MFOLFIRINOX

Language English

Regimen Monograph References:

Conroy T, Hammel P, Hebbar M, et al. FOLFIRINOX or gemcitabine as adjuvant therapy for pancreatic cancer. N Engl J Med 2018;379:2395-406. DOI: 10.1056/NEJMoa1809775

Cancer Type: Gastrointestinal Pancreas Type of Content: Regimen Regimen Code:

MFOLFIRINOX

Intent: Adjuvant Regimen Category:

Evidence-informed

Drugs Used: oxaliplatin leucovorin irinotecan fluorouracil Regimen Monograph Name:

MFOLFIRINOX_GI_PAN_A

Regimen Monograph Body:

Regimen Monograph

A - Regimen Name

MFOLFIRINOX Regimen

Folinic Acid (Leucovorin)-Fluorouracil-Irinotecan-Oxaliplatin

Disease Site

Gastrointestinal

Pancreas

Intent

Adjuvant

Regimen Category

Evidence-informed :

Regimen is considered appropriate as part of the standard care of patients; meaningfully improves outcomes (survival, quality of life), tolerability or costs compared to alternatives (recommended by the Disease Site Team and national consensus body e.g. pan-Canadian Oncology Drug Review, pCODR). Recommendation is based on an appropriately conducted phase III clinical trial relevant to the Canadian context OR (where phase III trials are not feasible) an appropriately sized phase II trial. Regimens where one or more drugs are not approved by Health Canada for any indication will be identified under Rationale and Use.

This Regimen Abstract is an abbreviated version of a Regimen Monograph and contains only top level information on usage, dosing, schedule, cycle length and special notes (if available). Information in regimen abstracts is accurate to the extent of the ST-QBP regimen master listings, and has not undergone the full review process of a regimen monograph. Full regimen monographs will be published for each ST-QBP regimen as they are developed.

Rationale and Uses

Adjuvant therapy in patients with resected pancreatic cancer

B - Drug Regimen

oxaliplatin

85 mg /m²

IV over 2 hours

Day 1

THEN,

leucovorin

400 mg /m²

IV over 2 hours

Day 1

30 minutes after starting leucovorin, give:

irinotecan

150 mg /m²

IV over 90 minutes, concurrently with leucovorin

Day 1

THEN,

fluorouracil

2400 mg /m²

IV continuous infusion over 46 hours (single dose)

Start on Day 1

C - Cycle Frequency

REPEAT EVERY 14 DAYS

For a usual total of 12 cycles unless disease progression or unacceptable toxicity occurs

D - Premedication and Supportive Measures

Antiemetic Regimen:

Moderate

Febrile Neutropenia Risk:

Moderate

Consider G-CSF in patients with high risk of febrile neutropenia. See G-CSF recommendations.

Other Supportive Care:

Screen for hepatitis B virus in all cancer patients starting systemic treatment. Refer to the hepatitis B virus screening and management guideline.
For irinotecan cholinergic adverse effects (early diarrhea):
- Unless contraindicated, atropine 0.25-1mg IV/SC may be given
- Prophylactic atropine may be considered in patients who have experienced cholinergic symptoms
Loperamide must be provided. Diarrhea (including abdominal cramps) may be severe and delayed with irinotecan.
Give loperamide 4mg at the onset of diarrhea, then 2mg q2h until patient is diarrhea-free for 12 hours. During the night the patient may take 4mg of loperamide every 4 hours.

May consider antibiotics for patients with ileus, fever or febrile neutropenia.
Avoid mucositis prophylaxis with ice chips as cold temperatures can precipitate or exacerbate acute neurological symptoms of oxaliplatin.

Premedication for oxaliplatin (prophylaxis for infusion reactions):

There is insufficient evidence that routine prophylaxis with pre-medications reduces IR rates.
Consider corticosteroids and H1-receptor antagonists ± H2-receptor antagonists in high-risk patients (i.e. ≥ cycle 6, younger age, female gender, prior platinum exposure, platinum-free interval ≥ 3 years).

E - Dose Modifications

Doses should be modified according to the protocol by which the patient is being treated.

Patients should be tested for DPD deficiency before starting treatment with fluorouracil. Refer to the DPD Deficiency Guidance for Clinicians for more information.

In patients with unrecognized DPD deficiency, acute, life-threatening toxicity may occur; if acute grade 2-4 toxicity develops, treatment should be stopped immediately and permanent discontinuation considered based on clinical assessment of the toxicities.

Dosage with toxicity

Do not start new cycle until platelets ≥ 100 x 10⁹/L and ANC ≥ 1.5 x 10⁹/L, recovery from diarrhea (to baseline without loperamide for at least 24 hours), and other non-hematologic toxicities have recovered to ≤grade 2.

Doses should be adjusted based on the worst preceding toxicity. Do not re-escalate dose if reduced for toxicity.

No dose adjustment is required for leucovorin. Leucovorin should be omitted if fluorouracil is omitted.

Dose Levels:

Drug	Dose level 0 (mg/m²)	Dose level -1* (mg/m²)
Irinotecan	150	120
Oxaliplatin	85	60
Fluorouracil infusion	2400	1800

* If further dose reduction is required, consider a 20% dose reduction or discontinuing the regimen.

Dose Modifications:

Toxicity	Occurrence	Irinotecan dose^a,b,c	Oxaliplatin dose^a,b,c	Fluorouracil dose^a,b,c
Febrile neutropenia OR Grade 4 ANC > 7 d OR Delay 1-2 weeks for ≥ Grade 2 ANC	1^st	↓ 1 dose level	No change	No change
	2^nd	Maintain same dose level	↓ 1 dose level	No change
	3rd	Consider further dose reduction, or only keep fluorouracil infusion if necessary
≥ grade 3 platelets OR Delay 1-2 weeks for platelets <100 x 10⁹/L	1^st	No change	↓ 1 dose level	No change
	2^nd	↓ 1 dose level	Maintain same dose level	↓ 1 dose level
	3rd	Discontinue		Maintain same dose level
Diarrhea ≥ grade 3 OR Diarrhea with fever or ≥ Grade 3 ANC	1^st	↓ 1 dose level	No change	No change
	2^nd	Maintain same dose level	↓ 1 dose level	↓ 1 dose level
	3rd	Discontinue	Maintain same dose level	Maintain same dose level
Grade 3 or 4 mucositis or hand-foot syndrome	-	No change	No change	↓ 1 dose level
Grade 2 persistent neurotoxicity	-	No change	↓ 1 dose level	No change
Grade 3 neurotoxicity (recovers prior to next cycle)	-	No change	↓ 1 dose level	No change
Grade 3 persistent neurotoxicity OR Grade 4 neurotoxicity	Any	No change	Discontinue	No change
Grade 2 other non-hematological	-	Consider ↓	Consider ↓	Consider ↓
Grade 3 other non-hematological	-	↓ 1 dose level	↓ 1 dose level	↓ 1 dose level
Pneumonitis	Any	Discontinue	Discontinue	Discontinue
Grade 4 other non-hematological OR RPLS OR Hemolytic uremic syndrome or any signs of microangiopathic hemolytic anemia	Any	Discontinue	Discontinue	Discontinue
Pharyngolaryngeal dysesthesia	-	-	↑ infusion to 6 hours	-
^aDo not treat until ANC ≥ 1.5 x 10⁹/L, platelets ≥ 100 x 10⁹/L, diarrhea resolved to baseline and other toxicity ≤ grade 2. Do not re-escalate dose if reduced for toxicity. ^bConsider discontinuing the regimen if cycle delayed for > 2 weeks. ^cConsider adding GCSF at restart for neutropenia.

