Irinotecan with fluorouracil (5FU) and folinic acid
This information is about a chemotherapy treatment for bowel cancer using irinotecan with fluorouracil and folinic acid.
You will see your hospital doctor regularly while you have this treatment so they can monitor the effects of the chemotherapy.
The drugs that are used
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This treatment involves the chemotherapy drugs irinotecan and fluorouracil (also known as 5FU), and a drug called folinic acid (also known as leucovorin). Folinic acid makes 5FU more effective. Throughout this fact sheet we will refer to fluorouracil by its more common name, 5FU.
5FU and folinic acid are commonly given together to treat bowel cancer. When irinotecan is given with fluoruracil and folinic acid, the regimen is sometimes known as FOLFIRI (FOL-folinic acid, F-fluorouracil, IRI-irinotecan).
How treatment is given
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Irinotecan with 5FU and folinic acid treatment can usually be given to you during a short stay in hospital or as a day patient. Before you start treatment you will need to have a blood test either on the same day or a few days beforehand.
You will also be seen by a doctor, specialist nurse or pharmacist. If the results of your blood test are normal, the pharmacy will prepare your chemotherapy drugs. All of this may take a couple of hours.
The nurse will put a thin, flexible tube (cannula) into a vein in your hand or arm. You may find this uncomfortable or a little painful, but it shouldn't take long. Some people have their chemotherapy given through a thin, plastic tube that is inserted under the skin into a vein near their collarbone (central line) or passed through a vein in the crook of their arm (PICC line). A central or PICC line will almost certainly be needed for people having treatment as outpatients. Your doctor or nurse will explain more about this to you.
You will be given an anti-sickness (anti-emetic) drug. This will usually be given by injection through the cannula or your central or PICC line, but some anti-sickness drugs can be taken as tablets.
The chemotherapy drugs are then given separately:
Irinotecan (a clear, slightly yellow fluid) and folinic acid (a clear, pale yellow fluid) are given as drips (infusions).
5FU (a colourless fluid) is given as an injection into your cannula or central line.
After this, you will be given an infusion of 5FU. The infusion lasts 20-46 hours depending on which schedule you are having. This means that you will need to stay in hospital unless you have a central or PICC line, in which case the long 5FU infusion can be given to you through a small, portable pump.
There are several different types of pump, but all are small enough to be carried on a belt or in a holster. Before you go home you should be given instructions on how to look after the pump. Your nurse should explain how to care for it and what to do if something goes wrong.
When the infusion is finished there may be some fluid left in the pump. This may be normal as some types of pump need to be overfilled to get the correct dose.You can check with your nurse or pharmacist whether you have this type of pump.
If you're having the treatment as an inpatient you can go home once the 5FU is finished. The cannula will be removed before you go. If you have a central or PICC line, it will usually stay in place ready for your next cycle of chemotherapy. You will be shown how to look after the line.
Before you go home you will be given a supply of anti-sickness drugs to take with you. It is important to take these regularly, as directed, even if you aren't feeling sick. This is because some anti-sickness drugs are much better at preventing sickness than stopping it once it has started.
How often treatment is given
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Your doctor may use the word 'regimen' (eg the FOLFIRI regimen) when talking about your chemotherapy. This means the whole plan or schedule of the particular chemotherapy treatment you are having.
Irinotecan with 5FU and folinic acid can be given in different ways. The following are descriptions of two different schedules.
You can ask your doctor or nurse to explain which one you are having.
On the first day of treatment you will be given an infusion of irinotecan over two hours, followed by an infusion of folinic acid over two hours. Next, you will be given an injection of 5FU into your cannula or line. This is followed by an infusion of 5FU that lasts for 20 hours.
On the second day the treatment will be repeated, but without irinotecan. If you're having treatment as an outpatient, you will return to the hospital for the second day of chemotherapy and to have your pump refilled. Your pump will be disconnected when your treatment is finished on the third day. After this, you will have a rest period, with no chemotherapy for 12 days. This completes what is called a cycle of your chemotherapy treatment. Each cycle takes 14 days (two weeks).
You will start the next cycle of your treatment after the rest period, which will be a fortnight after your first injection.
The treatment is usually given for 12 cycles over a period of six months. This makes up a course of treatment.
On the first day of your treatment you will be given an infusion of irinotecan that lasts for 90 minutes. This is followed by a two-hour infusion of folinic acid and an injection of 5FU. Next, you will be given an infusion of 5FU over 46 hours. If your treatment is given while you are an inpatient, you will be able to go home once the 5FU infusion has finished.
