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Treatment Name: FOLFIRI + Bevacizumab

FOLFIRI + Bevacizumab is a Chemotherapy Regimen for Colon Cancer

How does FOLFIRI + Bevacizumab work?
Each of the chemotherapy drugs in this combination therapy are designed to kill cancer cells. Bevacizumab (an immunotherapy drug) has a unique way to stop the growth of blood vessels that supply nutrition to the tumors.

FOL - folinic acid (leucovorin)
F - fluorouracil (5-FU)
IRI - irinotecan (Camptosar)
+
Bevacizumab 
(Avastin)

Goals of therapy: 
FOLFIRI + bevacizumab can be given to shrink tumors early in bowel cancer treatment with a goal of then removing the cancer by surgery. If the stage and grade of cancer are favorable, such as early stage cancer, the firstline treatment goal is to cure colon cancer. If the stage and grade are advanced, such as metastatic cancer, then chemotherapy can still decrease disease symptoms and extend life.

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Schedule

  • Folinic acid (Leucovorin) intravenous infusion (I.V.), over two hours before fluorouracil on Day 1
  • Fluorouracil (5-FU) I.V. push, usually given over 3 to 5 minutes on Day 1
  • Irinotecan I.V. infusion, usually given over ninety minutes on Day 1
  • Fluorouracil (5-FU) continuous I.V. infusion via home-infusion pump over 46 hours beginning Day 1
  • Bevacizumab (Avastin) I.V. infusion over 30 to 90 minutes on Day 1

Estimated total infusion time for this treatment:

  • Up to 5 hours
  • Infusion times are based on clinical studies, but may vary depending on doctor preference or patient tolerability.  Pre-medications and intravenous (I.V.) fluids, such as hydration, may add more time

FOLFIRI + Bevacizumab is usually given in an outpatient infusion center, allowing the person to go home afterwards. 

Each two-day FOLFIRI treatment is repeated every 14 days. This is known as one Cycle. Each cycle may be repeated indefinitely (not ending). Duration of therapy may last many months, or years, depending upon response, tolerability, and number of cycles prescribed.

Click here for common starting doses.

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Side Effects

In a multi-drug regimen, each medication has unique side effects. When these medicines are given together, drug-related side effects reported in clinical studies give the best estimate of what to expect. In clinical studies, the most common side effects with FOLFIRI + Bevacizumab are seen here:

Percentage of patients that discontinued due to unacceptable side effects is roughly 16%.

Side effect videos Side Effect Videos
Fatigue Fatigue Nausea and VomitingNausea and VomitingDiarrheaDiarrheaNeutropenic FeverNeutropenic Fever

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Monitoring

How often is monitoring needed? 
Labs (blood tests) are usually checked before each treatment.  Labs often include: Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), blood pressure, and urine protein level. CEA (carcinoembryonic antigen) may be checked every six weeks to monitor tumor response.

How often is imaging needed? 
Imaging of site of disease, such as CT-scan and/or MRI, is checked before treatment.  These are repeated after every few cycles or about every six weeks as determined by your doctor.

How might blood test results/imaging affect treatment? 
Depending upon the results, your doctor may advise to continue chemotherapy as planned, or delay or switch therapy. 

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ChemoExperts Tips

  • Colorectal cancer patients will have an infusion pump strapped to their body for 2 days to allow fluorouracil (5-FU) to continuously infuse into a vein.  The I.V. pump is connected at the end of the chemotherapy session by a nurse.  When the infusion is finished (two days later) the patient will have to go back to the infusion center or hospital to have it disconnected, unless a home health nurse comes to the patient’s home to do this
  • Diarrhea caused by irinotecan is treated with atropine injections in the medical setting, both before and after the infusion. Diarrhea at home can affect quality of life and is commonly treated with loperamide (Imodium) purchased over-the-counter at a pharmacy. You may receive special instructions on how to use loperamide for diarrhea caused by irinotecan. Tell your doctor immidiately of you have severe diarrhea at home or go to an emergency department immediately
  • A pharmacist should ALWAYS review your medication list to ensure that drug interactions are prevented or managed appropriately
  • Clinical trials may exist for colon cancer.  Ask your doctor if any studies are currently enrolling in your area. If not, go to clinicaltrials.gov to search for other centers offering study medications

Patient Assistance & Co-payment Coverage

Patients under the age of 65 years, or those with private insurance plans:
If you have insurance and are looking for patient assistance or copay assistance for FOLFIRI + Bevacizumab, we have provided links that may help.

Visit our Patient Assistance page and click the links to various patient assistance programs for help paying for FOLFIRI + Bevacizumab. Depending upon your income, they may be able to help cover the cost of:

  • Folinic acid
  • Fluorouracil
  • Irino­tecan
  • Bevacizumab

For Branded medications (may be available for generic medications too), check with the manufacturer to determine if a co-pay card is offered and if it could reduce your monthly copay.

  • If you are uninsured, check with the manufacturer to determine if you are eligible to receive medication at no cost.

Medicare and Medicaid patients (Patients 65 years or older):
The clinic providing treatment will likely pre-authorize medications and immune therapies such as FOLFIRI + Bevacizumab and are the best source to help you understand drug cost.

