de Gramont and modified de Gramont chemotherapy
This information is about a chemotherapy treatment for bowel cancer called de Gramont and modified de Gramont chemotherapy.
The drugs that are used
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The de Gramont regimen is named after the doctor who first used it and involves the following drugs:
fluorouracil – throughout this fact sheet we'll refer to fluorouracil by its more common name, 5FU
folinic acid, which is sometimes known as leucovorin – this is a drug that makes 5FU more effective.
There are many different ways of giving 5FU and folinic acid together. The de Gramont regimen and modified de Gramont are two ways of combining these two drugs. Your doctor will discuss with you which option is best for you. Some doctors in the UK use the modified de Gramont, because they feel it's easier to give and just as effective.
How treatment is given
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Treatment with de Gramont or modified de Gramont chemotherapy can be given to you during a short stay in hospital or as a day patient. You'll need to have a blood test before you start treatment – 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. This may take a couple of hours.
The nurse will insert 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's inserted under the skin and into a vein near the collarbone (central line), or passed through a vein in the crook of their arm (PICC line). A central or PICC line will be needed if you're going to have your treatment as an outpatient. Your doctor or nurse will explain more about this to you.
You may be given tablets of an anti-sickness drug, which can also be given by injection through the cannula. You may also be given a supply of anti-sickness drugs to take home with you.
After the anti-sickness drugs you'll be given folinic acid, which is given as a drip (infusion) over two hours. This is followed by an injection of 5FU (a colourless fluid) into your cannula or line.
After this you'll be given an infusion of 5FU, which will take 22 hours. This means you'll need to stay in hospital unless you have a central or PICC line. If you have a line, this part of the treatment (the 22-hour infusion of 5FU) can be given to you through a small portable pump. The pump is used to administer a controlled amount of the drug into your bloodstream over a set period of time. It's small enough to be carried in a belt or holster. This means that once the pump is connected to your line and the treatment is started, you can go home.
When the infusion is finished there might 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.
The next day (day 2), when the 22-hour infusion has finished, the exact same treatment is given again. If you're having treatment at home you'll go back to the hospital for more chemotherapy and to have your pump changed.
Sometimes the pump will be filled with enough 5FU to last for 44 hours. After the first 22 hours, the pump will be stopped to give more folinic acid and an injection of 5FU (as described earlier). Your pump will be disconnected when your treatment is finished on day 3.
You may have to return to the hospital to have the pump disconnected, or sometimes a nurse can visit you at home. If you stayed in hospital to have the chemotherapy through a cannula into a vein, you'll be able to go home after day 3.
After this you'll have a rest period with no chemotherapy for the next 11 days. This completes what is called a cycle of the chemotherapy treatment. Each cycle takes 14 days (two weeks).
Modified de Gramont
After the anti-sickness drugs, you'll be given folinic acid followed by an injection of 5FU (as described in the previous section). You'll then be given an infusion of 5FU that takes 46 hours, using either a small portable pump through a central or PICC line, or as a continuous infusion through a cannula into a vein.
If you have a central or PICC line, you'll be able to go home for the 46 hours and return to the hospital when the infusion is finished (on day 3). Your pump will then be disconnected. It may be possible to arrange for a district or community nurse to visit your home and disconnect the pump.
Your central or PICC line will usually stay in place, ready for the next cycle of your chemotherapy. You'll be shown how to look after the line.
If you have a cannula, you'll stay in hospital for the 46 hours and will be able to go home on day 3, once the infusion has finished. Your cannula will then be removed.
After this you'll have a rest period with no chemotherapy for the next 11 days. This completes a cycle of the chemotherapy treatment. Each cycle takes 14 days (two weeks).
How often treatment is given
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Your doctor may use the word 'regimen' (for example 'the de Gramont regimen') when talking about your chemotherapy. This refers to the whole plan or schedule of your particular chemotherapy treatment.
You'll 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.
Each person’s reaction to chemotherapy is different. Some people have very few side effects, while others may experience more. The side effects described here won't affect everyone who has de Gramont chemotherapy.
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 aren't listed here, discuss them with your doctor, chemotherapy nurse or pharmacist.
Risk of infection
5FU can reduce the number of white blood cells, which help fight infection. White blood cells are produced by the bone marrow. If the number of your white blood cells is low you'll 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'll 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 the number of your blood cells (blood count) is still low.
Bruising and bleeding
5FU 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 may need to have a platelet transfusion if your platelet count is low.
5FU 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 some gentle exercise, such as short walks, which will help. If tiredness is making you feel sleepy, don’t drive or operate machinery.
This is rare with this treatment, but your hair may become thinner. If you lose any hair it will grow back once the treatment has finished. Your nurse can give you advice about coping with hair loss.
Soreness and redness of the palms of the hands and soles of the feet
This is known as palmar plantar, or hand-foot syndrome. It's temporary and improves when the treatment finishes. If you get hand-foot syndrome, contact your specialist doctor or nurse for advice.
Your doctor may prescribe creams or a vitamin called pyridoxine (vitamin B6), which some people find helpful. It can also help to keep your hands and feet cool and to avoid tight-fitting clothing, such as socks, shoes and gloves.
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 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.
5FU can cause diarrhoea. This can usually be easily controlled with medicine, but tell your doctor if it's severe or continues. It's important to drink plenty of fluids if you have diarrhoea.
Less common side effects
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de Gramont chemotherapy can cause a rash or dry skin, which may be itchy. Your doctor can prescribe medicine to help with this. Areas of skin that have previously been treated with radiotherapy may become red and sore. Let your doctor know if this happens.
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'll 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.
5FU may cause an inflammation of the lining of the eyelids (conjunctiva) that makes your eyes feel sore, red and itchy. Let your doctor know so they can prescribe soothing eye drops if necessary.
Your nails may become brittle, chipped and ridged. These changes grow out slowly over a few months once the treatment has ended.
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.
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.
5FU interacts with the drugs phenytoin (Epanutin®), allopurinol (Zyloric®) and interferon (IntronA®, Roferon-A®). It may also affect the action of some medicines given to thin the blood (anti-coagulants), such as warfarin. Let your doctor know if you're taking any of these.
You should also tell your doctor if you’re taking folic acid because it might increase the side effects of 5FU.
Some other medicines, including those you can buy in a shop or chemist, can be harmful to take when you're having chemotherapy. Tell your doctor about any medicines you're 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 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.
There's a potential risk that chemotherapy drugs may be present in breast milk. Women are advised not to breastfeed during chemotherapy and for a few months afterwards.
Loss of periods in women
Due to the effect of chemotherapy on the ovaries, women may find that their periods become irregular and 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're 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 de Gramont and modified de Gramont 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.
electronic Medicines Compendium (eMC). (accessed October 2011).
Perry MC. The Chemotherapy Source Book. 4th edition. 2007. Lippincott Williams and Wilkins.