Oxaliplatin is a cytotoxic (toxic to normal cells) chemotherapy drug that is classified as an alkylating agent as well as a platinum analogue. It is indicated for a number of different cancers including colorectal, esophageal, gastric, hepatobiliary, Non-Hodgkin lymphoma, ovarian, pancreatic, and testicular cancer. (Whew! That's a bunch!) However, it is highly active in and most commonly used to treat colon or rectal cancer, in both the adjuvant (stage III) and metastatic setting.

It is typically given in combination with other anticancer drugs (fluorouracil [5FU] and leucovorin). Combined, this regimen is known as FOLFOX and is administered nearly on a daily basis in many outpatient treatment centers. Less often you may see FOLFIRINOX, a regimen for advanced pancreatic cancer. Basically, if you see "OX" in whatever combination, oxaliplatin is involved. So read up, folks! You're going to be seeing this one frequently. 

Oxaliplatin is administered intravenously and very notably, is not compatible with normal saline. So if you have a patient receiving oxaliplatin, please make sure you grab D5W as your fluids to start your lines, lest you will end up with an opaque white line full of precipitate. (Not good. I do not recommend.) The dose may vary depending on the disease being treated, but typically you will see 85–130mg/m2. Watch your infusion site closely with this agent, as it is an irritant with vesicant properties.

Generally you will administer oxaliplatin over two hours (in D5W). However, if the patient experiences any infusion-related symptoms, you can slow down the rate and extend the infusion time up to six hours, which often helps. Hypersensitivity reactions are usually mild if they occur. Symptoms may include, but are not limited to, flushing, hypotension, tachycardia, dyspnea/bronchospasm, back pain, chest discomfort, fever, pruritis, erythema, nausea, and rash. Educate your patient to tell you or another nurse if they experience any of these symptoms. Stop the infusion immediately to assess your patient and institute your protocol for hypersensitivity reactions as necessary.

Now for the peculiar part—this platinum drug has a particularly unusual side effect, neurotoxicity exacerbated by cold temperatures. Generally, the first thing that comes to mind when I hear "oxaliplatin" is "ixnay on the ice, okay?" This infamous side effect of cold sensitivity can occur within hours of the infusion and typically lasts several days. It usually lessens or goes away completely between treatments, but as the number of cycles increases, the numbness and tingling ordinarily takes longer to dissipate. This may present like typical peripheral neuropathies such as numbness and tingling or even cramping in the hands or feet; however, it's triggered by cold. So touching anything out of the refrigerator, freezer, cold section of the grocery store, or washing hands with cold water will set off the numbness and tingling pretty much as soon as they touch it. Think about all the things in daily life this affects (cold tiles on your bathroom or kitchen floor, cold hand railings outside, etc.). So educate your patients accordingly. Luckily, the cold sensitivity only lasts for a few days, but it certainly makes you have to think a bit more about normal daily functions.

And it doesn't stop with the hands and feet. The neurotoxicity can cause laryngeal spasms as well if a patient drinks cold fluids. Just like in the periphery, it typically sets off tingling on the lips and tongue pretty much from the onset of touching the cool liquid. However, it can continue and cause laryngeal spasms, which may make the patient feel like their throat is closing, or have difficulty swallowing, shortness of breath, jaw spasm, or abnormal tongue sensations. (Ixnay on the ice, okay?)

Because this can start quickly, avoid cold drinks even during the infusion. If you have volunteers or helpers checking on patients and bringing drinks or snacks in your infusion room, make sure they only bring room temperature or warm beverages to anyone receiving Oxaliplatin. As for the recent frigid temperatures we've been experiencing lately, make sure to instruct your patient to dress warm when going outside in cold weather including gloves, hats, and scarves to cover their mouth and nose to help protect against exposure to the cold air. I have had multiple patients tell me in winter months that the cold air caused symptoms—so bundle up!

Tips for Cold Sensitivity Associated With Oxaliplatin

  • Avoid ice and all cold beverages (and yes, ice cream too).
  • Keep gloves next to the refrigerator for reaching in and getting items needed for cooking.
  • Store room temperature beverages conveniently on your counter for easy access.
  • Wear gloves if you're doing the grocery shopping to pick up items in the refrigerated/frozen section.
  • Always wear socks (even to bed in case you have to get up to use the bathroom) to avoid cold tile/vinyl floors.
  • Wear gloves outside and avoid metal hand railings or other cold objects. 
  • In winter, dress extra warm including gloves, hats, and scarves to cover your mouth and nose to minimize exposure to cold air. Do not breathe deeply when exposed to cold air.

I also always educate my patients that if they forget (or decide to test the phenomenon—I'm not sure why they would, but some patients must think we make this stuff up) and experience the tingling on their lips, to drink something warm or hot to help it dissipate more quickly. The same goes for fingers and hands—run warm water over them to help minimize the cold exposure and reverse symptoms more quickly. As I mentioned, the good news is that this cold-triggered neurotoxicity only lasts a few days after infusion.

Other common toxicities include low blood counts, fatigue, loss of appetite, mouth sores, diarrhea, and nausea and vomiting. It is a platinum afterall, which are renowned emetogenics; however, oxaliplatin is certainly less emetogenic than its family cohorts: cisplatin and carboplatin. Still, oxaliplatin is considered to have high emetogenic potential (60%–90%), so make sure your patients are adequately premedicated and have appropriate antiemetics at home as needed. Less common side effects associated with oxaliplatin include constipation, fever, generalized pain, headache, cough, allergic reaction (infusion reactions noted above), and increase in liver function tests.

To recap, oxaliplatin is a peculiar platinum. It is notably not compatible with normal saline and must be infused with D5W generally over two hours. As a platinum, we know it has high emetogenic potential, so be sure your patients are adequately premedicated and have anit-nausea medications at home. And, most importantly, "ixnay on the ice, okay?"