Oxaliplatin with fluorouracil (5FU) and folinic acid chemotherapy (FOLFOX or OxMdG)
Oxaliplatin with fluorouracil (5FU) and folinic acid chemotherapy is a treatment which is usually used to treat bowel cancer. This combination of drugs may also be used to treat other types of cancer.
This information should ideally be read with our general information about chemotherapy and your type of cancer.
Folinic acid is not a chemotherapy drug. It is often given with 5FU as it’s been shown to make it work better.This treatment is sometimes called FOLFOX or oxaliplatin modified de Gramont (OxMdG).
You have the treatment in the chemotherapy day unit or during a short stay in hospital. A chemotherapy nurse will give it to you. During treatment, you usually see a cancer doctor, a chemotherapy nurse or a specialist nurse. This is who we mean when we mention doctor or nurse in this information.
Before or on the day of treatment, a nurse or person trained to take blood (phlebotomist) will take a blood sample from you. This is to check that it is okay for you to have chemotherapy.
You will also see a doctor or nurse before you have chemotherapy. They will ask you about how you have been. If your blood results are alright on the day of your treatment, the pharmacist will prepare your chemotherapy. Your nurse will tell you when your treatment is likely to be ready.
Your nurse will give you anti-sickness drugs as an injection into a vein or as tablets. They give you the drugs and chemotherapy through one of the following (depending if you have a line in or not):
a fine tube that goes under the skin of your chest and into a vein close by (central line)
a fine tube that is put into a vein in your arm and goes up into a vein in your chest (PICC line)
a short thin tube (cannula) the nurse puts into a vein in your arm or hand.
On the first day of treatment your nurse gives you folinic acid as a drip (infusion) and a drip of oxaliplatin. You have them at the same time over about two hours. The drips are run through a pump, which gives you the drugs over a set time. After this you have 5FU. There are different FOLFOX schedules depending on how 5FU is given:
FOLFOX4 – On day 1, your nurse gives you an injection of 5FU into your line or cannula. After this you have an infusion of 5FU over 22 hours. On day 2, you have a drip of folinic acid and an injection of 5FU. This is followed by another 22-hour infusion of 5FU.
FOLFOX6 – On day 1, your nurse gives you an injection of 5FU into your line or cannula followed by an infusion of 5FU over 2 days (48 hours).
If you have a line, you can have 5FU through a small portable pump you carry on a belt or in a holster. You can go home once the pump is connected to your line and the infusion has started. Your nurse or pharmacist will explain how it works and how to look after it. With Folfox 4, you come back to hospital on the second day to have folinic acid, a 5FU injection and another infusion pump.
A nurse will disconnect the pump when your treatment is finished. You may need to come back to the hospital to have this done. Sometimes a district nurse can do this at home.
If you don’t have a line, you need to stay in hospital to have the 22 hour or 48 hour infusion through your cannula. You can go home when it is finished.
Your course of FOLFOX
You have chemotherapy as a course of several sessions (or cycles) of treatment over a few months. Each cycle of FOLFOX takes 14 days (two weeks).
At the end of the 14 days you start your second cycle of FOLFOX. This is the same as the first cycle. You can have up to 12 cycles, or sometimes more, depending on your situation. Your doctor or nurse will tell you the number of cycles you are likely to have.
When the chemotherapy is being given
Some people might have side effects while they are having the chemotherapy:
Rarely, oxaliplatin may cause an allergic reaction while it’s being given. Your nurse will check you for this. If you have a reaction, they will treat it quickly. Signs of a reaction can include: a rash; feeling itchy, flushed or short of breath; swelling of your face or lips; feeling dizzy; having pain in your tummy, back or chest; or feeling unwell. Tell your nurse straight away if you have any of these symptoms.
Before you go home, the nurse or pharmacist will also give you anti-sickness drugs to take. They may also give you anti-diarrhoea tablets if you need them. Take all your tablets exactly as explained .
Possible side effects of FOLFOX
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We explain the most common side effects here. But we don’t include all the rare ones that are unlikely to affect you.
You may get some of the side effects we mention but you are very unlikely to get all of them. Always tell your doctor or nurse about the side effects you have. Your doctor can prescribe drugs to help control some of these.