Management of Oxaliplatin Infusion-related reactions:

Also refer to the CCO guideline for detailed description of Management of Cancer Medication-Related Infusion Reactions.

Grade

Management

Re-challenge

1 or 2

Stop or slow the infusion rate.
Manage the symptoms.

Restart:

After symptom resolution, restart with pre-medications ± reduced infusion rate.

Consider pre-medications^* and infusing at a reduced infusion rate prior to re-challenge.
May consider adding oral montelukast ± oral acetylsalicylic acid.

3 or 4

Stop treatment.
Aggressively manage symptoms.

Re-challenge is discouraged, especially if vital signs have been affected.
Consider desensitization if therapy is necessary.

^* _{Up to 50% of patients can experience recurrent reactions during re-challenge despite using pre-medications (e.g. corticosteroid and H1/H2-receptor antagonist).}

Hepatic Impairment

Transaminases		Bilirubin^	Irinotecan dose	Oxaliplatin dose	5FU dose
		1 to 1.5 X ULN or Gilbert's	Consider ↓	No change	No change
> 3 to 5 X ULN*	and/or	>1.5 to 4 X ULN	Omit	No change	Consider ↓ (e.g. 75% of previous dose)
>5 to 10 X ULN	and/or	>1.5 to 4 X ULN	Omit	No change	Consider ↓ (e.g. 50-75% of previous dose)
> 10 X ULN	and/or	> 4 X ULN	Omit	No info found	Omit
* or >5 X ULN with liver metastases

^ If bilirubin ↑, consider investigating for reversible causes such as biliary obstruction and re-evaluate after stent.

Renal Impairment

Creatinine Clearance (mL/min)	oxaliplatin (% previous dose)	fluorouracil (% previous dose)	irinotecan (% previous dose)
≥50	No change	No change	No change
30 to < 50	Caution	No change	No change
<30	Discontinue	Consider dose reduction	Caution

F - Adverse Effects

Refer to oxaliplatin, leucovorin, irinotecan, fluorouracil drug monograph(s) for additional details of adverse effects

Very common (≥ 50%)

Common (25-49%)

Less common (10-24%)

Uncommon (< 10%),

but may be severe or life-threatening

Sensory neuropathy
Myelosuppression ± infection, bleeding (may be severe)
Nausea/ vomiting
Fatigue
Alopecia
↑ Bilirubin/ LFTs
Diarrhea (early 51%; late 88%; may be severe)
Anorexia, weight loss

Mucositis
Pharyngolaryngeal dysesthesia
Constipation
Cholinergic symptoms
Conjunctivitis/tearing

Cough/ dyspnea
Rash/dry skin/ photosensitivity
Anorexia
Insomnia
Headache
Dizziness
Edema
Rhinitis
Musculoskeletal pain
Hyperglycemia
Hand-foot syndrome
Flushing
Dyspepsia
Dysgeusia
Abnormal electrolytes (↓Ca, K, Na)
Injection site reaction
Hypersensitivity

Cardiotoxicity
Arrhythmia/QT prolongation
Arterial/venous thromboembolism
DIC
ITP
Hypotension
Radiation recall reaction
GI ulceration/ ischemia/ obstruction/ perforation
Hemolysis
Hemolytic uremic syndrome
Hepatic necrosis
VOD
Pancreatitis
Acute cerebellar syndrome
Rhabdomyolysis
Guillain-Barre syndrome
Extrapyramidal disorder
Leukoencephalopathy
RPLS/PRES
Optic neuritis
Seizure
Renal failure
Pneumonitis
Hearing impairment

G - Interactions

Refer to oxaliplatin, leucovorin, irinotecan, fluorouracil drug monograph(s) for additional details

Use of fluorouracil within 4 weeks of treatment with brivudine, sorivudine (and chemically related analogues) is contraindicated.
Azole antifungals are contraindicated with irinotecan (discontinue one week before the first dose of irinotecan).
Avoid concomitant use of metronidazole and fluorouracil if possible.
Avoid concomitant use of strong CYP3A4 inhibitors and inducers with irinotecan.
Avoid concomitant use of prochlorperazine (on same day of irinotecan treatment), turmeric and azatanavir with irinotecan.
Thiazide diuretics may decrease renal excretion of fluorouracil; consider an alternative antihypertensive.
Monitor INR closely while on concomitant warfarin and fluorouracil or oxaliplatin; adjust warfarin dose accordingly.
Monitor phenytoin levels if used concurrently with fluorouracil.
Monitor for toxicity when oxaliplatin is used with other drugs that are nephrotoxic, prolong QT or are associated with rhabdomyolysis.
Caution with the concurrent use of cimetidine due to interference with fluorouracil metabolism; fatal cases have been reported.

H - Drug Administration and Special Precautions

Refer to oxaliplatin, leucovorin, irinotecan, fluorouracil drug monograph(s) for additional details

Oxaliplatin:

Oxaliplatin is administered by intravenous infusion.
Oxaliplatin should always be administered before fluorouracil.
May be mixed in 250-500 mL bag of D5W only. Do not mix oxaliplatin with NS, chloride containing or alkaline solutions, or with fluorouracil.
Administer by slow infusion. Concentration must be between 0.2 to 0.7 mg/mL
Infuse IV over 2 hours. Increasing infusion time to 6 hours may decrease acute toxicity such as pharyngolaryngeal dysesthesia.
Do not mix oxaliplatin with other drugs in the same infusion bag or infusion line.
If another drug is given before oxaliplatin, flush infusion line with D5W before giving oxaliplatin. Flush the line with D5W after oxaliplatin before giving a subsequent drug.
The compatibility of oxaliplatin solution for infusion has been tested with representative, PVC-based, administration sets.
Do not use with injection equipment containing aluminum, as this can degrade platinum compounds.
Unopened vials should be stored at 15-30°C; protect from light.

Leucovorin:

Leucovorin may be diluted in 250mL D5W.
Leucovorin should not be mixed in the same infusion as 5-fluorouracil as a precipitate may form.
Keep refrigerated; protect from light.

Irinotecan:

Mix in 500mL bag D5W in a concentration range between 0.12 to 3 mg/mL; infuse IV over 90 minutes.
Infusion may be given at the same time as leucovorin in separate D5W bags using a Y-site.
Avoid freezing irinotecan and its admixtures since this may result in drug precipitation.
Do not admix with other drugs.
Protect from light.
Prior to the initial irinotecan treatment, patients should be given a sufficient supply of loperamide and instructed on its appropriate use.