If you have your treatment as an outpatient, the 5FU infusion will be given through a portable pump. You will need to have the pump disconnected when the 5FU infusion has finished. A district nurse may be able to disconnect the pump, or you may have to return to the hospital.
After this, there is a rest period of 12 days. This completes one cycle of treatment. Each cycle lasts for 14 days (two weeks). After the rest period you will start the next cycle of treatment.
Each person’s reaction to chemotherapy is different. Some people have very few side effects while others may experience more. The side effects described below won't affect everyone who has irinotecan with 5FU and folinic acid.
We have outlined the most common side effects but haven't included those that are rare and unlikely to affect you. If you notice any effects that are not listed below, discuss them with your doctor, chemotherapy nurse or pharmacist.
Risk of infection
Irinotecan with 5FU and folinic acid can reduce the number of white blood cells, which help to fight infection. White blood cells are produced by the bone marrow. If the number of your white blood cells is low you will be more prone to infections. A low white blood cell count is called neutropenia.
Neutropenia begins a few days after treatment. The number of your white blood cells will then increase steadily and usually return to normal before your next cycle of chemotherapy is due.
Contact your doctor or the hospital straight away if:
your temperature goes above 38°C (100.4°F)
you suddenly feel unwell, even with a normal temperature.
You will have a blood test before having more chemotherapy to check the number of white blood cells. Occasionally, your treatment may need to be delayed if your number of blood cells (blood count) is still low.
Bruising and bleeding
Irinotecan with 5FU and folinic acid can reduce the production of platelets, which help the blood to clot. Tell your doctor if you have any unexplained bruising or bleeding, such as nosebleeds, bleeding gums, blood spots or rashes on the skin. You can have a platelet transfusion if your platelet count is low.
Irinotecan with 5FU and folinic acid can reduce the number of red blood cells, which carry oxygen around the body.
A low red blood cell count is called anaemia. This may make you feel tired and breathless. Tell your doctor or nurse if you have these symptoms. You may need to have a blood transfusion if the number of red blood cells becomes too low.
Feeling sick (nausea) or being sick (vomiting)
Your doctor can prescribe very effective anti-sickness (anti-emetic) drugs to prevent, or greatly reduce, nausea and vomiting. If the sickness isn't controlled, or if it continues, tell your doctor; they can prescribe other anti-sickness drugs that may be more effective.
Some anti-sickness drugs can cause constipation. Let your doctor or nurse know if this is a problem.
Feeling tired is a common side effect of chemotherapy, especially towards the end of treatment and for some weeks after it’s over.
It’s important to try to pace yourself and get as much rest as you need. Try to balance this with taking some gentle exercise, such as short walks, which will help. If tiredness is making you feel sleepy, don’t drive or operate machinery.
This usually starts 3-4 weeks after starting treatment, although it may occur earlier. Hair usually falls out completely. You may also have thinning and loss of eyelashes, eyebrows and other body hair. This is temporary and your hair will start to grow again once the treatment has finished. Your hair may grow back straighter, curlier, finer, or a slightly different colour than it was before.
Your nurse can give you advice about coping with hair loss.
Scalp cooling is a method of reducing hair loss that may be helpful for some people. You can ask your doctor or nurse if it's available at your hospital.
Your mouth may become sore or dry, or you may notice small ulcers during this treatment. Drinking plenty of fluids, and cleaning your teeth regularly and gently with a soft toothbrush, can help to reduce the risk of this happening. Some people may find sucking on ice soothing. Tell your nurse or doctor if you have any of these problems, as they can prescribe mouthwashes and medicine to prevent or clear mouth infections.
You may notice that food tastes different. Normal taste usually comes back after treatment finishes.
A dietitian or specialist nurse at your hospital can give you advice about ways of coping with this side effect.
Increased sweating, production of saliva, stomach cramps and diarrhoea
Irinotecan can cause increased sweating and production of saliva, stomach cramps and diarrhoea. This is a particular group of side effects known as acute cholinergic syndrome. They happen because irinotecan can cause the cells in the body to release too much of a chemical called acetylcholine. The side effects tend to occur during, or within the first 24 hours after, an infusion of irinotecan.
These symptoms can usually be prevented or controlled by a drug called atropine. Atropine is given as an injection under the skin (subcutaneously), which can be repeated if necessary.
