Modified de Gramont

Modified de Gramont describes a way of giving the chemotherapy drug fluorouracil (5FU) in combination with folinic acid (calcium folinate or leucovorin).

It is a treatment for bowel cancer. 

How it works

Fluorouracil is a chemotherapy drug that works by destroying quickly dividing cells, such as cancer cells. Folinic acid makes the fluorouracil work better.

How you have it

You have fluorouracil and folinic acid into your bloodstream (intravenously).

Drugs into your bloodstream

You have the treatment through a drip into your arm or hand. A nurse puts a small tube (a cannula) into one of your veins and connects the drip to it.

You might need a central line. This is a long plastic tube that gives the drugs into a large vein, either in your chest or through a vein in your arm. It stays in while you’re having treatment, which may be for a few months.

When you have it

You have a 2 hour drip of folinic acid on the first day. This is followed by an injection of fluorouracil which takes a few minutes. You then go home with a portable pump. The pump gives the correct dose of fluorouracil over 46 hours.

On the third day you go back to the hospital to have the pump disconnected. Or a nurse can come to your home to do this. You then have 12 days with no treatment before starting another cycle.

If you don't have a central line you stay in hospital and have the fluorouracil through a cannula. 

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. 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.

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:

Breathless and looking pale

You might be breathless and look pale due to a drop in red blood cells. This is called anaemia.

Increased 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. 

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).

Difficulty breathing

Your airway might narrow due to a spasm causing: 

  • shortness of breath
  • coughing
  • wheezing
  • a tight feeling in the chest

This often happens in the morning, at night or after exercise. Contact your advice line or tell your healthcare team if this happens. 

Changes to the level of uric acid in the blood

You might have a high level of uric acid in your blood. This can cause gout. You have regular blood tests during treatment to check this.

An abnormal heart trace (ECG)

This could be caused by not enough blood getting to your heart. Contact your healthcare line or tell your healthcare team if you have any chest pain.  

Sore mouth and throat

It may be painful to swallow drinks or food. Painkillers and mouth washes can help to reduce the soreness and keep your mouth healthy. 

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.

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.

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. 

Sore, red, peeling palms of hands or soles of 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.

Delayed wound healing

It might take longer for wounds to heal while having this treatment. 

Feeling tired, weak and lacking energy (fatigue)

You might feel very tired and as though you lack energy.

Various things can help you to reduce tiredness and cope with it, for example exercise. Some research has shown that taking gentle exercise can give you more energy. It is important to balance exercise with resting.

Occasional side effect

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:

  • chest pain that can be severe. Contact your advice line or tell your healthcare team if this happens
  • red, itchy, watery, sore eyes (conjuntivits)

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:

  • a severe whole body infection (sepsis) - if you feel confused, have slurred speech, breathlessness and shivering or muscle pain contact your advice line or healthcare team straight away
  • a feeling or state of intense excitement and happiness (euphoria)
  • rapid eye movements
  • headache
  • sleepiness
  • dizziness
  • tremors, shaking, stiffness and slow movement (like Parkinson's disease)
  • eye problems such as red, sore, watery eyes, blurred or double vision, lower eyelid turning out, dry eyes, inflammation of the nerve, narrowing or blockage of the tear ducts
  • heart problems such as an irregular beat or heart attack
  • low blood pressure
  • not enough fluid in the body (dehydration)
  • ulcers in the food pipe (oesophagus), stomach and bowels
  • liver damage
  • skin problems such as a rash, hives, darkening of the skin and 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, 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.

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.

Sodium

This drug contains sodium (salt). You might need to take account of this if you are on a controlled sodium diet. Tell your doctor if you are on a low salt 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.    

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.

Breastfeeding

It is not known whether this drug comes through into the breast milk. Doctors usually advise that you don’t breastfeed during this treatment.

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.

Immunisation

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 Open a glossary item 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.

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.

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