Monitoring Acute CRS Following T-cell Redirection Therapy for Myeloma

When treating with CAR T-cell therapies and bispecific antibodies in patients with multiple myeloma, oncology nurses and advanced practice providers (APPs) should be aware of the risk for acute cytokine release syndrome (CRS) to occur as an adverse effect (AE), according to a nurse practitioner.

Kiah Purcell, MSN, AGPCNP-BC, spoke with Oncology Nursing News^® about the most common and dangerous AEs to look out for when treating patients with CAR T-cell therapy and bispecific antibodies. Purcell highlighted acute CRS as a common AE that nurses and providers should look out for.

Symptoms can include tachycardia; low blood pressure; and flulike symptoms, including fevers and body aches, advised Purcell, who is a nurse practitioner at Mount Sinai. If symptoms worsen, patients may require hospitalization.

Purcell added that indications of CRS may call for more workups to plan for later treatment, including infectious workups, due to CRS’ similar presentation to infections like sepsis. According to Purcell, acetaminophen (Tylenol), dexamethasone, and tocilizumab (Actema) are common for treating CRS early on.

Transcript

Both CAR T-cell therapy and bispecific [antibodies] are in a category that we call T-cell redirection therapy. And because [they] both deal with T cells, we see a slew of side effects that are similar in both [types of treatment] and then some that are a little bit different.

The activation of the T cells with these therapies causes a cytokine release syndrome. That’s really number 1. That is a huge safety issue with patients.

Everyone who was treated with these [therapies] originally was admitted to the hospital….Some institutions are now moving to outpatient dosing with very strict requirements on how far away the person is [located] from the hospital and what the protocol is if they do develop symptoms at home.

[There are 2] CAR T-cell therapies [approved] right now for myeloma. They’re both directed at the same receptor on the myeloma cell. Cilta-cel [ciltacabtagene autoleucel; Carvykti] and ide-cel [idecabtagene vicleucel; Abecma] are the 2 CAR T-cell therapies.

As far as approvals for bispecific antibodies [goes], this would be talquetamab [Talvey], teclistamab [Tecvayli], and elranatamamab [Elrexfio]….

The activation of the T cells leads to the cytokine response, which leads to fevers; body aches; low blood pressure; tachycardia;…[and] flu-like symptoms, which can get more severe…

If they’re mild, they’re not really a big deal. You treat them with Tylenol, dexamethasone, and tocilizumab, but if they progress to a later stage of cytokine release syndrome, it can be very dangerous, because you’re looking at low blood pressure, low oxygen, patients who sometimes end up admitted in the ICU….

As a nurse, [in the bedside setting], you’re really looking for fever, chills, generally feeling unwell, low blood pressure, tachycardia-these are signs that you need to do a further workup. Further workup usually would be an infectious workup, because these look a lot like a severe infection like sepsis….

The label calls for Tylenol and dexamethasone….I will say at our institution, we do intervene with tocilizumab very early. This works on one of those cytokines to bring down the…cytokine response and cool it down.

So it makes it so it’s not as severe or completely resolves it. But that is really the number 1 thing you’re looking for in the acute phase….

CAR T-cell therapy is a 1-time dose, so it’s more of a risk with CAR T-cell therapy. A very high percent of people get them.

[With] bispecifics, we usually do step-up dosing….Once you’re on the treatment dose and have had cytokine release syndrome, it is very rare that it happens….Usually once we see it, it resolves and people can be treated outpatient. They don’t have to be treated inpatient every single time.

This transcript has been edited for clarity and conciseness.