It is very important to take the drugs exactly as your nurse or pharmacist has explained. This means they will be more likely to work better for you.
Your nurse will give you advice about managing your side effects. After your treatment is over, the side effects will start to improve.
Contact the hospital
Your nurse will give you telephone numbers for the hospital. You can call them if you feel unwell or need advice any time of day or night. Save these numbers in your phone or keep them somewhere safe.
Risk of infection
Chemotherapy can reduce the number of white blood cells in your blood. This will make you more likely to get an infection. When the number of white blood cells is low, it’s called neutropenia.
Contact the hospital straight away on the contact number you’ve been given if:
your temperature goes over 37.5°C (99.5°F) or over 38°C (100.4°F), depending on the advice given by your chemotherapy team
you suddenly feel unwell, even with a normal temperature
you have symptoms of an infection – this can include feeling shaky, a sore throat, a cough, diarrhoea or needing to pass urine a lot.
The number of white blood cells usually increases steadily and return to normal before your next treatment. You will have a blood test before having more chemotherapy. If your white blood cells are still low, your doctor may delay your treatment for a short time
Bruising and bleeding
This treatment can reduce the number of platelets in your blood. Platelets are cells that help the blood to clot. Tell your doctor if you have any bruising or bleeding you can’t explain. This includes nosebleeds, bleeding gums, blood spots or rashes on the skin.
Anaemia (low number of red blood cells)
This treatment can reduce the number of red blood cells in your blood. These cells carry oxygen around the body. If the number of red blood cells is low, you may be tired and breathless. Tell your doctor or nurse if you feel like this. If you are very anaemic, you may need a drip to give you extra red cells (blood transfusion).
Your doctor will prescribe anti-sickness (anti-emetic) drugs to help prevent or control sickness. Take the drugs exactly as your nurse or pharmacist explains to you. It’s easier to prevent sickness than to treat it after it has started.
If you still feel sick or are vomiting, contact the hospital as soon as possible. They can give you advice and change the anti-sickness drug to one that works better for you.
Numb or tingling hands or feet
These symptoms are caused by the effect of oxaliplatin on the nerves. It’s called peripheral neuropathy. You may also find it hard to fasten buttons or do other fiddly tasks.
Tell your doctor if you have these symptoms. They sometimes need to lower the dose of the drug. The symptoms usually improve slowly after treatment finishes but in some people they may never go away. Talk to your doctor if you are worried about this.
Feeling very tired is a common side effect. It’s often worse towards the end of treatment and for some weeks after. Try to pace yourself and get as much rest as you need. It helps to balance this with taking some gentle exercise, such as short walks. If you feel sleepy, don’t drive or operate machinery.
Your mouth may become sore and you may get ulcers. This can make you more likely to get an infection in your mouth. Gently clean your teeth and/or dentures morning and night and after meals. Use a soft-bristled or children’s toothbrush. Your nurse might ask you to rinse your mouth regularly or use mouthwashes. It’s important to follow any advice you are given and to drink plenty of fluids.
Tell your nurse or doctor if you have any problems with your mouth. They can prescribe medicines to prevent or treat mouth infections and reduce any soreness.
This can sometimes be severe. Your doctor can prescribe anti-diarrhoea drugs to control it. You may be given these before you leave hospital. It’s important to take them exactly as your nurse or pharmacist explained. Make sure you drink at least two litres (three and a half pints) of fluids every day if you have diarrhoea.
If you have diarrhoea more than 4–6 times a day, or at night, contact the hospital straightaway on the numbers your nurse gave you.
Your hair may thin but you’re unlikely to lose all the hair from your head. This usually starts after your first or second cycle of chemotherapy. It is almost always temporary and your hair will grow back after chemotherapy ends. Your nurse can give you advice about coping with hair loss.
Your eyes may become watery, or feel sore and dry. Your doctor can prescribe eye drops to help with this. If your eyes get red and inflamed (conjunctivitis) tell your doctor. This is because you may need antibiotic eye drops.
