you are either most fatigued or have the most energy. Note what you think may be contributing factors.
  • Be alert to the warning signs of impending fatigue - tired eyes, tired legs, whole-body tiredness, stiff shoulders, decreased energy or a lack of energy, inability to concentrate, weakness or malaise, boredom or lack of motivation, sleepiness, increased irritability, nervousness, anxiety or impatience.

Energy conservation:

  • Plan ahead and organize your work.
  • Schedule rest
  • Pace yourself
  • Practice proper body mechanics
  • Limit overhead work
  • Limit isometric work
  • Identify effects of your environment
  • Prioritize

Nutrition:

  • Fatigue is often made worse if you are not eating enough due to flu-like symptoms or if you are not eating the right foods. Maintaining good nutrition can help you feel better and have more overall energy.
  • Increase fluid intake.
  • Supplemental vitamins (A recommended supplement would be a multivitamin that provides at least 100% of the recommended daily allowances (RDA) for most nutrients.)
  • Vitamin supplements do not provide calories, which are essential for energy production. So vitamins cannot substitute for adequate food intake.

Exercise:

  • Decreased physical activity, which may be the result of flu-like syndrome or of treatment, can lead to tiredness and lack of energy. Scientists have found that even healthy athletes forced to spend extended periods in bed or sitting in chairs develop feelings of anxiety, depression, weakness, fatigue, and nausea. Regular moderate exercise can prevent these feelings, and help a person feel energetic and stay active. Even during cancer therapy, it is often possible to continue exercise.

What is the right kind of exercise?

  • A good exercise plan starts slowly, allowing your body time to adjust.
  • It is important that you do something to exercise the whole body on a regular basis. Regular means every day, or, at least every other day.
  • The right kind of exercise never makes you feel sore, stiff, or exhausted.
  • Any kind of exercise is O.K. Walking, stationary bike, or swimming (if the immune system is O.K.) are examples of types of exercise.

What is the wrong kind of exercise?

  • Even more dangerous than doing no exercise is exercising only occasionally and doing too much, too fast.
  • If you experience soreness, stiffness, exhaustion, or feel out of breath as a result of your exercise, you are overdoing it.

Stress Management:

  • Managing stress can play an important role in combating fatigue from flu-like syndrome. The following are suggestions:
    • Adjust your expectations. For example, if you have a list of ten things you want to accomplish today, pare it down to two and leave the rest for other days. A sense of accomplishment goes a long way to reducing stress.
    • Help others to understand and support you. Family and friends can be helpful if they can "put themselves in your shoes" and understand what fatigue means to you. Cancer support groups can be a source of support as well. Other people with cancer truly understand what you are going through.
    • Relaxation techniques such as audio tapes that teach deep breathing or visualization can help reduce stress.
    • Activities that divert your attention away from flu-like symptoms of fatigue can also be helpful. For example, activities such as knitting, reading, or listening to music require little physical energy bur require attention.
    • If your stress seems out of control, talk to a health care professional. They are here to help.
Talk to your health care professionals

Drugs that may be prescribed by your doctor for fatigue:

  • There is no single medication available to treat fatigue. However, there are medications available that can treat some of the underlying causes. Make sure you speak with your health care professional if you are feeling fatigued.

When to Contact Your Doctor or Health Care Provider:

Keep in mind flu-like symptoms, especially fevers, may represent a serious infection, therefore it is important to seek medical attention if:
  • You have a fever greater than 38.5° that is new and not associated with the expected fever related to your medication.
  • You develop flu-like symptoms that are unusual, unexpected or bothersome.
  • Nausea (interferes with ability to eat and unrelieved with prescribed medication).
  • Vomiting (vomiting more than 4-5 times in a 24 hour period).
  • Fatigue that limits your ability to care for yourself.
  • Increasing shortness of breath with minimal exertion.
  • Unable to eat or drink for 24 hours or have signs of dehydration: tiredness, thirst, dry mouth, dark and decrease amount of urine, or dizziness.
  • Diarrhea (4-6 episodes in a 24-hour period).
  • Pain not relieved by comfort measures, prescribed analgesics (pain medications).
  • Uncontrollable anxiety or nervousness.
  • Ongoing depression.

Always inform your health care provider if you experience any unusual symptoms during flu-like syndrome or you have questions or are having difficulty with side effects.

Note: We strongly encourage you to talk with your health care professional about your specific medical condition and treatments. The information contained in this website about flu-like syndrome and other medical conditions is meant to be helpful and educational, but is not a substitute for medical advice.

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