FOLFOX Protocol - Quick Reference

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FOLFOX (5-FU, Leucovorin, Oxaliplatin)

Adjuvant Palliative

Clinical Indications

Adjuvant Setting

  • • Stage III colon cancer (standard of care)
  • • High-risk Stage II colon cancer (MSS)
  • • Duration: 6 months (12 cycles)
  • • Consider 3 months for low-risk Stage III

Palliative Setting

  • • First-line metastatic colorectal cancer
  • • Combination with biologics (cetuximab, bevacizumab)
  • • Continue until progression or toxicity
  • • Consider maintenance after 4-6 months

Dosing Regimen (14-day cycle)

Day 1 Administration

Oxaliplatin

Dose: 85 mg/m²

Route: IV infusion

Duration: 2 hours

Diluent: 250-500ml D5W

Leucovorin (Folinic Acid)

Dose: 400 mg/m²

Route: IV infusion

Duration: 2 hours (concurrent)

Diluent: 250ml 0.9% NaCl

5-Fluorouracil

Bolus: 400 mg/m² IV push

Infusion: 2400 mg/m²

Duration: 46-hour continuous

Requires: Ambulatory pump

Administration Timeline

Day 1 (Clinic Visit)
  • • Pre-medications (see below)
  • • Oxaliplatin + Leucovorin (concurrent, 2 hours)
  • • 5-FU bolus (after leucovorin)
  • • Connect 5-FU pump (46 hours)
Day 3 (Pump Disconnect)
  • • Patient returns for pump disconnection
  • • Brief assessment for acute toxicity
  • • Next cycle Day 15 (2-week cycle)
  • • Blood tests Day 14 (pre-cycle)

Pre-medications & Supportive Care

Standard Pre-meds

Ondansetron 8mg IV
30 minutes before chemotherapy
Dexamethasone 8mg IV/PO
Anti-emetic and anti-allergic
Ranitidine 50mg IV (optional)
If history of oxaliplatin reactions

Take-Home Medications

Domperidone 10mg TDS
Days 2-5 for nausea
Loperamide 2mg PRN
For diarrhea management
Allopurinol 300mg OD
If high tumor burden

Dose Modifications & Toxicity Management

Dose Reduction Levels

Level Oxaliplatin 5-FU Bolus 5-FU Infusion Leucovorin
Full Dose 85 mg/m² 400 mg/m² 2400 mg/m² 400 mg/m²
Level -1 (20%) 65 mg/m² 320 mg/m² 1920 mg/m² 320 mg/m²
Level -2 (40%) 50 mg/m² 240 mg/m² 1440 mg/m² 240 mg/m²

Neuropathy Management

Grade 1: Continue full dose, cold avoidance advice
Grade 2: Reduce oxaliplatin by 20%
Grade 3: Hold oxaliplatin, continue FUFOL
Persistent: Discontinue oxaliplatin permanently

Hematological Toxicity

ANC 1.0-1.5: Continue with monitoring
ANC 0.5-1.0: Delay cycle, reduce 20%
ANC <0.5: Delay cycle, reduce 40%
Febrile neutropenia: Delay + reduce 40%

Key Toxicity Profile

Common (>30%)

  • • Peripheral neuropathy (85%)
  • • Nausea/vomiting (65%)
  • • Fatigue (60%)
  • • Diarrhea (45%)
  • • Mucositis (40%)

Serious (Grade 3-4)

  • • Neutropenia (20%)
  • • Thrombocytopenia (5%)
  • • Severe neuropathy (12%)
  • • Severe diarrhea (8%)
  • • Anaphylaxis (<1%)

Patient Education

  • • Cold sensitivity (acute)
  • • Infection precautions
  • • Diarrhea management
  • • When to contact team
  • • Fertility preservation

Monitoring Schedule

Pre-Cycle Assessments

Performance Status Every cycle
Full Blood Count Every cycle
Renal Function Every cycle
Liver Function Every cycle
Neuropathy Assessment Every cycle

Response Monitoring

CT Staging Every 8-12 weeks
CEA Level Every 4 weeks
Toxicity Review Every cycle
Quality of Life Every 4 cycles

Evidence Base

Key Trials

  • • MOSAIC (2004): Adjuvant FOLFOX vs 5-FU/LV
  • • IDEA Collaboration (2018): 3 vs 6 months adjuvant
  • • CRYSTAL (2009): FOLFOX + cetuximab
  • • NO16966 (2008): FOLFOX + bevacizumab

Guidelines

  • • NCCN Guidelines v3.2025
  • • ESMO Clinical Practice Guidelines 2023
  • • NICE NG151 (2020, updated 2023)
  • • St Luke's SACT Protocol v2.1