Fluorouracil:

IV CONTINUOUS INFUSION:

Refer to local guidelines on preparation of fluorouracil IV infusion.
Continuous infusion via central line or PICC using CADD infusion pump, infusor bottle or similar device
Incompatible with doxorubicin, epirubicin, diazepam, methotrexate and cytarabine; line must be flushed between administrations of fluorouracil and these agents.
Store at room temperature (15 to 25ºC). Protect from light.

Refer to Section L - Other Notes section for Information on the Antidote for Fluorouracil Overdose.

Also refer to the CCO guideline for detailed description of Management of Cancer Medication-Related Infusion Reactions.

Contraindications:

Hypersensitivity to fluorouracil, irinotecan, leucovorin, oxaliplatin or to other platinum agents (e.g. cisplatin, carboplatin) or to any component of the formulation.
Patients with severe renal impairment (CrCl < 30 mL/min), with oxaliplatin
Patients with poor nutritional state
Patients with depressed bone marrow function (prior pelvic irradiation / marrow infiltration)
Patients with potentially serious infections
Patients with known complete absence of dihydropyrimidine dehydrogenase (DPD) activity, with fluorouracil. Refer to the DPD Deficiency Guidance for Clinicians for more information.
Avoid in patients with hereditary fructose intolerance since the irinotecan formulation contains sorbitol.
Avoid the use of live or live attenuated vaccines.
Fluorouracil should not be used within 4 weeks of treatment with brivudine, sorivudine or their chemically related analogues. (See interactions section)
Irinotecan should not be co-administered with azole antifungals (ketoconazole etc. See Interactions section)

Warnings/Precautions:

Oxaliplatin may result in dizziness or visual disturbances (including transient vision loss) in some patients; patients should exercise caution in driving or operating machinery.
Do not give oxaliplatin intraperitoneally.
Irinotecan is not recommended for use in patients with ECOG performance status 3 or 4, or in patients with moderate or severe increases in bilirubin.
Carefully monitor and consider irinotecan dose reduction for elderly patients, patients with poor performance status (= 2), limited marrow reserve, 3rd space accumulation, Gilbert’s syndrome and patients with reduced UGT1A1 activity; they may be more susceptible to the toxic effects of irinotecan.
Concurrent administration of irinotecan with irradiation is not recommended. Patients with prior pelvic or abdominal irradiation are at an increased risk of severe myelosuppression following irinotecan therapy.
Use fluorouracil with extreme caution in patients who:
- have undergone recent major surgery,
- have renal or hepatic impairment,
- have widespread bone marrow involvement,
- have previous use of other myelosuppressive chemotherapeutic agents,
- have a history of high dose irradiation to bone marrow-bearing areas,
- have a history of heart disease,
- or are suspected to have DPD deficiency. Refer to the DPD Deficiency Guidance for Clinicians for more information.

Pregnancy/Lactation:

This regimen is contraindicated for use in pregnancy. Adequate contraception should be used by patients and their partners while on treatment and after the last treatment dose. Recommended methods and duration of contraception may differ depending on the treatment. Refer to the drug monograph(s) for more information.
Breastfeeding is contraindicated during this treatment and after the last treatment dose. Refer to the drug monograph(s) for recommendations after the last treatment dose (if available).
Fertility effects: Yes

I - Recommended Clinical Monitoring

Treating physicians may decide to monitor more or less frequently for individual patients but should always consider recommendations from the product monograph.

Refer to the hepatitis B virus screening and management guideline for monitoring during and after treatment.

Recommended Clinical Monitoring

CBC; baseline and before each cycle
Liver and renal function tests; baseline and before each cycle
Electrolytes, including magnesium; baseline and before each cycle
INR for patients on warfarin; baseline and as clinically indicated
Routine toxicity rating of diarrhea and other GI effects, fatigue, cholinergic symptoms, hypersensitivity, pneumonitis, bleeding, infection, dehydration, pancreatitis, neuropathy, thromboembolism, local reactions, skin (including rash, hand-foot syndrome), ophthalmic and cardiac toxicity.
Grade toxicity using the current NCI-CTCAE (Common Terminology Criteria for Adverse Events) version

Suggested Clinical Monitoring

Blood glucose, especially in patients with diabetes; Baseline and regularly

J - Administrative Information

Approximate Patient Visit

4 hours

Pharmacy Workload (average time per visit)

39.92 minutes

Nursing Workload (average time per visit)

69.17 minutes

K - References

Conroy T, Hammel P, Hebbar M, et al. FOLFIRINOX or gemcitabine as adjuvant therapy for pancreatic cancer. N Engl J Med 2018;379:2395-406. DOI: 10.1056/NEJMoa1809775

PEBC Advice Documents or Guidelines

Role of Adjuvant Treatment in Resected Pancreatic Ductal Adenocarcinoma

November 2023 Modified Pregnancy/lactation section

L - Other Notes

Diarrhea can be severe, with either immediate or delayed onset. Patients must be instructed in the use of Loperamide as treatment for diarrhea, and must have a supply of this drug upon starting Irinotecan treatments.

Antidote for Fluorouracil Overdose:

Uridine triacetate is a prodrug of uridine and is a specific antidote for treating fluorouracil overdose or severe early onset toxicities. If available, consider administering as soon as possible (i.e. within 96 hours) for suspected overdose. If not available, treatment is symptomatic and supportive.

For usage approval and supply, contact Health Canada’s Special Access Program (SAP) (Phone: 613-941-2108. On-call service is available for emergencies). Uridine triacetate (Vistogard®) is supplied by its manufacturer in the United States (Wellstat Therapeutics).

The recommended dosing and administration for uridine triacetate in patients ≥18 years is:

10 grams (1 packet of coated granules) orally every 6 hours for 20 doses in total, without regards to meals.
Granules should not be chewed. They should be mixed with 3 to 4 ounces of soft foods such as applesauce, pudding or yogurt.
The dose should be ingested within 30 minutes of preparation, followed by at least 4 ounces of water.
Refer to the prescribing information on dose preparation for NG-tube or G-tube use.