  • Ask to speak with a patient assistance technician or financial counselor at the clinic or hospital administering this therapy.

Emotional Wellness

What is Emotional Wellness?
Emotional wellness is having a positive outlook balanced with a realistic understanding of current life events. This requires both an awareness and acceptance of your emotions. It is with this knowledge that you can develop a plan to take the necessary actions to positively impact your life.

Emotional wellness uses an ongoing process to continually reflect on the stressors of life in a constructive manner to move forward and create happiness.

Because emotional wellness is deeply connected with physical, social, and spiritual wellness, pursuing it often becomes particularly difficult in times of major illness. Despite this difficulty, working toward emotional wellness has been connected to improved treatment outcomes and a higher likelihood of achieving goals of therapy.

Learn more about pursuing emotional wellness while receiving treatment with FOLFIRI + Bevacizumab

Individual Drug Label Information

Folinic acid (Leucovorin)

  • Folinic acid is an intravenous (I.V.) drug that is a derivative of folic acid, also known as vitamin B9
  • Is clear to slightly yellow in color
General Folinic Acid (Leucovorin) Side Effects
  • Seizures and fainting have been rarely reported
  • Click on the Folinic Acid (Leucovorin) package insert for all reported side effects and possible drug interactions
See DailyMed package insert.

Fluorouracil (Adrucil®)

  • Fluorouracil (5-FU) Is an intravenous (I.V.) drug
  • Recommended to be given only under the supervision of a qualified physician well versed in administering chemotherapy
General Fluorouracil (5-FU, Adrucil) Side Effects
  • Low white blood cell count (leucopenia and neutropenia)
  • Mouth and throat sores or ulcers (mucositis)
  • Diarrhea
  • Nausea and vomiting
  • Low red blood cell and platelet counts
  • Allergic reactions, rarely
  • Eye pain, light sensitivity, excess watering, visual changes
  • Headache
  • Skin conditions:  dryness, redness, tingling, light sensitivity, pain, swelling, loss of nails (hand-foot syndrome)
  • Dosage adjustments may be required for severe liver dysfunction
  • Click on the Fluorouracil (5-FU, Adrucil) package insert below for reported side effects and possible drug interactions

Side Effect Videos
Nausea and VomitingNausea and VomitingDiarrheaDiarrheaFatigue Fatigue PainPainNeutropenic FeverNeutropenic Fever

See DailyMed package insert.

Irino­tecan (Camp­tosar®)

  • Irinotecan is an intravenous (I.V.) drug
  • Recommended to be given only under the supervision of a qualified physician well versed in administering chemotherapy
  • Can induce two forms of diarrhea: early and late. Late usually occurs 24 hours after finishing an irinotecan infusion.  Late diarrhea can be life threatening and should be quickly reported to your physician or visit an emergency department immediately
  • Severe low white blood count may occur, which can lead to infections
  • Dosage adjustments may be required for patients experiencing severe diarrhea, liver dysfunction, or patients with very low white blood cell counts (neutropenia)
  • Irinotecan can interact with ketoconazole and St. John’s Wort.  Those medications should be stopped 2 weeks before starting irinotecan therapy
  • There are known drug interactions of irinotecan with CYP3A4 inducers:  phenytoin, phenobarbital, carbamazepine, rifampin, rifabutin, and atazanavir
General Irinotecan (Camptosar) Side Effects
  • Diarrhea
  • Nausea
  • Vomiting
  • Low white blood cell count (neutropenia)
  • Fevers from low white blood cell count (neutropenic fever)
  • Mouth sores and inflammation (mucositis)
  • Inflammation of the large intestine (colitis)
  • Kidney impairment or kidney failure has rare reports
  • Blockage of blood vessels by a clot (thromboembolism)
  • Lung toxicities, such as shortness of breath or cough
  • Avoid during pregnancy, known to cause fetal harm
  • Click on the irinotecan (Camptosar) package insert link below for a complete list of reported side effects and possible drug interactions

Side Effect Videos
Nausea and VomitingNausea and VomitingDiarrheaDiarrheaHair LossHair LossFatigue Fatigue PainPainNeutropenic FeverNeutropenic FeverBlood ClotsBlood Clots

See DailyMed package insert.

Bevacizumab (Avastin®)

  • Bevacizumab is an intravenous (I.V.) drug
  • Use extreme caution in patients with a history of stomach and intestine perforations or disorders
  • Do not use 28 days before or after any surgery
  • Bleeding is more likely in patients taking this drug
  • Bevacizumab treatment may be delayed or stopped for: surgery, high blood pressure, protein in urine, severe infusion reactions
General Bevacizumab Side Effects
  • Infusion reactions: usually does not happen after first successful dose
  • Bleeding
  • Blood clots
  • Stomach and intestinal problems
  • Poor wound healing
  • High blood pressure
  • Protein leaking from kidneys into urine
  • Avoid during pregnancy, Bevacizumab is known to cause fetal harm
  • Ovarian failure
  • Click on the bevacizumab (Avastin) package insert below for reported side effects and possible drug interactions

Side Effect Videos
BleedingBleedingBlood ClotsBlood Clots

See DailyMed package insert.

