FOLFIRINOX (FOLFOXIRI) is used to treat pancreatic cancer and bowel cancer.
FOLFIRINOX (FOLFOXIRI) is a combination treatment used to treat pancreatic cancer and bowel cancer. It may sometimes be used to treat other cancers. It is best to read this information with our general information about chemotherapy and the type of cancer you have.
Your doctor will talk to you about this treatment and its possible side effects before you agree (consent) to have treatment.
FOLFIRINOX and FOLFOXIRI are different names for the same combination of chemotherapy drugs. They are named after the initials of the drugs used for treatment. The drugs are:
- FOL – folinic acid (sometimes called calcium folinate or leucovorin)
- F – fluorouracil (5FU)
- IRIN – irinotecan
- OX – oxaliplatin.
When these drugs are used to treat pancreatic cancer, they are called FOLFIRINOX. When they are used to treat bowel cancer, they are usually called FOLFOXIRI.
In this information, we call fluorouracil by its more common name, 5FU.
Folinic acid is not a chemotherapy drug. It is often given with 5FU to make 5FU work better.
Before starting this treatment, you should have a blood test to check whether you have low levels of an enzyme called DPD. This is called DPD deficiency. People who have low DPD levels can develop serious or life-threatening side effects if they have 5FU. If you have DPD deficiency, this can affect the treatments that are available for you.
You will not know without a test if you have DPD deficiency, as there are no symptoms. Testing can detect most cases of DPD deficiency, but not all cases. You can talk to your cancer doctor about your risk of having DPD deficiency before you start treatment.
You will be given FOLFIRINOX in the chemotherapy day unit or during a 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, and a specialist pharmacist. This is who we mean when we mention doctor, nurse or pharmacist 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 your blood cells are at a safe level to have chemotherapy.
You will see a doctor or nurse before you have chemotherapy. They will talk to you about your blood results and ask you how you have been feeling. If your blood results are okay, the pharmacist will prepare your chemotherapy. Your nurse will tell you when your treatment is likely to be ready.
Your nurse usually gives you anti-sickness (anti-emetic) drugs before the chemotherapy. The chemotherapy drugs can be given through:
- a short thin tube the nurse puts into a vein in your arm or hand (cannula)
- 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).
You will have oxaliplatin, folinic acid and irinotecan as a drip (infusion). They are usually run through a pump, which gives the drip over a set time.
Your nurse will give some 5FU as an injection into your line. Then the rest of the 5FU is usually given through a small pump that you carry on a belt or in a holder. You will be able to go home once the pump is connected to your line and has been started.
You may come back to the hospital to have the pump disconnected. Sometimes a district nurse will do this for you at home. Your chemotherapy nurse will explain how to look after the pump. They can also tell you what to do if there is a problem.
If you have a cannula, you will need to stay in hospital to have the 5FU.
Your course of chemotherapy
You usually have a course of several cycles of treatment over a few months.
FOLFIRINOX and FOLFOXIRI are usually given every 14 days.
On the first day of your treatment you will have the following. They may not always be given in this order:
- Oxaliplatin as a drip over 2 hours.
- Folinic acid as a drip over two hours – some people have it at the same time as oxaliplatin.
- Irinotecan as drip over 90 minutes, the first time you have it (after this you can have it over 30 minutes).
- If you are having FOLFIRINOX, you have 5FU first as an injection into a vein over a few minutes, then through an infusion pump over the next 46 hours.
- If you are having FOLFOXIRI you have 5FU through an infusion pump over the next 48 hours.
When the pump is finished you have a rest period of 12 days with no treatment. This completes your first cycle of FOLFIRINOX or FOLFOXIRI.
After this you then start your second cycle of FOLFIRINOX or FOLFOXIRI.
Your nurse or doctor will talk to you about how the treatment will be given. They may give you a copy of a treatment plan to take home with you.
We explain the most common side effects of this treatment here. We also include some less common side effects. You may get some of the side effects we mention, but you are unlikely to get all of them.
You may also have some side effects that we have not listed here. Always tell your doctor, nurse or pharmacist about any side effects you have.
Your doctor can give you drugs to help control some side effects. It is important to take them exactly as your nurse or pharmacist explains. This means they will be more likely to work for you. Your nurse will give you advice about managing your side effects. After your treatment is over, most side effects start to improve.
Serious and life-threatening side effects
Some cancer treatments can cause severe side effects. Rarely, these may be life-threatening. Your cancer doctor, nurse or pharmacist can explain the risk of these side effects to you.
If you have low levels of an enzyme called DPD (DPD deficiency), you may have a higher risk of severe or life-threatening side effects.
