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FOLFIRINOX

FOLFIRINOX is the name of a combination of cancer drugs.

What is FOLFIRINOX?

FOLFIRINOX is a combination of drugs, including:

  • FOL – folinic acid (also called leucovorin, calcium folinate or FA)
  • F – fluorouracil (also called 5FU)
  • Irin – irinotecan
  • Ox – oxaliplatin

It is a treatment for advanced pancreatic cancer.

How does FOLFIRINOX work?

These cancer drugs destroy quickly dividing cells, such as cancer cells.

How do you have FOLFIRINOX?

You have all drugs as a drip 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

Pumps

You might be able to have the infusion of 5FU at home through a small pump (if you have a central line Open a glossary item). You can keep the pump in a small bag, or a bag on a belt (like a bum bag). You’ll need to go back to the hospital after the second day of treatment, to have the pump disconnected. Or sometimes a chemotherapy nurse may be able to do this at your home.

How often do you have FOLFIRINOX?

You usually have FOLFIRINOX chemotherapy as cycles of treatment Open a glossary item. This means you have the drugs and then a rest to allow your body to recover.

Each cycle of treatment lasts 2 weeks. Depending on your needs, you may have up to 12 cycles, taking 6 months in total.

You have each cycle of treatment in the following way:

Day 1
  • You have oxaliplatin as a drip into your vein over 2 hours.
  • You have folinic acid as a drip into your vein over 2 hours at the same time you have oxaliplatin.
  • You have irinotecan as a drip into your vein for 60 to 90 minutes.
  • You have fluorouracil as a injection into your vein for 5 minutes (you might not have this, it depends on your individual situation).
  • You start fluorouracil as an infusion over 46 hours given by a small portable pump.
Day 2
  • You continue to have fluorouracil as an infusion given by a small portable pump.
Day 3 to 14
  • You have no 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 FOLFIRINOX?

We haven't listed all the side effects. It's very unlikely that you will have all of these side effects, but you might have some of them at the same time.

How often and how severe the side effects are can vary from person to person. They also depend on what other treatments you're having. For example, your side effects could be worse if you're also having other drugs or radiotherapy.

When to contact your team

Your doctor, nurse or pharmacist will go through the possible side effects. They will monitor you closely 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. 

Contact your doctor or nurse immediately if you have signs of infection, including a temperature above 37.5C or below 36C.

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:

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. 

Breathlessness 

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).

Allergic reaction

A reaction may happen during the infusion, causing 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. Tell your nurse or doctor immediately if at any time you feel unwell. They will slow or stop your drip for a while

You might have difficulty swallowing or breathing that can be triggered by cold (such as cold air). This can start during the drip or up to a few hours after the infusion.

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.

Feeling or being sick

Feeling or being sick is usually well controlled with anti sickness medicines. Avoiding fatty or fried foods, eating small meals and snacks, drinking plenty of water, and relaxation techniques can all 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 treating it once it has started.

Loss of appetite

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

Diarrhoea

Contact your advice line if you have diarrhoea, such as if you've had 4 or more loose watery poos (stools) in 24 hours. Or if you can't drink to replace the lost fluid. Or if it carries on for more than 3 days.

Your doctor may give you anti diarrhoea medicine to take home with you after treatment. Eat less fibre, avoid raw fruits, fruit juice, cereals and vegetables, and drink plenty to replace the fluid lost.

Acute cholinergic syndrome

Irinotecan can cause some people to develop a set of side effects during or within the first 24 hours after having the drug. These side effects include diarrhoea (which may be severe), sweating, stomach cramps, increased production of saliva, and watery eyes. You may have an injection of atropine before the irinotecan to reduce these side effects.

Diarrhoea can be severe. Contact your treatment centre straight away if you have diarrhoea within 24 hours of having irinotecan. You’ll need to have treatment.

Hair loss

You could lose all your hair. This includes your eyelashes, eyebrows, underarm, leg 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. 

Headaches

Tell your doctor or nurse if you keep getting headaches. They can give you painkillers to help.