Diarrhoea can occur as a delayed side effect (occurring more than 24 hours after an infusion). It can usually be easily controlled but may occasionally be severe. If you get diarrhoea and abdominal cramps, start taking the anti-diarrhoea medicine that you have been given (usually loperamide tablets or capsules). These should be taken exactly as instructed by the hospital treating you, which may be different from the instructions provided on any printed leaflets from the manufacturer.
Normally, your doctor will tell you to take two tablets or capsules when the diarrhoea starts, and then one every two hours until you have not had a loose bowel movement for 12 hours. If loperamide does not work quickly and if you still have diarrhoea after 48 hours, it is important that you contact the hospital. You may become dehydrated if you have several episodes of diarrhoea. In some situations, you may be asked to take liquids to rehydrate yourself and replace any salts that you have lost. Antibiotics are also sometimes given if diarrhoea occurs.
Less common side effects
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Irinotecan with 5FU and folinic acid can cause a rash or dry skin, which may be itchy. Your doctor can prescribe medicine to help with this.
Rarely, your skin may darken. If it does, it usually goes back to normal a few months after the treatment has finished. During treatment and for several months afterwards, you will be more sensitive to the sun and your skin may burn more easily than normal. You can still go out in the sun, but should wear a suncream with a high sun protection factor (SPF) and cover up with clothing and a hat. You might find our information about taking care in the sun useful.
Irinotecan with 5FU and folinic acid may cause an inflammation of the lining of the eyelids (conjunctiva) that makes your eyes feel sore, red and itchy. Let your doctor know if this happens so they can prescribe soothing eye drops if necessary.
Changes in the way your heart works
5FU may affect the way your heart works. Some people can experience chest pain and tightening across the centre of the chest while taking it. Chest pain can be caused by many different things other than chemotherapy. If you develop any of these symptoms, contact your doctor immediately.
Always let your doctor or nurse know about any side effects that you have. There are usually ways in which they can be controlled or improved.
It’s important to let your doctor know straight away if you feel unwell or have any severe side effects, even if they’re not mentioned above.
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Risk of developing a blood clot
Cancer can increase the risk of developing a blood clot (thrombosis), and chemotherapy may increase this risk further.
A blood clot may cause symptoms such as pain, redness and swelling in a leg, or breathlessness and chest pain. Blood clots can be very serious so it’s important to tell your doctor straight away if you notice any of these symptoms. Most clots can be treated with drugs that thin the blood. The doctor or nurse can give you more information.
Some medicines, including those that you can buy in a shop or chemist, can be harmful to take when you are having chemotherapy. Tell your doctor about any medicines you are taking, including over-the-counter drugs, complementary therapies and herbal drugs.
Your ability to become pregnant or father a child may be affected by having this treatment. It's important to discuss fertility with your doctor before starting treatment.
It's not advisable to become pregnant or father a child while having irinotecan and 5FU, as it may harm the developing baby. It’s important to use effective contraception while having this drug, and for at least a few months afterwards. You can discuss this with your doctor.
It’s not known whether chemotherapy drugs can be present in semen or vaginal fluids. To protect your partner, it’s safest to either avoid sex or use a barrier form of contraception for about 48 hours after chemotherapy.
Loss of periods in women
Due to the effect of chemotherapy on the ovaries, women may find their periods become irregular and they may eventually stop.
In some women this may be temporary, but for others it will be permanent. This will result in menopausal symptoms such as hot flushes, sweats and vaginal dryness.
If you’re admitted to hospital for a reason not related to the cancer, it’s important to tell the doctors and nurses looking after you that you are having chemotherapy treatment.
You should tell them the name of your cancer specialist so that they can ask for advice.
It’s a good idea to know who you should contact if you have any problems or troublesome side effects when you’re at home. Your chemotherapy nurse or doctor will give you details of who to contact for advice. This should include ‘out-of hours’ contact details if you need to call someone at evenings, overnight or at the weekend.
This section is based upon our Irinotecan with fluorouracil and folinic acid chemotherapy fact sheet, which has been compiled using information from a number of reliable sources including:
Sweetman, et al. Martindale: The Complete Drug Reference. 37th edition. 2011. Pharmaceutical Press.
British National Formulary. 62nd edition. 2011. British Medical Association and Royal Pharmaceutical Society of Great Britain.
Perry MC. The Chemotherapy Source Book. 4th edition. 2007. Lippincott Williams and Wilkins.
electronic Medicines Compendium (eMC). www.medicines.org.uk (accessed October 2011).