Additional resources on the management of fluorouracil infusion overdose:

Management of Fluorouracil Infusion Overdose Guideline (Alberta Health Services)
Management of Fluorouracil Infusion Overdose at the BCCA - Interim Guidance (BC Cancer Agency)

M - Disclaimer

Regimen Abstracts
A Regimen Abstract is an abbreviated version of a Regimen Monograph and contains only top level information on usage, dosing, schedule, cycle length and special notes (if available). It is intended for healthcare providers and is to be used for informational purposes only. It is not intended to constitute or be a substitute for medical advice, and all uses of the Regimen Abstract are subject to clinical judgment. Such information is provided on an “as-is” basis, without any representation, warranty, or condition, whether express, or implied, statutory or otherwise, as to the information’s quality, accuracy, currency, completeness, or reliability, and Cancer Care Ontario disclaims all liability for the use of this information, and for any claims, actions, demands or suits that arise from such use.
Information in regimen abstracts is accurate to the extent of the ST-QBP regimen master listings, and has not undergone the full review process of a regimen monograph. Full regimen monographs will be published for each ST-QBP regimen as they are developed.
Regimen Monographs
Refer to the New Drug Funding Program or Ontario Public Drug Programs websites for the most up-to-date public funding information.
The information set out in the drug monographs, regimen monographs, appendices and symptom management information (for health professionals) contained in the Drug Formulary (the "Formulary") is intended for healthcare providers and is to be used for informational purposes only. The information is not intended to cover all possible uses, directions, precautions, drug interactions or adverse effects of a particular drug, nor should it be construed to indicate that use of a particular drug is safe, appropriate or effective for a given condition. The information in the Formulary is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. All uses of the Formulary are subject to clinical judgment and actual prescribing patterns may not follow the information provided in the Formulary.
The format and content of the drug monographs, regimen monographs, appendices and symptom management information contained in the Formulary will change as they are reviewed and revised on a periodic basis. The date of last revision will be visible on each page of the monograph and regimen. Since standards of usage are constantly evolving, it is advised that the Formulary not be used as the sole source of information. It is strongly recommended that original references or product monograph be consulted prior to using a chemotherapy regimen for the first time.
Some Formulary documents, such as the medication information sheets, regimen information sheets and symptom management information (for patients), are intended for patients. Patients should always consult with their healthcare provider if they have questions regarding any information set out in the Formulary documents.
While care has been taken in the preparation of the information contained in the Formulary, such information is provided on an “as-is” basis, without any representation, warranty, or condition, whether express, or implied, statutory or otherwise, as to the information’s quality, accuracy, currency, completeness, or reliability.
CCO and the Formulary’s content providers shall have no liability, whether direct, indirect, consequential, contingent, special, or incidental, related to or arising from the information in the Formulary or its use thereof, whether based on breach of contract or tort (including negligence), and even if advised of the possibility thereof. Anyone using the information in the Formulary does so at his or her own risk, and by using such information, agrees to indemnify CCO and its content providers from any and all liability, loss, damages, costs and expenses (including legal fees and expenses) arising from such person’s use of the information in the Formulary.

Regimen Info Sheet Name: FOLFIRINOX (Pancreas_P) Regimen Info Sheet Body:

MFOLFIRINOX Treatment

This handout gives general information about this cancer treatment.

You will learn:

who to contact for help
what the treatment is
how it is given
what to expect while on treatment

This handout was created by Ontario Health (Cancer Care Ontario) together with patients and their caregivers who have also gone through cancer treatment. It is meant to help support you through your cancer treatment and answer some of your questions.

This information does not replace the advice of your health care team. Always talk to your health care team about your treatment.

Who do I contact if I have questions or need help?

My cancer health care provider is: _____________________________________________

During the day I should contact: _______________________________________________

Evenings, weekends and holidays: _____________________________________________

This page gives general information about this cancer treatment.

You will learn:

who to contact for help
what the treatment is
how it is given
what to expect while on treatment

This information was created by Ontario Health (Cancer Care Ontario) together with patients and their caregivers who have also gone through cancer treatment. It is meant to help support you through your cancer treatment and answer some of your questions.

This information does not replace the advice of your health care team. Always talk to your health care team about your treatment.

What is this treatment?

mFOLFIRINOX is the code name of your pancreatic cancer treatment regimen. Most people call this regimen FOLFIRINOX. A regimen is a combination of medications to treat cancer.

This regimen name is made up of one or more letters from the names of the 4 medications in your treatment.

Here are the names of the medications in this regimen:

FOL = FOLinic acid (also called leucovorin)

F = Fluorouracil (also called 5-FU)

IRIN = IRINotecan
OX = OXaliplatin

Treatment is divided into cycles. Each cycle is 2 weeks long. Your health care team will tell you how many cycles you need.

Here is a picture of the schedule for FOLFIRINOX treatment:

Cycle 1

FOLFIRINOX

(2 weeks)

Repeat 

FOLFIRINOX

(2 weeks)

Your health care 
team will tell you
how many cycles 
you will have.

During each 2-week cycle, you will have FOLFIRINOX treatment on day 1 at the hospital. Your nurse will also start an IV of fluorouracil that will continue at home for a total of 46 hours. See below for more information.

Each cycle looks like this:

Day 1

Treatment Day:

Go to the hospital for FOLFIRINOX
treatment.

Fluorouracil infusion will

continue for 46 hours.

Fluorouracil infusion continues at home.

Fluorouracil infusion continues at home. A nurse will disconnect it.

No FOLFIRINOX Treatment

Remember To:

Tell your health care team about all of the other medications you are taking.
Keep taking other medications that have been prescribed for you, unless you have been told not to by your health care team.

You will have a blood test to check for hepatitis B before starting treatment. See the Hepatitis B and Cancer Medications pamphlet for more information.

Your health care team may ask you to have a blood test to check for DPD deficiency before starting treatment.

DPD deficiency is when you have low or no activity of an enzyme called DPD (dihydropyrimidine dehydrogenase). A deficiency can cause you to have severe side effects from fluorouracil.
See the Testing for people taking capecitabine or 5-fluorouracil (5-FU) pamphlet for more information.

How is this treatment given?

The medications in your treatment are given through an IV (injected into a vein) at the hospital on day 1 of your treatment. You will also be given a device to take home that will continue to give you fluorouracil at home. The device looks like a bottle. It slowly gives you fluorouracil over 46 hours.

Your health care team may suggest that you get a PICC line or a Port-a-Cath.

These are special IV’s used to give medicines and fluids into larger veins.
A PICC or Port-a-Cath can be safer for some medications that can cause reactions
when given through an IV in your hand.
If you have a PICC or Port-a-Cath you do not need an IV (needle) put into your arm
every time you come for treatment.

Talk to your healthcare team about the benefits and risks of a PICC or a Port-a-Cath to see if one of these options is right for you.

You will have a blood test before each treatment cycle to make sure it is safe for you to get treatment.

What other medications are given with this treatment?

To Prevent Nausea and Vomiting

You will be given medications to help prevent nausea (feeling like throwing up) and vomiting (throwing up) before they start.

These are called anti-nausea medications and include medications such as ondansetron (Zofran®), granisetron (Kytril®), dexamethasone or others.

To Treat Diarrhea

The Irinotecan in your treatment regimen can cause diarrhea. Diarrhea is when you have loose bowel movements (watery poo) or you need to have bowel movements (go poo) more often than usual. Diarrhea may start a few days after your treatment.

You will be given a medication called loperamide (Imodium®) to help treat your diarrhea. Take this medication only if you need it.

Keep your loperamide with you all the time. When diarrhea starts, take the loperamide right away.

If you start to have diarrhea:

Take 2 tablets (4mg) of loperamide right away.
Take 1 tablet (2mg) every 2 hours after that.
During the night you may take 2 tablets (4mg) every 4 hours.
Keep taking loperamide until you have no diarrhea for 12 hours.

