Oxaliplatin and capecitabine (CAPOX, XELOX)

Oxaliplatin and capecitabine is a chemotherapy drug combination. It is also called CAPOX or XELOX.

You pronounce the drug names:

• oxaliplatin - ox-ali-pla-tin
• capecitabine - ka-pe-site-a-been

It is a treatment for:

• bowel cancer
• cancer of the food pipe (oesophagus)
• stomach cancer

How does oxaliplatin and capecitabine work?

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

How do you have oxaliplatin and capecitabine?

You have oxaliplatin into your bloodstream (intravenously).

Capecitabine comes as tablets that you swallow whole, with plenty of water. You usually take the tablets twice a day, about 12 hours apart. You should take them within 30 minutes of finishing a meal.

Your doctor will tell you the amount (dose) of capecitabine you need to take. You might have two different strengths of tablets to make up the correct dose. 

Taking your tablets

Speak to your pharmacist if you have problems swallowing the tablets.

Whether you have a full or an empty stomach can affect how much of a drug gets into your bloodstream.

You should take the right dose, no more or less.

Talk to your healthcare team before you stop taking a cancer drug or if you miss a dose.

Into your bloodstream

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

If you don't have a central line

You might have treatment through a thin short tube (a cannula) that goes into a vein in your arm. You have a new cannula each time you have treatment.

How often do you have oxaliplatin and capecitabine?

You have oxaliplatin and capecitabine chemotherapy as cycles of treatment. This means you have the drugs and then a rest to allow your body to recover.

Each cycle lasts 3 weeks (21 days). You usually have it as a course of several cycles of treatment. Each cycle varies depending on what type of cancer you have. Your doctor or nurse will tell you more about this.

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 capecitabine 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 these drugs. So you may start treatment with a lower amount (dose) of the drug or have a different treatment. Your doctor, pharmacist or nurse will talk to you about this.

What are the side effects of oxaliplatin and capecitabine?

Side effects can vary from person to person. They also depend on what other treatment you are having. 

When to contact your team

Your doctor, pharmacist or nurse 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

• the side effects are affecting your daily life

Early treatment can help manage side effects better. 

We haven't listed all the side effects here. Talk to your healthcare team if you have any new symptoms that you think might be a side effect of your treatment.

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:

Numbness and tingling in the hands and feet

Numbness or tingling in fingers or toes is often temporary and can improve after you finish treatment. Tell your healthcare team if you're finding it difficult to walk or complete fiddly tasks such as doing up buttons. 

Increased risk of getting an infection

Increased risk of getting an infection is due to a drop in white blood cells. Symptoms include a change in temperature, aching muscles, cough, headaches, feeling cold and shivery, pain or burning feeling when weeing, or generally feeling 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 and looking pale

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

Bruising, bleeding gums, nosebleeds, or bleeding from other areas of the body

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. Rarely some people might cough up blood or have unusual bleeding from the vagina.

Let your healthcare team know straight away if you have any bleeding. 

Tiredness and weakness (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.

Allergic reaction

A reaction may happen during the infusion, causing a skin rash, itching, swelling of the lips, face or throat, breathing difficulties, fever and chills. Your nurse will give you medicines beforehand to try to prevent a reaction. Tell your nurse or doctor immediately if at any time you feel unwell. They will slow or stop your drip for a while and give you medicine to help relieve your symptoms.

Increased sensitivity to 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 a few 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 before and after oxaliplatin.

Let your nurse know straight away if it's affecting your breathing and swallowing. They can slow down your drip if this happens. 

Changes to levels of substances in the blood

This treatment can cause your blood sugar and sodium levels to go up. Or your level of potassium might go down. Less commonly your calcium levels might drop. 

You will have regular blood tests to check on these.

Feeling or being sick

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.

Diarrhoea 

Contact your advice line if you have diarrhoea. For example, in one day you have 2 or more loose bowel movements than usual. If you have a stoma , you might have more output than normal. Your doctor may give you anti diarrhoea medicine to take home with you after treatment.

Try to eat small meals and snacks regularly. It’s best to try to have a healthy balanced diet if you can. You don’t necessarily need to stop eating foods that contain fibre. But if your diet is normally very high in fibre, it might help to cut back on high fibre foods such as beans, nuts, seeds, dried fruit, bran and raw vegetables. 

Drink plenty to try and replace the fluid lost. Aim for 8 to 10 glasses per day.

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.

Less commonly you might have a dry mouth.

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.

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 goes back to normal a few weeks after your treatment finishes.

Tummy (abdominal) pain

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

Headaches

Tell your doctor or nurse if you keep getting headaches. They can give you painkillers to help.

Soreness, redness and peeling on hands and soles of the 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.

It is important to keep hands and feet well moisturised.

Skin problems 

Skin problems include a skin rash which might be red and itchy. Less common skin problems might include your skin getting dry, peeling, blistering, cracked, and changes in skin colour. Other rare skin changes include ulcers, raised areas of skin that may be itchy, being sensitive to sunlight and previously treated areas of skin with radiation can become irritated and inflamed 

This usually goes back to normal when your treatment finishes. Your nurse will tell you what products you can use on your skin to help.

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.

Pain in different parts of your body 

This treatment can cause back pain. Or you might get pain from other areas of the body such as in your muscles and joints.

Inflammation and pain at your drip site

Tell your nurse straight away if you have any redness, swelling, pain or leaking at your drip site. 

High temperature (fever)

If you get a high temperature, let your health care team know straight away. Ask them if you can take paracetamol to help lower your temperature.