Contact the hospital
Your nurse will give you telephone numbers for the hospital. If you feel unwell or need advice, you can call them at any time of the day or night. Save these numbers in your phone or keep them somewhere safe.
We cannot list every side effect for this treatment. There are some rare side effects that are not listed. You can visit the electronic Medicines Compendium (eMC) for more detailed information.
Some people have an allergic reaction while having this treatment. Signs of a reaction can include:
- feeling hot or flushed
- a skin rash
- feeling dizzy
- a headache
- feeling breathless or wheezy
- swelling of your face or mouth
- pain in your back, tummy or chest.
Your nurse will check you for signs of a reaction during your treatment. If you feel unwell or have any of these signs, tell them straight away. If you do have a reaction, it can be treated quickly.
Sometimes a reaction happens a few hours after treatment. If you develop any signs or feel unwell after you get home, contact the hospital straight away.
Pain along the vein
Irinotecan reaction (acute cholinergic syndrome)
Some people may have side effects within 24 hours of having irinotecan. These include:
- tummy cramps
- sweating more than usual
- producing a lot of saliva
- problems with vision.
This is called acute cholinergic syndrome. Contact your doctor or nurse if you have any of these symptoms. If this happens do not drive or operate machinery.
Acute cholinergic syndrome can usually be prevented or controlled by a drug called atropine. If it is needed, your nurse gives you atropine as an injection under the skin (subcutaneously).
Rarely, oxaliplatin can cause a spasm in the throat area around the voice box (larynx). This can make swallowing and breathing difficult. Throat spasm may happen during treatment or in the first few days after treatment. It can be frightening, but it should not last long. If you have breathing difficulties, take long, deep breaths through your nose. This will help calm you and help your breathing return to normal.
Throat spasm may be worse in cold temperatures. It is best to avoid cold drinks and ice cubes during treatment and for a few days afterwards. It might also help to wrap up warm and cover your nose and mouth in cold weather.
It is important to let your doctor know if you have this side effect. Your doctor may increase the time of your infusion to 4 to 6 hours in future cycles. This will reduce the chance of it happening again.
Risk of infection
This treatment can reduce the number of white blood cells in your blood. These cells fight infection. If the number of white blood cells is low, you are more likely to get an infection. A low white blood cell count is sometimes called neutropenia.
An infection can be very serious when the number of white blood cells is low. It is important to get any infection treated as soon as possible. Contact the hospital straight away on the 24-hour contact number you have been given if:
- your temperature goes over 37.5°C (99.5°F)
- you suddenly feel unwell, even with a normal temperature
- you have symptoms of an infection
- your temperature goes below 36°C (96.8°F).
Symptoms of an infection include:
- feeling shivery and shaking
- a sore throat
- a cough
- needing to pass urine (pee) a lot, or discomfort when you pass urine.
It is important to follow any specific advice your cancer treatment team gives you.
The number of white blood cells will usually return to normal before your next treatment. You will have a blood test before having more treatment. If your white blood cell count is low, your doctor may delay your treatment for a short time, until your cell count increases.
Bruising and bleeding
This treatment can reduce the number of platelets in your blood. Platelets are cells that help the blood to clot.
If the number of platelets is low, you may bruise or bleed easily. You may have:
- bleeding gums
- heavy periods
- blood in your urine (pee) or stools (poo)
- tiny red or purple spots on the skin that may look like a rash.
Tell your doctor if you have any unexplained bruising or bleeding. You may need a drip to give you extra platelets. This is called a platelet transfusion.
Anaemia (low number of red blood cells)
This treatment can reduce the number of red blood cells in your blood. Red blood cells carry oxygen around the body. If the number of red blood cells is low, this is called anaemia. You may have symptoms such as:
- pale skin
- lack of energy
- feeling breathless
- feeling dizzy and light-headed.
Tell your doctor or nurse if you have these symptoms.
If you are very anaemic, you may need a drip to give you extra red blood cells. This is called a blood transfusion.
This treatment may cause severe diarrhoea. Diarrhoea means passing more stools (poo) than is usual for you, or having watery or loose stools. If you have a stoma, it will be more active than usual.
Your hospital team may give you anti-diarrhoea drugs to take at home.
If you have diarrhoea or a mild increase in stoma activity:
- follow any advice from your cancer team about taking anti-diarrhoea drugs
- drink at least 2 litres (3½ pints) of fluids each day
- avoid alcohol, caffeine, milk products, high-fat foods and high-fibre foods.
Contact the hospital straight away if:
- you have diarrhoea at night
- you have diarrhoea more than 4 times in a day
- you have a moderate or severe increase in stoma activity
- the anti-diarrhoea drugs do not work within 24 hours.
