Folinic acid, fluorouracil and oxaliplatin (FOLFOX)

FOLFOX is the name of a chemotherapy combination. It includes the drugs we list below, next to each drug we have how you pronounce the drug name in brackets.

• folinic acid also called leucovorin, calcium folinate or FA (foh-lin-ik ass-id)
• fluorouracil also known as 5FU (floor-oh-yoor-uh-sil)
• oxaliplatin (ox-ali-pla-tin)

It is a treatment for a number of different cancer types. It is also known as Oxaliplatin de Gramont or OxMdG, which means modified Oxaliplatin de Gramont.

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

How does FOLFOX work?

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

How do you have FOLFOX?

You have folinic acid, 5FU and oxaliplatin as a drip into your bloodstream (intravenously).

You might have treatment through a long plastic tube that goes into a large vein in your chest. The tube stays in place throughout the course of treatment. This can be a:

• central line
• PICC line
• portacath

5FU pump

You usually have your infusion of 5FU at home 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 after the second day of treatment, to have the pump disconnected. Or sometimes a chemotherapy nurse may be able to do this at your home

How often do you have FOLFOX?

You have FOLFOX chemotherapy as cycles of treatment. This means that you have the drug and then a rest to allow your body to recover.

Each cycle of treatment lasts 14 days (2 weeks). You might have up to 12 cycles of FOLFOX, taking around 6 months in total.

You have each cycle of treatment in the following way: 

You then start your next cycle of treatment.

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.

Before starting treatment with fluorouracil (5FU) you have a blood test to check levels of an enzyme called dihydropyrimidine dehydrogenase (DPD). A low DPD level means you are more likely to have severe side effects from this chemotherapy, so you may start treatment with a lower amount (dose) of the drug or have a different treatment. Your doctor, nurse or pharmacist will talk to you about this.

What are the side effects of FOLFOX?

Side effects 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:

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. 

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).

Less commonly you might also bleed from other areas of the body for other reasons. For instance, some people might notice their poo is quite dark or they might pass fresh blood.

Cough

You may get a cough while you are having treatment. 

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.

Nerve problems

Numbness or tingling in fingers or toes is caused by oxaliplatin and is often temporary and can improve after you finish treatment. This is due to its effects on the nerves. The medical name for this is peripheral neuropathy.

Peripheral neuropathy can make it difficult to do fiddly things such as doing up buttons. It might be triggered and get worse with cold temperatures: for example, cold air, cold drinks, or touching anything cold.

Other nerve problems might include having abnormal sensation to different parts of the body such as a shock-like sensation passing down your arms.

Feeling and being sick (nausea)

Feeling or being sick is usually well controlled with anti sickness medicines. It might help to avoid fatty or fried foods, eat small meals and snacks and take regular sips of water. Relaxation techniques might also 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 treat it once it has started.

Inflammation and pain at your drip site

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. 

Pain in different parts of the body

This treatment can cause pain in different parts of your body such as you back or tummy (abdomen) pain. Less commonly in your bones and joints.

Tell your healthcare team if you have this. They can check the cause and give you medicine to help. 

Diarrhoea or constipation

Tell your healthcare team if you have diarrhoea or constipation. They can give you medicine to help. 

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

Loss of appetite

You might lose your appetite for various reasons while having cancer treatment. Sickness, taste changes or tiredness can put you off food and drinks.

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.

Hair loss

You could lose all your hair. This includes your eyelashes, eyebrows, underarms, legs 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. 

Soreness, redness and peeling on palms and 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 healthcare team will tell you what moisturiser to use.

Taste changes

Taste changes may make you go off certain foods and drinks. You may also find that some foods taste different from usual or that you prefer to eat spicier foods. Your taste gradually returns to normal a few weeks after your treatment finishes.

Skin changes

You might notice skin changes, such as dryness, itching and a rash. Rarely these drugs can also make your skin sensitive to sunlight. And patches of skin may get darker or lighter near veins. 

Tell your healthcare team if you have any rashes or itching.

If your skin gets dry or itchy, using unperfumed moisturising cream may help. Check with your doctor, nurse or pharmacist before using any creams or lotions. Wear a high factor sun block if you’re going out in the sun.

Changes in levels of salts or minerals in your blood

You may have changes in levels of minerals and salts in your blood, such as low levels of potassium and calcium or high levels of sodium.

You have regular blood tests during treatment to check this.

Liver changes

You might have liver changes that are usually mild and unlikely to cause symptoms. They usually go back to normal when treatment finishes. You have regular blood tests to check for any changes in the way your liver is working.

