Summary for doctors
- Only for fit patients (ECOG 0 to 1) with bilirubin up to 1.5 times the upper limit of normal [1].
- Adjuvant after surgery: 12 cycles (6 months) of mFOLFIRINOX is the standard [2].
- Moderately to highly emetogenic; neutropenia is common and many patients need G-CSF [1].
Dose and schedule
FOLFIRINOX (metastatic disease)
Metastatic pancreatic cancer, first line, ECOG 0 to 1Cycle length: Every 14 days
Metastatic pancreatic cancer, first line, ECOG 0 to 1
| Drug | Dose | Route | Schedule |
|---|---|---|---|
| Oxaliplatin | 85 mg/m² | IV over 2 hours | Day 1 |
| Leucovorin | 400 mg/m² | IV over 2 hours | Day 1 |
| Irinotecan | 180 mg/m² | IV over 90 minutes | Day 1 |
| Fluorouracil | 400 mg/m² | IV bolus | Day 1 |
| Fluorouracil | 2400 mg/m² | Continuous 46-hour infusion | Starting on day 1 |
Doses as in the PRODIGE 4/ACCORD 11 study [1]. Many centres omit the bolus or reduce irinotecan to lower toxicity.
Evidence: PRODIGE 4 / ACCORD 11 (2011)
mFOLFIRINOX (adjuvant)
Pancreatic cancer after surgery, within 12 weeks of the operationCycle length: Every 14 days
Pancreatic cancer after surgery, within 12 weeks of the operation
| Drug | Dose | Route | Schedule |
|---|---|---|---|
| Oxaliplatin | 85 mg/m² | IV over 2 hours | Day 1 |
| Leucovorin | 400 mg/m² | IV over 2 hours | Day 1 |
| Irinotecan | 150 mg/m² | IV over 90 minutes | Day 1 |
| Fluorouracil | 2400 mg/m² | Continuous 46-hour infusion (no bolus) | Starting on day 1 |
Doses as in the PRODIGE 24 study [2].
Evidence: PRODIGE 24 / CCTG PA.6 (2018)
Doses follow the trial protocol, guideline or official drug label (source given in the notes of each regimen). Before prescribing, check blood counts, renal and hepatic function, drug interactions and the patient’s condition, and adjust the dose according to the drug label.
Premedication and supportive care
- Antiemetics: an NK1 antagonist, 5-HT3 and dexamethasone (and olanzapine if needed); atropine for cholinergic syndrome.
- Diarrhoea: loperamide as for FOLFIRI.
- G-CSF: primary or secondary prophylaxis in many patients (about 42% received G-CSF in the metastatic study) [1].
- DPYD: before the first fluoropyrimidine dose, consider testing for DPD deficiency (DPYD genotype); in carriers of one reduced-function allele the starting dose is reduced by about 50%, and these drugs are contraindicated in complete deficiency [3].
Monitoring and dose adjustment
- Before each cycle: full blood count, bilirubin (biliary drainage before starting), electrolytes.
- Common thresholds for starting a cycle: ANC 1500 and platelets 75,000 or more.
- Neuropathy: reduce or stop oxaliplatin; grade 3 diarrhoea: reduce irinotecan.
Main evidence
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Metastatic: FOLFIRINOX vs gemcitabine increased median survival from 6.8 to 11.1 months, with more neutropenia, febrile neutropenia, diarrhoea and neuropathy [1]. Adjuvant: mFOLFIRINOX vs gemcitabine increased median disease-free survival from 12.8 to 21.6 months and median overall survival from 35 to 54.4 months [2].
Related cancer types
Treatment regimens (physicians)
Physician tools and lessons
References
3 referencesShow all references, 3 with a study cardClose the reference list
Numbers in the text, such as [1], refer to these sources. Sources with a “Study card” button are summarised in the site’s evidence library.
- 1
- 2
- 3Clinical Pharmacogenetics Implementation Consortium (CPIC) Guideline for Dihydropyrimidine Dehydrogenase Genotype and Fluoropyrimidine Dosing: 2017 Update
This page is based on reputable scientific sources and was last updated on 28 October 2026. The content of this website is for educational and informational purposes only and does not replace consultation, diagnosis or treatment by a specialist physician. Consult your treating physician about any treatment decision.
Printed from the website; the full and up-to-date version: https://drdabiri.com/en/regimens/folfirinox/