What other important things should I know about this treatment?

This treatment causes cold sensitivity.

One of the medications in your treatment (oxaliplatin) can cause an unusual side effect where different parts of your body may become very sensitive to cold. This can cause discomfort from things such as cold food, cold drinks and cool or cold temperatures.

How does the cold sensitivity feel?

You may feel:

Numbness or tingling in your fingers and toes. Sometimes it can be painful and feel like burning, which may be severe.
Tightness in your throat or jaw
Like it is hard to swallow
Like it is hard to breathe, or that you have pressure on your chest

Tightness in your throat will usually go away after a few hours. If it lasts longer, or if you have trouble breathing, contact your health care team or get emergency help right away.

How can I help prevent sensitivity to cold?

Avoid the cold as much as possible.
If you must go outside in the cold, protect your face and mouth with a scarf or high-neck sweater, wear mittens and warm socks.
Only eat and drink things that are room temperature or warmer. Do not drink cold drinks or put ice cubes in anything you drink. Do not eat cold foods, such as ice cream.
Avoid direct exposure to air conditioning, such as in your car.
Take shallow breaths when you are exposed to cold air (such as from a freezer or when you are outside in winter).
Wear gloves if you need to touch cold objects, such as items in the freezer.
Do not use an ice pack on any part of your body.

DO this while on treatment

DO tell your health care team about any other medical conditions that you have such as problems with nerves in hands and feet (numbness or tingling), heart, liver, lung or kidney problems, diabetes, or any allergies.
DO check with your health care team before getting any vaccinations, surgery, dental work or other medical procedures.
DO protect your skin from the sun. Wear a long-sleeved shirt, long pants and a hat. Apply sunscreen with UVA and UVB protection and an SPF of at least 30. Your skin may be more sensitive to the sun and you could develop a bad sunburn or rash more easily.
DO talk to your health care team about your risk of getting other cancers and heart problems with this treatment.
DO consider asking someone to drive you to and from the hospital on your treatment days. You may feel drowsy or dizzy after your treatment.

DO NOT do this while on treatment

Stop Icon

DO NOT take any other medications, such as vitamins, over the counter (non-prescription) drugs, or natural health products without checking with your health care team.
DO NOT start any complementary or alternative therapies, such as acupuncture or homeopathic medications, without checking with your health care team.
DO NOT eat or drink grapefruit, starfruit, Seville oranges or their juices (or products that contain these) while on this treatment. They may increase side effects.
DO NOT smoke or drink alcohol while on treatment without talking to your health care team first. Smoking and drinking can make side effects worse and make your treatment not work as well.

DO this while on treatment

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DO tell your health care team about any other medical conditions that you have such as problems with nerves in hands and feet (numbness or tingling), heart, liver, lung or kidney problems, diabetes, or any allergies.
DO check with your health care team before getting any vaccinations, surgery, dental work or other medical procedures.
DO protect your skin from the sun. Wear a long-sleeved shirt, long pants and a hat. Apply sunscreen with UVA and UVB protection and an SPF of at least 30. Your skin may be more sensitive to the sun and you could develop a bad sunburn or rash more easily.
DO talk to your health care team about your risk of getting other cancers and heart problems with this treatment.
DO consider asking someone to drive you to and from the hospital on your treatment days. You may feel drowsy or dizzy after your treatment.

DO NOT do this while on treatment

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DO NOT take any other medications, such as vitamins, over the counter (non-prescription) drugs, or natural health products without checking with your health care team.
DO NOT start any complementary or alternative therapies, such as acupuncture or homeopathic medications, without checking with your health care team.
DO NOT eat or drink grapefruit, starfruit, Seville oranges or their juices (or products that contain these) while on this treatment. They may increase side effects.
DO NOT smoke or drink alcohol while on treatment without talking to your health care team first. Smoking and drinking can make side effects worse and make your treatment not work as well.

Will this treatment interact with other medications or natural health products?

Yes, the medications in this regimen can interact with other medications, vitamins, foods and natural health products. Interactions can make the treatment not work as well or cause severe side effects.

Tell your health care team about all of your:

prescription and over-the-counter (non-prescription) medications
natural health products such as vitamins, herbal teas, homeopathic medicines, and other supplements

Check with your health care team before starting or stopping any of them.

If you are taking seizure medications (such as phenytoin), your health care team will monitor your blood levels closely and may change your dose.

If you are taking a blood thinner (such as warfarin), your health care team may need extra blood tests and may change your dose.

Talk to your health care team BEFORE taking or using these :

Anti-inflammatory medications such as ibuprofen (Advil^® or Motrin^®), naproxen (Aleve^®) or Aspirin^®.
Over-the-counter products such as dimenhydrinate (Gravol^®)
Natural health products such as St. John’s Wort
Supplements such as vitamin C
Alcoholic drinks
Tobacco
All other drugs, such as marijuana or cannabis (medical or recreational)

What should I do if I feel unwell, have pain, a headache or a fever?

Always check your temperature to see if you have a fever before taking any medications for fever or pain (such as acetaminophen (Tylenol^®) or ibuprofen (Advil^®)).
- Fever can be a sign of infection that may need treatment right away.
- If you take these medications before you check for fever, they may lower your temperature and you may not know you have an infection.

How to check for fever:

Keep a digital (electronic) thermometer at home and take your temperature if you feel hot or unwell (for example, chills, headache, mild pain).

You have a fever if your temperature taken in your mouth (oral temperature) is:
- 38.3°C (100.9°F) or higher at any time
OR
- 38.0°C (100.4°F) or higher for at least one hour.

If you do have a fever:

Try to contact your health care team. If you are not able to talk to them for advice, you MUST get emergency medical help right away.
Ask your health care team for the Fever pamphlet for more information.

If you do not have a fever but have mild symptoms such as headache or mild pain:

Ask your health care team about the right medication for you. Acetaminophen (Tylenol^®) is a safe choice for most people.

Talk to your health care team before you start taking ibuprofen (Advil^®, Motrin^®), naproxen (Aleve^®) or ASA (Aspirin^®), as they may increase your chance of bleeding or interact with your cancer treatment.

Talk to your health care team if you already take low dose aspirin for a medical condition (such as a heart problem). It may still be safe to take.

How will this treatment affect sex, pregnancy and breast feeding?

Talk to your health care team about:

How this treatment may affect your sexual health.
How this treatment may affect your ability to have a baby, if this applies to you.

This treatment may harm an unborn baby. Tell your health care team if you or your partner are pregnant, become pregnant during treatment, or are breastfeeding.

If there is any chance of pregnancy happening, you and your partner together must use 2 effective forms of birth control at the same time while you are on treatment. Talk to your health care team about which birth control options are best for you, and how long you should use them after your last treatment dose.
Do not breastfeed while on this treatment. Talk to your health care team about how long to wait before you start breastfeeding after your last treatment dose, if this applies to you.

