Folinic acid, fluorouracil and oxaliplatin (FOLFOX)

FOLFOX is a combination of chemotherapy drugs used to treat bowel cancer. It is also known as Oxaliplatin de Gramont or OxMdG, which means modified Oxaliplatin de Gramont.

It is made up of:

• folinic acid (also called leucovorin, FA or calcium folinate)
• fluorouracil (5FU)
• oxaliplatin

How does AC work?

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

How you have FOLFOX chemotherapy

You have folinic acid, 5FU and oxaliplatin into your bloodstream. If you have a central line you may be able to have the infusions of 5FU at home.

If you are at home, you have the infusions through a small pump. 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 for the second day of your treatment, to have the pump changed. Or sometimes a chemotherapy nurse may be able to change the infusion at your home.

Into your bloodstream

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

Or you might have treatment through a long line: a central line, a PICC line or a portacath. These are long plastic tubes that give the drug into a large vein in your chest. The tube stays in place throughout the course of treatment.

When you have treatment

You have FOLFOX chemotherapy as cycles of treatment each lasting 2 weeks. Depending on your needs, you may have up to 12 cycles. 

Day 1

Day 2

Day 3 to 14

Then you start the cycle again.

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

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. 

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:

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).

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.

Numbness and tingling (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. 

Feeling sick (nausea)

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.

Pain

You might have pain in your vein when you have your treatment. Tell your nurse straight away if you have any stinging, pain, redness or swelling around the vein. This could be due to the chemotherapy leaking into the tissue around the vein. This damages the tissue and needs quick treatment. 

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.

Sore mouth

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 the mouth moist. Tell your doctor or nurse if you have ulcers.

Allergic reaction to oxaliplatin

A mild or severe allergic reaction to oxaliplatin, mostly happens when you are having it. Tell your nurse or doctor immediately if at any time you feel odd or strange, especially if you have difficulty breathing, a skin rash, chest pain or itchy eyes.

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:

• soreness, redness and peeling on palms and soles of feet
• runny nose
• skin sensitivity to sunlight
• a brown marking on the skin following the vein
• hair thinning
• brittle, chipped and ridged nails
• watery or sore eyes
• blood clots

Rare side effects

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

• difficulty swallowing or breathing
• ringing in your ears (tinnitus)
• heart problems

Coping with side effects

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

What else should I know?

Other medicines, food 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.

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.    

Contraception and pregnancy

This treatment may 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 at least 6 months afterwards.

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

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

DPD deficiency 

Between 2 and 8 out of 100 people (2 to 8%) have low levels of an enzyme called dihydropyrimidine dehydrogenase (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.

Before starting treatment with capecitabine or fluorouracil you have a blood test to check levels of DPD. So you may start treatment with a lower amount (dose) of the drug or have a different treatment. Your doctor or nurse will talk to you about this.

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 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.

This page is due for review. We will update this as soon as possible.