Weight changes

You may gain weight while having this treatment. Or less commonly you may lose weight.

You may be able to control it with diet and exercise. Tell your doctor or nurse if you are finding it difficult to control your weight. 

Difficulty breathing or a cough 

It is important to tell your doctor or nurse if you have a cough or are breathless. This could be a sign of infection or more rarely lung problems such as asthma, a blood clot in the lung, a collapsed lung (pneumothorax), or changes to the lung tissue, making it less flexible.

Constipation

Constipation is easier to sort out if you treat it early. Drink plenty and eat as much fresh fruit and vegetables as you can. Try to take gentle exercise, such as walking. Tell your healthcare team if you think you are constipated. They can give you a laxative if needed.

Liver problems

This includes inflammation of the liver and changes to the levels of liver enzymes. You have regular blood tests to check for this.

Rarely you might have yellowing of the skin and whites of the eyes.

High blood pressure

Tell your doctor or nurse if you have headaches, nosebleeds, blurred or double vision or shortness of breath. You have your blood pressure checked regularly.

Fluid build up in your legs, ankles and feet

You may have swelling of your hands and legs due to a build up of fluid (oedema). 

Eye problems

You may have watery eyes due to an increase in the production of tears.

Swallowing problems or indigestion

You might have a sore throat, difficulty swallowing or indigestion. Speak to your healthcare team if this is a problem for you.

Blood clots

Blood clots can develop in the deep veins of your body, usually the leg. This is called deep vein thrombosis (DVT). A blood clot can be very serious if it travels to your lungs (pulmonary embolism), although this isn’t common.

Symptoms of a blood clot include:

•    pain, redness and swelling around the area where the clot is and may feel warm to touch
•    breathlessness
•    pain in your chest or upper back – dial 999 if you have chest pain
•    coughing up blood

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:

• eye problems such as inflammation of the conjunctiva (conjunctivitis) or vision changes such as blurred or double vision
• hiccups
• indigestion or reflux
• passing wind (flatulence)
• kidney changes – you will have regular blood tests to check for this
• problems with passing urine such as burning or stinging when going, passing blood and changes to how often you go. Rarely you might be unable to control when you pass urine  
• feeling generally unwell (malaise)
• low levels of fluid in the body (dehydration)
• feeling very low (depression)
• difficulty sleeping (insomnia)
• dizziness
• flushing pain along the vein
• runny, itchy nose and sneezing
• inflammation of the membranes covering the brain and spinal cord (meninges) causing symptoms similar to meningitis such as stiff neck, headaches and unable to look at bright light
• swelling of the nerves to your muscles, this can cause problems with moving your body causing weakness, clumsiness, loss of balance and falls
• a sudden feeling of being hot and your skin going red (flushing)
• bleeding in your stomach or from your back passage
• dry mouth
• cold sores
• numbness and tingling sensation on the skin
• an infection in your chest or throat

Rare side effects

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

• ear problems such as hearing loss, ear pain and deafness
• heart problems such as changes to heartrate or rhythm, angina or a heart attack
• severe skin reaction that may start as tender red patches which leads to peeling or blistering of the skin. You might also feel feverish and your eyes may be more sensitive to light. This is serious and could be life threatening
• lumps under the skin (lipoma)
• a blood disorder where your red blood cells get destroyed faster than they can be made (haemolytic anaemia)
• numbness and tingling sensation on the skin, makes it difficult to do fiddly things such as doing up buttons (peripheral neuropathy)
• changes in blood sugar levels (diabetes)
• confusion or memory changes
• sepsis – a life threatening reaction to infection - signs include blood pressure dropping dangerously low, confusion, diarrhoea, feeling or being sick and cold, clammy skin
• posterior reversible encephalopathy syndrome (PRES) - a rare disorder of the nerves causing headaches, fits, confusion and changes in vision. Contact your healthcare team straight away if you have these symptoms. This condition is reversible
• lack of interest in sex
• high levels of a type of fat in your blood
• panic attacks this can make you feel as though your heart is pounding, sweating, feeling weak and dizzy and having trouble breathing
• fainting
• difficulty speaking
• problems with your balance and coordination of your movements
• the feeling of the room around you is spinning or moving (vertigo)
• flu-like symptoms such as fever, chills and muscle aches
• blockage or slow movement of the gut
• inflammation of different parts of the digestive system symptoms can include tummy pain and discomfort, runny poo (diarrhoea) that may or may not have blood in, loss of appetite and urgency to go to the toilet
• difficulty swallowing
• feeling nervous
• oral thrush symptoms can include white patches on the tongue
• tooth infection or abscess
• coughing up blood
• changes to the way that your blood clots
• heavy vaginal bleeding
• shivering and chills (rigors)
• imbalance of substances in your blood (metabolic acidosis) – it can cause confusion, tiredness, shortness of breath and headaches

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.

Pregnancy and contraception

This treatment may harm a baby developing in the womb. It is important not to become pregnant or get someone pregnant while you are having treatment. Talk to your doctor or nurse about effective contraception before starting treatment.

Women must not become pregnant for at least 9 months after the end of treatment. Men should not get someone pregnant for at least 3 months after treatment. 

Talk to your doctor or nurse about effective contraception before starting treatment. Let them know straight away if you or your partner falls pregnant while having treatment.

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.    

Breastfeeding

Don’t breastfeed during this treatment and for 2 weeks after your final treatment. This is because the drug may come through into 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.