What are the side effects of this treatment?

The following table lists side effects that you may have when getting FOLFIRINOX treatment. The table is set up to list the most common side effects first and the least common last. It is unlikely that you will have all of the side effects listed and you may have some that are not listed.

Read over the side effect table so that you know what to look for and when to get help. Keep this paper during your treatment so that you can refer to it if you need to.

Very Common Side Effects (50 or more out of 100 people)
Side effects and what to do	When to contact health care team
Neuropathy (Tingling, numb toes or fingers) (May be severe) What to look for? Numbness or tingling of your fingers and toes may happen after starting oxaliplatin. Sometimes it can be painful and feel like a burning sensation, which may be severe. What to do? Talk to your health care team if you have symptoms of neuropathy. Numbness may slowly get better after your treatment ends. Avoid exposure to cold as it can trigger this side effect. Do not use ice packs on your body. Dress warmly and cover all of your skin if you must go outside in cold temperatures. Wear gloves to touch cold objects. Avoid breathing deeply when exposed to cold air. For some people, symptoms of neuropathy may continue long after treatment ends. If you continue to have bothersome symptoms, talk to your health care team for advice.	Talk to your health care team, especially if you have trouble doing tasks like doing up buttons, writing, moving, or if you have severe pain or numbness
Low neutrophils (white blood cells) in the blood (neutropenia) When neutrophils are low, you are at risk of getting an infection more easily. Ask your health care team for the Neutropenia (Low white blood cell count) pamphlet for more information. What to look for? If you feel hot or unwell (for example if you have chills or a new cough), you must check your temperature to see if you have a fever. Do not take medications that treat a fever before you take your temperature (for example, Tylenol® (acetaminophen), or Advil® (ibuprofen)). Do not eat or drink anything hot or cold right before taking your temperature. You have a fever if your temperature taken in your mouth (oral temperature) is: 38.3°C (100.9°F) or higher at any time OR 38.0°C (100.4°F) or higher for at least one hour. What to do? If your health care team has told you that you have low neutrophils: Wash your hands often to prevent infection. Check with your health care team before getting any vaccines, surgeries, medical procedures or visiting your dentist. Keep a digital thermometer at home so you can easily check for a fever. If you have a fever: If you have a fever, try to contact your health care team. If you are unable to talk to the team for advice, you must get emergency medical help right away.	If you have a fever, try to contact your health care team. If you are unable to talk to the team for advice, you MUST get emergency medical help right away.
Low platelets in the blood When your platelets are low, you are at risk for bleeding and bruising. Ask your health care team for the Low Platelet Count pamphlet for more information. What to look for? Watch for signs of bleeding: bleeding from your gums unusual or heavy nosebleeds bruising easily or more than normal black coloured stools (poo) or blood in your stools (poo) coughing up red or brown coloured mucus dizziness, constant headache or changes in your vision heavy vaginal bleeding red or pink coloured urine (pee) What to do? If your health care team has told you that you have low platelets: Tell your pharmacist that your platelet count may be low before taking any prescriptions or over-the-counter medication. Check with your healthcare team before you go to the dentist. Take care of your mouth and use a soft toothbrush. Try to prevent cuts and bruises. Ask your health care team what activities are safe for you. Your treatment may have to be delayed if you have low platelets. Your health care team may recommend a blood transfusion. If you have signs of bleeding: If you have a small bleed, clean the area with soap and water or a saline (saltwater) rinse. Apply pressure for at least 10 minutes. If you have bleeding that does not stop or is severe (very heavy), you must get emergency medical help right away	Talk to your health care team if you have any signs of bleeding. If you have bleeding that doesn’t stop or is severe (very heavy), you MUST get emergency help right away.
Anemia (low red blood cells) (May be severe) What to look for? You may feel more tired or weaker than normal. Pale skin and cold hands and feet. You may feel short of breath, dizzy or lightheaded. This may occur in days to weeks after your treatment starts. What to do? If your health care team has told you that you have anemia (low red blood cells): Rest often and eat well. Light exercise, such as walking may help. You may need medication or a blood transfusion. If it is very bad, your doctor may need to make changes to your treatment regimen.	Talk to your health care team if it does not improve or if it is severe
Nausea and vomiting What to look for? Nausea is feeling like you need to throw up. You may also feel light-headed. You may feel nausea within hours to days after your treatment. What to do? To help prevent nausea: It is easier to prevent nausea than to treat it once it happens. If you were given anti-nausea medication(s), take them as prescribed, even if you do not feel like throwing up. Drink clear liquids and have small meals. Get fresh air and rest. Do not eat spicy, fried foods or foods with a strong smell. Limit caffeine (like coffee, tea) and avoid alcohol. If you have nausea or vomiting: Take your rescue (as-needed) anti-nausea medication(s) as prescribed. Ask your health care team for the Nausea & Vomiting pamphlet for more information. Talk to your health care team if: nausea lasts more than 48 hours vomiting lasts more than 24 hours or if it is severe	Talk to your health care team if nausea lasts more than 48 hours or vomiting lasts more than 24 hours or if it is severe
Fatigue What to look for? Feeling of tiredness or low energy that lasts a long time and does not go away with rest or sleep. What to do? Be active. Aim to get 30 minutes of moderate exercise (you are able to talk comfortably while exercising) on most days. Check with your health care team before starting any new exercise. Pace yourself, do not rush. Put off less important activities. Rest when you need to. Ask family or friends to help you with things like housework, shopping, and child or pet care. Eat well and drink at least 6 to 8 glasses of water or other liquids every day (unless your health care team has told you to drink more or less). Avoid driving or using machinery if you are feeling tired. Ask your health care team for the Fatigue pamphlet for more information.	Talk to your health care team if it does not improve or if it is severe
Hair thinning or loss What to look for? Your hair may become thin or fall out during or after treatment. In most cases, your hair will grow back after treatment. The texture or colour may change. In very rare cases, hair loss may be permanent. What to do? Use a gentle soft brush. Do not use hair sprays, bleaches, dyes and perms.	Talk to your health care team if this bothers you
Liver problems Your health care team may check your liver function with a blood test. Liver changes do not usually cause any symptoms. What to look for? Rarely, you may develop yellowish skin or eyes, unusually dark pee or pain on the right side of your belly. This may be severe. What to do? If you have any symptoms of liver problems, get emergency medical help right away.	Get emergency medical help right away
Diarrhea and other early side effects of irinotecan that start during treatment or within 24 hours What to look for? Loose, watery, unformed stool (poo) Some other symptoms you may have include sweating a lot, belly cramps, runny nose, watery eyes, more saliva (spit) in your mouth than usual, redness (flushing) on your face or neck. What to do? Let your healthcare team know right away if this happens. Medication(s) may be given to you to control these symptoms.	Tell your health care team right away if you have any of these symptoms
Diarrhea that starts more than 24 hours after treatment. Loose, watery, unformed stool (poo) Diarrhea may be severe in some cases and it might cause dehydration (when your body doesn’t have enough water) What to do? If you have diarrhea: Take the loperamide (Imodium®) that your health care team prescribed or told you to take. Do not have foods or drinks with artificial sweetener (like chewing gum or ‘diet’ drinks), coffee and alcohol. Eat many small meals and snacks instead of 2 or 3 large meals. Drink at least 6 to 8 cups of liquids each day, unless your health care team has told you to drink more or less. Talk to your health care team if you can’t drink 6 to 8 cups of liquids each day when you have diarrhea. You may need to drink special liquids with salt and sugar, called Oral Rehydration Therapy. Talk to your health care team if your diarrhea does not get better after 24 hours of taking diarrhea medication or if you have diarrhea more than 7 times in one day. Ask your health care team for the Diarrhea pamphlet for more information.	Talk to your health care team if no improvement after 24 hours of taking diarrhea medication or if severe (more than 7 times in one day)
Low appetite, weight changes What to look for? Loss of interest in food or not feeling hungry. Weight loss. What to do? Try to eat your favourite foods. Eat small meals throughout the day. You may need to take meal supplements to help keep your weight up. Talk to your health care team if you have no appetite. Ask your health care team for the Loss of Appetite pamphlet for more information.	Talk to your health care team if it does not improve or if it is severe