Mouth sores and ulcers 

Mouth sores and ulcers can be painful. Keep your mouth and teeth clean; drink plenty of fluids; avoid acidic foods such as oranges, lemons and grapefruits; chew gum to keep the mouth moist and tell your doctor or nurse if you have ulcers.

You might also have inflammation of the food pipe (oesophagus) making it difficult and sore to swallow. Or inflammation and soreness of the back passage (anus).

Liver changes 

You might have liver changes that are usually mild and unlikely to cause symptoms. They usually go back to normal when treatment finishes. You have regular blood tests to check for any changes in the way your liver is working.

Skin problems

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

Eye changes 

You might have eye problems including blurred vision, sore, red, itchy, dry eyes (conjunctivitis) or an infection. Tell your doctor or nurse if you have this. They can give you eye drops or other medication to help. 

Less commonly you might have more tears than usual.

Soreness, redness and peeling on palms or soles of the feet 

The skin on your hands and feet may become sore, red, or may peel. You may also have tingling, numbness, pain and dryness. This is called hand-foot syndrome or palmar plantar syndrome.

Moisturise your skin regularly. Your doctor or nurse will tell you what moisturiser to use.

Numbness or tingling in the fingers and 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. 

Tummy (abdominal) pain

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

Heart problems 

Heart problems include changes to how your heart works. This can cause changes to your heart rhythm and your ankles can swell.

Tell your doctor or nurse straight away if you have any chest pain. Your doctor might ask you to have tests to check your heart, such as an electrocardiogram (ECG).

Raised uric acid levels in the blood

High levels of uric acid in your blood can lead to a build up of crystals in body tissues and cause inflamed joints. You’ll have regular blood tests to check your levels. Drinking plenty of fluids helps to flush out the excess uric acid. You might also have medicines to control the uric acid levels.

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 doctor or nurse if you are constipated for more than 3 days. They can prescribe a laxative.

Occasional side effects

These side effects happen in between 1 and 10 out of every 100 people (between 1 and10%). You might have one or more of them. They include:

  • blood clots - 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 symptom
  • brittle, chipped and ridged nails
  • low levels of fluid in the body (dehydration)
  • low mood (depression)
  • difficulty sleeping (insomnia)
  • kidney changes - you will have regular blood tests to check for this
  • indigestion and reflux
  • bleeding in your digestive system causing blood or from the back passage (rectum) causing blood in the poo
  • dizziness
  • high blood pressure
  • difficulty or pain on passing urine, or blood in your urine

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:

  • hearing loss
  • changes to handwriting, hands and or fingers shaking, slow movement, stiff legs and or arms, voice changes, stooping, rigid facial expression (symptoms similar to Parkinson's disease)
  • sleepiness
  • feeling nervous
  • skin sensitivity to sunlight

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.

DPD deficiency 

Between 2 and 8 out of 100 people (2 to 8%) have low levels of an enzyme called DPD in their bodies. A lack of DPD can mean you’re more likely to have severe side effects from capecitabine or fluorouracil. It might take you a bit longer to recover from the chemotherapy. These side effects can rarely be life threatening.

Low DPD levels don’t cause symptoms so you won’t know if you have a deficiency. You should have a test before you start this treatment to check if you have a DPD deficiency. 

Some people have severe side effects from capecitabine or fluorouracil even if they don't have low DPD levels. Contact your doctor or nurse if your side effects are severe.

Sodium

Talk to your team if you are on a low sodium diet

Loss of fertility 

You may not be able to become pregnant or father a child 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 may harm a baby developing in the womb. It is important not to become pregnant or father a child while you are having treatment and for at least 6 months afterwards. Talk to your doctor or nurse about effective contraception before starting treatment.

Breastfeeding

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

Treatment for other conditions

Always tell other doctors, nurses, pharmacists or dentists that you’re having this treatment if you need treatment for anything else, including teeth problems.

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 the shingles vaccine (Zostavax).

You can:

  • have other vaccines, but they might not give you as much protection as usual
  • have the flu vaccine (as an injection)

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.

If your immune system is severely weakened, you should avoid contact with children who have had the flu vaccine as a nasal spray. 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 go to the electronic Medicines Compendium (eMC) website.

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