You may need to go to hospital to have fluids through a drip.
Your doctor will give you anti-sickness drugs to help prevent or control sickness during your treatment. Take the drugs exactly as your nurse or pharmacist tells you. It is easier to prevent sickness than to treat it after it has started.If you feel sick, take small sips of fluids often and eat small amounts regularly. It is important to drink enough fluids. If you continue to feel sick, or are sick (vomit) more than once in 24 hours, contact the hospital as soon as possible. They will give you advice. Your doctor or nurse may change the anti-sickness drug to one that works better for you.
Sore mouth and throat
This treatment may cause a sore mouth and throat. You may also get mouth ulcers. This can make you more likely to get a mouth or throat infection. Use a soft toothbrush to clean your teeth or dentures in the morning, at night and after meals.
If your mouth or throat is sore:
- tell your nurse or doctor – they can give you a mouthwash or medicines to help
- try to drink plenty of fluids
- avoid alcohol, tobacco, and foods that irritate your mouth and throat.
Sucking ice chips may sometimes help relieve mouth or throat pain. But if you are having radiotherapy to the head or neck, do not suck on ice. It can cause damage.
Changes to your taste
You may get a bitter or metal taste in your mouth. Sucking sugar-free sweets may help with this. Some foods may taste different or have no taste. Try different foods to find out what tastes best to you. Taste changes usually get better after treatment finishes. Your nurse can give you more advice.
Numb or tingling hands or feet (peripheral neuropathy)
This treatment affects the nerves, which can affect your sense of touch. You may have numb, tingling or painful hands or feet. You may 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 between treatments and get better after treatment finishes. But for some people they may never go away. Talk to your doctor if you are worried about this.
During treatment, these symptoms are often made worse by the cold. It can help to keep warm and avoid iced drinks. You may need to take care opening the fridge and use gloves to handle frozen food.
Feeling tired is a common side effect of this treatment. It is often worse towards the end of treatment and for some weeks after it has finished. Try to pace yourself and plan your day so you have time to rest. Gentle exercise, like short walks, can give you more energy.
If you feel sleepy, do not drive or use machinery.
Your hair will get thinner. Or you may lose all the hair from your head. You may also lose your eyelashes and eyebrows, as well as other body hair. Hair loss usually starts after your first or second treatment.
Your nurse can talk to you about ways to cope with hair loss. There are ways to cover up hair loss if you want to. Your scalp may be sensitive. It is important to cover your head to protect your skin when you are out in the sun.
Hair loss is almost always temporary. Your hair will usually grow back after treatment finishes.
Muscle or joint pain
You may get pain in your muscles or joints for a few days after treatment. If this happens, tell your doctor so they can give you painkillers. Tell them if the pain does not get better. Having warm baths and taking regular rests may help.
Sore and red palms of hands and soles of feet
You may get sore and red palms of hands and soles of feet. The skin may also begin to peel. This is called palmar-plantar or hand-foot syndrome. It usually gets better after treatment ends.
Tell your doctor or nurse about any changes to your hands or feet. They can give you advice and prescribe creams to improve any symptoms you have. It can help to:
- keep your hands and feet cool
- moisturise your hands and feet regularly
- 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. 5FU can cause a rash, which may be itchy.
During treatment and for several months afterwards, you will 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
- cover up with clothing
- wear a hat.
Your skin may darken. It will return to its normal colour after you finish treatment.
Always tell your doctor or nurse about any skin changes. They can give you advice and may give you creams or medicines to help. Any changes to your skin are usually temporary and improve when treatment finishes.
Changes in the way the heart works
5FU can affect how the heart works. You may have tests to see how well your heart is working. These may be done before, during and after treatment.
It is still possible for the heart to be affected even if these test results are normal. Very rarely, this can cause heart failure or a heart attack. The risk of this happening is very low (less than 1 in 100 or 1%). But it is important that you know about it.
Call your doctor straight away on the 24-hour number the hospital has given you if you have any of these symptoms at any time during treatment:
- pain or tightness in your chest
- changes to your heartbeat.
If you cannot get through to your doctor, call the NHS urgent advice number which is 111.
5FU can cause a sudden tightness in your chest, making it difficult to breath. This can happen if the muscles in your airway contract for a short time (spasm). This can also cause a cough or wheeze. Contact your doctor straight away if you have difficulty breathing.
Effects on the lungs
This treatment can cause changes to the lungs. Tell your doctor if you develop:
- a cough
- a fever (high temperature)
You should also tell them if any existing breathing problems get worse. You may have tests to check your lungs.