Common Side Effects (25 to 49 out of 100 people)
Side effects and what to do	When to contact health care team
Mouth sores (May be severe) What to look for? Round, painful, white or gray sores inside your mouth that can occur on the tongue, lips, gums, or inside your cheeks. In more severe cases they may make it hard to swallow, eat or brush your teeth. They may last for 3 days or longer. What to do? To help prevent mouth sores: Take care of your mouth by gently brushing and flossing regularly. Rinse your mouth often with a homemade mouthwash. To make a homemade mouthwash, mix 1 teaspoonful of baking soda and 1 teaspoonful of salt in 4 cups (1L) of water. Do not use store-bought mouthwashes, especially those with alcohol, because they may irritate your mouth. If you have mouth sores: Avoid hot, spicy, acidic, hard or crunchy foods. Your doctor may prescribe a special mouthwash to relieve mouth sores and prevent infection. Talk to your health care team as soon as you notice mouth or lip sores or if it hurts to eat, drink or swallow. Ask your health care team for the Oral Care (Mouth Care) pamphlet for more information.	Talk to your health care team as soon as you notice mouth or lip sores or if it hurts to eat, drink or swallow
Sensation that you are not breathing properly This can be caused by drinking cold fluids or inhaling cold air. What to look for? Trouble swallowing or talking. Tightness in your jaw. Unusual feelings in your tongue. Feeling like it is hard to breathe or pressure in your chest. What to do? Avoid the cold as much as possible. If you must go outside in the cold, protect your face and mouth with a scarf or high-neck sweater. Only eat and drink things that are room temperature or warmer. Do not drink cold drinks or put ice cubes in anything you drink. Do not eat cold foods, such as ice cream. Avoid direct exposure to air conditioning, such as in your car. Take shallow breaths when you are exposed to cold air (such as from a freezer or when you are outside in winter). Do not use an ice pack on any part of your body. Problems with breathing and swallowing can be unpleasant. They should only last a few minutes. If they do not go away quickly or if you also feel chest pain, speak with your health care team as soon as possible. If severe, get emergency medical help right away.	Talk to your health care team if it does not improve. Get emergency medical help right away if it is severe.
Constipation What to look for? Having bowel movements (going poo) less often than normal. Small hard stools (poo) that look like pellets. The need to push hard and strain to have any stool (poo) come out. Stomach ache or cramps. A bloated belly, feeling of fullness, or discomfort. Leaking of watery stools (poo). Lots of gas or burping. Nausea or vomiting. What to do? To help prevent constipation: Try to eat more fiber rich foods like fruits with skin, leafy greens and whole grains. Drink at least 6 to 8 cups of liquids each day unless your health care team has told you to drink more or less. Be active. Exercise can help to keep you regular. If you take opioid pain medication, ask your health care team if eating more fibre is right for you. To help treat constipation: If you have not had a bowel movement in 2 to 3 days you may need to take a laxative (medication to help you poo) to help you have regular bowel movements. Ask your health care team what to do. Ask your health care team for the Constipation Pamphlet for more information.	Talk to your health care team if it does not improve or if it is severe
Eye problems What to look for? Your eyes may feel dry, irritated, or painful. They may look red and have a lot of tears. They may feel sensitive to light and your vision may be blurry. What to do? Avoid wearing contact lenses. Wear sunglasses with UV protection. Use protective eyewear (goggles or helmet with face mask) when playing sports, mowing the lawn or doing anything that may get particles or fumes in your eyes. You may try artificial tears (eye drops) or ointment.	Talk to your health care team as soon as possible