Headaches

Let your doctor or nurse know if you have headaches. They can give you painkillers such as paracetamol to help.

Slow wound healing

Any wounds you might have can take longer to heal. Keep wounds clean to prevent infection. Contact your GP or specialist nurse if you are worried about a wound.

Heart problems

Heart problems include changes to how your heart works. This can cause changes to your heart rhythm and your ankles can swell.

Tell your doctor or nurse straight away if you have any chest pain.

Your doctor might ask you to have tests to check your heart, such as a heart trace (ECG).

High blood sugar levels

High blood sugar levels can cause headaches, feeling thirsty and blurred vision. You have regular tests to check your blood sugar levels. You may need to check your levels more often if you have diabetes .

High temperature (fever)

Tell your healthcare team straightaway if you get a high temperature. Ask them if you can take paracetamol to help lower your temperature.

Weight gain

You may gain weight while having this treatment. You may be able to control it with diet and exercise. Tell your healthcare team if you are finding it difficult to control your weight. 

Feeling generally unwell

Speak to your doctor or nurse if you feel generally unwell after having this treatment.

Inflammation of the food pipe and back passage

An inflamed food pipe (oesophagus) can cause heartburn. Inflammation of the back passage (rectum) can cause diarrhoea. Other symptoms are pain, bleeding and discharge and the feeling that you want to pass a bowel movement.

Speak to your doctor or nurse if you have these symptoms.

Increased sensitivity to the cold

Oxaliplatin can make you more sensitive to the cold. It can affect your throat causing it to feel as though it is difficult to breathe and swallow. This can happen whilst you have oxaliplatin or within 2 hours of it finishing. It’s only temporary but can feel quite frightening.

Opening and closing the fridge or freezer, touching metal, eating or drinking cold foods and changes in temperature from the weather can trigger this.

It can help wearing gloves and avoid very cold food and drink for 24 hours before and after oxaliplatin.

Let your nurse know straight away if it's affecting your breathing and swallowing.

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:

• brittle, chipped and ridged nails
• eye problems – this includes problems with your vision and watery or sore eyes
• dizziness
• sweating
• hiccups
• muscle wasting
• high blood pressure that can give you headaches, nose bleeds, blurred or double vision or shortness of breath. Rarely you might get low blood pressure, this might cause you to feel dizzy, weak or even faint
• difficulty getting to sleep or staying asleep (insomnia)
• feeling depressed
• blood clots that can be life threatening; signs are pain, redness and swelling where the clot is. Feeling breathless can be a sign of a blood clot in the lung. Contact your advice line or doctor straight away if you have any of these symptoms
• weight loss
• loss of body fluid (dehydration)
• inflammation of the membranes covering the brain and spinal cord (meninges) causing symptoms similar to meningitis (stiff neck, unable to look at bright light and headache)
• kidney problems – you may pass blood when you wee, it may be painful and you might notice you are going more or less often than usual. Blood tests might show changes to how your kidneys are working
• heartburn or indigestion
• your nose can become irritated causing a blocked or runny nose
• episodes of feeling warm and reddening of the skin (flushing)
• a risk of falling

Rare side effects

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

• hearing or balance problems
• intestine muscle problems which can cause bloating, vomiting, constipation, cramps, and loss of appetite
• a blockage in your gut
• kidney changes - you will have regular blood tests to check for this
• feeling nervous
• a rare condition causing headaches, vision problems, mental changes, seizures, and swelling in the brain. These can come on quickly and be life threatening
• lung disease which can cause high blood pressure in your lungs and be life threatening
• a blood disorder where your red blood cells get destroyed faster than they can be made (haemolytic anaemia)
• damage to pancreas
• blocked veins in the liver

Coping with side effects

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

What else do you need to know?

Other medicines, food and drink

Cancer drugs can interact with medicines, herbal products, and some food and drinks. We are unable to list all the possible interactions that may happen. An example is grapefruit or grapefruit juice which can increase the side effects of certain drugs.

Tell your healthcare team about any medicines you are taking. This includes vitamins, herbal supplements and over the counter remedies. Also let them know about any other medical conditions or allergies you may have.

Loss of fertility

You may not be able to become pregnant or get someone pregnant 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 get someone pregnant 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 become 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

If you are having tests or treatment for anything else, always mention your cancer treatment. For example, if you are visiting your dentist.

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 and possible side effects go to the electronic Medicines Compendium (eMC) website. You can find the patient information leaflet on this website.

You can report any side effect you have to the Medicines Health and Regulatory Authority (MHRA) as part of their Yellow Card Scheme.