This treatment may make your eyes feel sore, red and itchy (conjunctivitis). Your doctor will prescribe eye drops to help prevent this. It is important to use these as you are told to.
This treatment may also cause blurry vision. If you have pain or notice any change in your vision, always tell your doctor or nurse.
This treatment may cause you discomfort when you pass urine (pee). You may also pass urine more often than usual. Make sure you drink plenty of fluids during the 24 hours following chemotherapy. Try to drink at least 2 litres (3½ pints) of fluids each day.
It is also important to empty your bladder regularly and to try to pass urine as soon as you feel the need to go.
Contact the hospital straight away if you feel any discomfort or stinging when you pass urine, or if you notice any blood in it.
Effects on the liver
This treatment may cause changes in the way your liver works. You are very unlikely to notice any problems. Your doctor will take regular blood samples to check how your liver is working.
Rarely treatment can cause:
- skin or the whites of eyes to turn yellow (jaundice)
- a swollen tummy (abdomen)
- vomiting with blood in it.
Tell your doctor straight away if you notice any of these symptoms.
This treatment may cause hearing changes, including hearing loss. You may have ringing in the ears. This is called tinnitus. You may also become unable to hear some high-pitched sounds. Hearing changes usually get better after this treatment ends. But some can be permanent. Tell your doctor if you notice any changes in your hearing.
Effects on the nervous system
Rarely, this treatment can affect the nervous system. This can cause symptoms including:
- eye pain or changes in eyesight
- confusion or drowsiness
- seizures (fits)
- weakness in an arm or leg.
Contact the hospital straight away if you notice any of these symptoms. It is important not to drive or operate machinery if you notice these effects.
Blood clot risk
Cancer and some cancer treatments can increase the risk of a blood clot. Symptoms of a blood clot include:
- throbbing pain, redness or swelling in a leg or arm
- suddenly feeling breathless or coughing
- sharp chest pain, which may be worse when you cough or take a deep breath.
If you have any of these symptoms, contact the hospital straight away on the 24-hour contact number you have been given. If you cannot get through to your doctor, call the NHS urgent advice number on 111.
A blood clot is serious, but it can be treated with drugs that thin the blood (anticoagulants). Your doctor or nurse can give you more information.
You can help reduce the risk of developing a blood clot by:
- staying active during treatment
- drinking plenty of fluids, especially water.
You may be given anticoagulants to help prevent a clot.
Some medicines can affect how this treatment works or be harmful when you are having it. Always tell your cancer doctor about any drugs you are taking or planning to take, such as:
- medicines you have been prescribed
- medicines you buy in a shop or chemist
- vitamins, herbal drugs and complementary therapies.
Tell other doctors, pharmacists or dentists who prescribe or give you medicines that you are having this cancer treatment.
You can visit the electronic Medicines Compendium (eMC) for more detailed information about your treatment.
Vaccinations can reduce your risk of getting certain infections. Your doctor or nurse may talk to you about having vaccinations.
Doctors usually recommend that people with cancer have a flu vaccination and a coronavirus vaccination. These are both inactivated vaccinations that can help reduce the risk of infection. People with weak immune systems can have these, as they are not live vaccinations.
If your immune system is weak, you need to avoid live vaccinations. This is because they can make you unwell. Live vaccines, such as shingles, contain a very weak version of the illness they are vaccinating you against. Your cancer doctor or GP can tell you more about live and inactivated vaccinations.
Your doctor will advise you not to get pregnant or make someone pregnant while having this treatment. The drugs may harm a developing baby. It is important to use contraception during your treatment and for a while after treatment finishes. Your doctor, nurse or pharmacist can tell you more about this.
You are advised not to breastfeed while having this treatment, or for some time after treatment finishes. This is because the drugs could be passed to the baby through breast milk.
Your doctor or nurse can give you more information.
If you have sex in the first few days after this treatment, you should use barrier protection such as a condom or dental dam. This will protect your partner if any of the drug is in your semen or vaginal fluids.
Medical and dental treatment
If you need medical treatment for any reason other than cancer, always tell the doctors and nurses you are having cancer treatment. Give them the contact details for your cancer doctor so they can ask for advice.
If you think you need dental treatment, talk to your cancer doctor or nurse. Always tell your dentist you are having cancer treatment.
This information has been written, revised and edited by Macmillan Cancer Support’s Cancer Information Development team. It has been reviewed by expert health professionals and people living with cancer.
Our cancer information has been awarded the PIF TICK. Created by the Patient Information Forum, this quality mark shows we meet PIF’s 10 criteria for trustworthy health information.