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References

Fuchs CS, Marshall J, Mitchell E, et al. Randomized, controlled trial of irinotecan plus infusional, bolus, or oral fluoropyrimidines in first-line treatment of metastatic colorectal cancer: results from the BICC-C Study. J Clin Oncol. 2007;30:4779-4786.

Created: August 31, 2015 Updated: August 28, 2018

What is Colon Cancer?

A disease of the cells from the large intestine.  Colon cancer is the third most common cancer among both men and women.  Known causes include:  family history, poor diet, sedentary lifestyle, obestity, diabetes, history of colon polyps, smoking, heavy alcohol use, prior radiation treatment to abdomen for other cancers, and old age.  The stage can vary at diagnosis and throughout treatment.  Stages of colon cancer use Tumor, Node, Metastasis (TNM) staging as well as Stage Grouping using Stages I, II, III, or IV.  The effectiveness of the treatment may depend upon the stage at diagnosis.

NOTE: Treatment Options listed below are not all-inclusive. Other treatments may be available. ChemoExperts provides drug information and does not recommend any one treatment over another. Only your Doctor can choose which therapy is appropriate for you.

Common Starting Doses

  • Folinic acid (Leucovorin) 400 mg/m2 intravenous infusion (I.V.) over 2 hours before fluorouracil on Day 1
  • Fluorouracil 400 mg/m2 I.V. infusion, over 3 to 5 minutes on Day 1
  • Irinotecan 180 mg/m2 I.V. infusion, over ninety minutes on Day 1
  • Fluorouracil 2400 mg/m2 continuous I.V. infusion via home-infusion pump over 46 hours beginning Day 1 and ending on Day 3
  • Bevacizumab 5 mg/kg I.V. infusion, over 30 to 90 minutes on Day 1

What is an I.V. Push?

An intravenous medication that is usually prepared in a syringe and infused by vein over a short period of time, such as 15 minutes or less

What is a CBC?

A Complete Blood Count (CBC) is a frequently ordered blood test that tells clinicians the status of your: 1) White blood cell count, 2) Hemoglobin, and 3) Platelet count at the time the test was taken.

Common uses:
1) White blood cell count (WBC): is used to determine infection risk, or response to chemotherapy. Certain chemotherapy agents may harm our good infection-fighting cells. Sometimes chemotherapy may need to be delayed to allow these cells to recover.

2) Hemoglobin: is used to determine if someone is anemic. Anytime the hemoglobin is below 12 g/dL, the person is said to be anemic. Red blood cell transfusions, and sometimes iron can be given to restore the hemoglobin level, but anemia treatment should always aim at treating the underlying cause or condition.

3) Platelet count: is used to determine if the risk of bleeding is increased or if a platelet transfusion is required to prevent bleeding. Certain medications that increase bleeding risk, such as: aspirin, certain chemotherapy agents, and blood thinners, may need to be stopped temporarily until the platelet count is within a safe range.

What is a CMP?

A Comprehensive Metabolic Panel (CMP) is a frequently ordered blood test that tells clinicians the status of your: 1) Electrolytes & Acid/Base status2) Kidney function, 3) Liver function, 4) Blood sugar, and 5) Calcium at the time the test was taken. It is commonly used to monitor liver and kidney function when beginning new medications such as chemotherapy. A total of 14 tests are run simultaneously and are shown below.

Electrolytes & Acid/Base status:
1) Sodium, 2) Potassium, 3) Carbon dioxide, 4) Chloride

Kidney Function:
5) BUN (blood urea nitrogen), 6) Serum creatinine (Scr)

Liver Function:
7) AST, 8) ALT, 9) Total bilirubin, 10) Alk Phos, 11) Albumin, 12) Total protein

Blood sugar:
13) Serum glucose

Calcium:
14) Serum calcium

What is neutropenia?

This occurs when there is an abnormally low amount of a certain type of white blood cells, called neutrophils, in the blood. These neutrophils help the body body fight infections caused by bacteria and viruses. Many chemotherapy drugs temporarily damage bone marrow where white blood cells are created, resulting in neutropenia. Please watch our video on neutropenia to learn more.

What does Cure mean?

The word “cure” means there are no cancer cells left in the body and cancer will never come back. Depending on the cancer type and stage, this may be the true goal of therapy. However, it is very difficult to prove all cancer cells are gone. Even though images, like X-rays and MRI’s, and blood tests may not show any signs of cancer, there can be a small amount of cancer cells still left in the body. Because of this, the word “remission” is used more often. This means there are no signs or symptoms of cancer. Patients in remission are followed closely for any signs of cancer returning. Sometimes, more chemotherapy may be given while in remission to prevent the cancer from coming back.

Doctors usually do not consider a patient “cured” until the chance of cancer returning is extremely low. If cancer does return, it usually happens within 5 years of having a remission. Because of this, doctors do not consider a patient cured unless the cancer has not come back within 5 years of remission. The five-year cutoff does not apply to all cancers.

What does metastatic mean?

Metastatic disease is when cancer cells have spread from their primary (original) location to other parts of the body and started more tumor(s).