Rarely the drugs may cause blurry vision and/or eye pain. Always tell your doctor or nurse if you have eye pain or notice any change in your vision.
Soreness and redness of palms of hands and soles of feet
This is called palmar-plantar or hand-foot syndrome. It gets better when treatment ends. Your doctor or nurse may prescribe creams to improve the symptoms. It can help to keep your hands and feet cool and to avoid tight-fitting socks, shoes and gloves.
Chemotherapy may affect your skin. Your doctor or nurse can tell you what to expect. If your skin feels dry, try using an unperfumed moisturising cream every day. During treatment and for several months afterwards, you'll be more sensitive to the sun and your skin may burn more easily than usual. You can still go out in the sun, but use a suncream with a sun protection factor (SPF) of at least 30, and cover up with clothing and a hat.
Always tell your doctor or nurse about any skin changes. They can give you advice and may prescribe creams or medicines to help. Any changes to your skin are usually temporary and improve when treatment finishes.
Less common side effects of FOLFOX
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Breathing and swallowing
Oxaliplatin can affect the area around the voicebox (larynx). This can make you feel as if it’s difficult to swallow or to breathe. It can feel very frightening but only lasts a short while. Try taking long deep breaths through your nose to help your breathing get back to normal. The symptoms can be made worse by cold temperatures. So avoid having cold drinks or ice cubes for a few days after treatment.
It’s important to tell your doctor or nurse if you have this side effect. They can give you the oxaliplatin over a longer time (4–6 hours) to reduce the chance of this happening.
Changes in the way the heart works
The drug 5FU can affect the way the heart works but this isn’t common. If you have pain or tightness in your chest or feel breathless or notice changes to your heartbeat at any time during or after treatment, tell a doctor straight away. These symptoms can be caused by other conditions but it’s important to get them checked by a doctor.
Rarely, oxaliplatin may affect your hearing. Tell your doctor if you notice ringing in your ears (tinnitus), or if you have other hearing changes or pain in your ear.
Other information about FOLFOX chemotherapy
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Blood clot risk
Cancer increases the chance of a blood clot (thrombosis) and chemotherapy can add to this. A clot can cause symptoms such as pain, redness and swelling in a leg, breathlessness and chest pain. Contact your doctor straight away if you have any of these symptoms. A blood clot is serious but your doctor can treat it with drugs that thin the blood. Your doctor or nurse can give you more information.
Oxaliplatin and capecitabine may interact with different drugs or affect the way blood thinning drugs such as warfarin work. Some medicines can interact with chemotherapy or be harmful when you are having chemotherapy. This includes medicines you can buy in a shop or chemist.. Tell your doctor about any medicines you are taking, including over-the-counter drugs, complementary therapies and herbal drugs.
Chemotherapy may affect your fertility (being able to get pregnant or father a child). If you are worried about this, you can talk to your doctor or nurse before treatment starts.
Your doctor will advise you not to become pregnant or to father a child during treatment. This is because the drugs may harm a developing baby. It’s important to use effective contraception during and for a few months after chemotherapy. You can talk to your doctor or nurse about this.
If you have sex within the first couple of days of having chemotherapy you need to use a condom. This is to protect your partner in case there is any chemotherapy in semen or vaginal fluid.
Changes to your periods
Chemotherapy can sometimes stop the ovaries working. You may not get a period every month and they may eventually stop. In some women, this is temporary, but for others it is permanent and they start the menopause.
Women are advised not to breastfeed during treatment and for a few months after. This is in case there is chemotherapy in their breast milk.
Medical and dental treatment
If you need to go into hospital for any reason other than cancer, always tell the doctors and nurses that you are having chemotherapy. Give them contact details for your cancer doctor.
Talk to your cancer doctor or nurse if you think you need dental treatment. Always tell your dentist you are having chemotherapy.
This section has been compiled using information from a number of reliable sources including:
electronic Medicines Compendium (eMC). medicines.org.uk (accessed July 2013).
Perry MC. The Chemotherapy Source Book. 5th edition. 2012 Lippincott Williams and Wilkins.
With thanks to Bruce Burnett, Teacher Practitioner in Clinical Pharmacy Practice, who reviewed this edition.
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