Less Common Side Effects (10 to 24 out of 100 people)
Side effects and what to do	When to contact health care team
Cough and feeling short of breath (May be severe) What to look for? You may have a cough and feel short of breath. Symptoms that commonly occur with a cough are: wheezing or a whistling breathing runny nose sore throat heartburn weight loss fever and chills Rarely this may be severe with chest pain, trouble breathing or coughing up blood. What to do? Check your temperature to see if you have a fever. Read the above section "What should I do if I feel unwell, have pain, a headache or a fever?". If you have a fever, try to talk to your health care team. If you are not able to talk to them for advice, you MUST get emergency medical help right away. If you have a severe cough with chest pain, trouble breathing or you are coughing up blood, get medical help right away.	Talk to your health care team. If you are not able to talk to your health care team for advice, and you have a fever or severe symptoms, you MUST get emergency medical help right away.
Rash; dry, itchy skin What to look for? You may have cracked, rough, flaking or peeling areas of the skin. Your skin may look red and feel warm, like a sunburn. Your skin may itch, burn, sting or feel very tender when touched. The rash may be seen in areas where you have had radiation before. What to do? To prevent and treat dry skin: Use fragrance-free skin moisturizer. Protect your skin from the sun and the cold. Use sunscreen with UVA and UVB protection and a SPF of at least 30. Avoid perfumed products and lotions that contain alcohol. Drink 6 to 8 cups of non-alcoholic, non-caffeinated liquids each day, unless your health care team has told you to drink more or less. Rash may be severe in some rare cases and cause your skin to blister or peel. If this happens, get emergency medical help right away	Talk to your health care team if it does not improve or if it is severe
Trouble Sleeping Your medications may cause trouble sleeping. It may get better once your body gets used to the medication or when your treatment ends. What to look for? You may find it hard to fall asleep or stay asleep. How well you sleep may change over your treatment. For example, you may have several nights of poor sleep followed by a night of better sleep. You may wake up too early or not feel well-rested after a night's sleep. You may feel tired or sleepy during the day. What to do? Talk to your health care team if it does not improve or if it is severe.	Talk to your health care team if it does not improve or if it is severe
Headache; Mild joint, muscle pain or cramps What to look for? Mild headache New pain in your muscles or joints, muscle cramps, or feeling achy. What to do? Take pain medication (acetaminophen or opioids such as codeine, morphine, hydromorphone, oxycodone) as prescribed. Read the above section: "What should I do if I feel unwell, have pain, a headache or a fever?" before taking acetaminophen (Tylenol®), ibuprofen (Advil®, Motrin®), naproxen (Aleve®) or Aspirin. These medications may hide an infection that needs treatment or they may increase your risk of bleeding. Rest often and try light exercise (such as walking) as it may help. Ask your health care team for the Pain pamphlet for more information.	Talk to your health care team if it does not improve or if it is severe
Dizziness What to look for? You may feel light-headed and like you might faint (pass out). What to do? Lay down right away so you do not fall. Slowly get up and start moving once you feel better. Do not drive a motor vehicle or use machinery if you feel dizzy.	Talk to your health care team if it does not improve or if it is severe
Mild swelling What to look for? You may have mild swelling or puffiness in your arms and/or legs. Rarely, this may be severe. What to do? To help prevent swelling: Eat a low-salt diet. If you have swelling: Wear loose-fitting clothing. For swollen legs or feet, keep your feet up when sitting.	Talk to your health care team if it does not improve or if it is severe
Swelling inside your nose What to look for? You may have a stuffy, sneezy, itchy, runny nose. What to do? Talk to your health care team if it does not improve or if it is severe.	Talk to your health care team if it does not improve or if it is severe
Rash on your hands and feet (hand-foot syndrome) What to look for? Tingling or swelling of the skin on the palms of your hands and the bottoms of your feet. This can become painful, red and numb. In worse cases your skin may start to peel and you can get blisters or sores. This may happen days or weeks after you start treatment. What to do? To help prevent Hand-foot syndrome: Do not do activities that cause rubbing or pressure on your skin, like heavy-duty washing, gripping tools, typing, playing musical instruments, and driving. Moisturize your hands and feet often, especially in the skin folds. Wear loose, comfortable footwear and clothes. Rest and try to keep off your feet. Do not let your hands and feet get too hot. Ask your health care team for the Hand-foot syndrome pamphlet for more information.	Talk to your health care team if it does not improve or if it is severe
Flushing What to look for? Your face may feel warm and the skin on your neck, upper chest, or face may quickly get red. What to do? Talk to your health care team if no improvement or if severe.	Talk to your health care team if it does not improve or if it is severe
Heartburn; upset stomach; bloating What to look for? Pain or burning in the middle or top part of your chest. It may get worse when you are lying down or bending over or when you swallow. A bitter or acidic taste in your mouth. What to do? Drink clear liquids and eat small meals. Do not eat acidic, fatty or spicy foods. Limit caffeine (like coffee, tea) and avoid alcohol. Avoid smoking or being around tobacco. Sit up or stand after eating. Do not lie down. Raise the head of your bed six to eight inches. You may need to use extra pillows to do this.	Talk to your health care team if it does not improve or if it is severe
Taste changes What to look for? Food and drinks may taste different than usual. What to do? Eat foods that are easy to chew, such as scrambled eggs, pasta, soups, cooked vegetables. Taste foods at different temperatures, since the flavour may change. Try different forms of foods, like fresh, frozen or canned. Experiment with non-spicy foods, spices and seasonings.	Talk to your health care team if it does not improve or if it is severe
Allergic reaction What to look for? Fever, itchiness, rash, swollen lips, face or tongue, chest and throat tightness. It may happen during or shortly after your treatment is given to you and may be severe. What to do? Tell your nurse right away if you feel any signs of allergic reaction during or just after your treatment. Talk to your health care team for advice if you have a mild skin reaction.	Get emergency medical help right away for severe symptoms

Other rare, but serious side effects are possible with this treatment.

If you have any of the following, talk to your cancer health care team or get emergency medical help right away:

Pain and swelling or hardening of a vein in your arm or leg
Sudden confusion, seizure, trouble speaking, or difficulty moving your arms or legs, or weakness on one side of your body
Irregular heartbeat, fainting (passing out)
Any severe pain in your belly
Severe belly pain, severe bloating or feeling of fullness
Leg weakness that may spread to the upper body, trouble with eye or face movements
Severe weakness, problems with your balance, or having falls
Unusual muscle spasms, tremors, irregular or jerky movements
Severe fatigue, muscle pain
Any changes in your eye sight
Redness or rash in areas where you had radiation before
Signs of kidney problems, such as weight gain that is not normal for you, new pain in your lower back, changes in urination (peeing) such as less urine (pee) than usual or urine (pee) that is red-brown coloured
Ringing in your ears or changes to your hearing

Notes

October 2023 Updated " How will this medication affect sex, pregnancy and breastfeeding" section

For more links on how to manage your symptoms go to www.cancercareontario.ca/symptoms.

The information set out in the medication information sheets, regimen information sheets, and symptom management information(for patients) contained in the Drug Formulary (the "Formulary") is intended to be used by health professionals and patients for informational purposes only. The information is not intended to cover all possible uses, directions, precautions, drug interactions or side effects of a certain drug, nor should it be used to indicate that use of a particular drug is safe, appropriate or effective for a given condition.

A patient should always consult a healthcare provider if he/she has any questions regarding the information set out in the Formulary. The information in the Formulary is not intended to act as or replace medical advice and should not be relied upon in any such regard. All uses of the Formulary are subject to clinical judgment and actual prescribing patterns may not follow the information provided in the Formulary.

Regimen Info Sheet (English):

FOLFIRINOX Pancreas_P.pdf Regimen Monograph (English):

MFOLFIRINOX_GI_PAN_A.pdf Global Date: Wednesday, November 15, 2023 Info Sheet Date: Tuesday, January 16, 2024 AddThis: Universal Date: 2024-01-16 00:00:00 Monograph Status: Null Info Sheet Status: Null Info Sheet Status 10: Hidden Info Sheet Status 11: Hidden Info Sheet Status 12: Hidden Info Sheet Status 13: Hidden Info Sheet Status 14: Hidden Info Sheet Status 15: Hidden Info Sheet Status 16: Hidden Info Sheet Status 17: Hidden Info Sheet Status 18: Hidden Info Sheet Status 19: Hidden Info Sheet Status 2: Hidden Info Sheet Status 20: Hidden Info Sheet Status 3: Hidden Info Sheet Status 4: Hidden Info Sheet Status 5: Hidden Info Sheet Status 6: Hidden Info Sheet Status 7: Hidden Info Sheet Status 8: Hidden Info Sheet Status 9: Hidden QBP Drug Name: NULL NULL NULL NULL QBP Type: NULL NULL NULL NULL QBP Description: NULL NULL NULL NULL Revision Summary:
Patient Info Sheet FR: Updated "How will this treatment affect sex, pregnancy and breast feeding?" section (Mise à jour de la section « Comment ce traitement influe-t-il sur la vie sexuelle, la grossesse et l’allaitement? ») Regimen Info Sheet (French):

FOLFIRINOX Pancreas pour le patient.pdf