CAR T-Cell Therapy in MMRR: Managing Adverse Events
Ajai Chari, MD: We’ve heard a lot about efficiency. Cristina, can you tell us a bit about the management of toxicity for CAR [chimeric antigen receptor] T cell therapy?
Cristina Gasparetto, MD: Were [still] learn a little; we talked about CRS [cytokine release syndrome] and the level of toxicity. The one that scares us the most…we can handle CRS with education. I think with a [CAR T treatment] it is a little earlier than the other, a few days against 7 days….
Krina Patel MD: With ide-cel [idecabtagene vicleucel] usually you see it on day 1 vs cilta-cel [ciltacabtagene autoleucel]which is around day 7.
Cristina Gasparetto, MD: Exactly. Important to our care, knowing these details is very important, when to expect toxicity. But what scares me the most is the neurotoxicity. Especially later, patients have to be kept under observation….
Krina Patel MD: I am also thinking of cytopenias. That’s something, especially in our high-risk patients who also have a significant tumor burden. We have seen that even 3 or 4 months later, they still have cytopenias. So, you need to make sure that you monitor these patients very closely. I think a lot of us are trying to figure out what to do with the 10 and 7 packs a week. People are trying different things, but we don’t have a standard of care yet on how to do that. Some patients recovered their autoimmune cells. But even then, we’re not 100% sure that’s the right thing to do. If CAR T actually works, would we reverse something in this bone marrow? I think there is still a lot to learn, but for cytopenia I have to give G-CSF [granulocyte colony-stimulating factor] from time to time. We do the same with IVIG [intravenous immunoglobulin] right now, because these patients…. We actually showcased some of the real-world data from ide-cel. We have about 195 patients that 10 different centers have brought together, and we have lost patients with COVID-19 during this time. I think it’s really important to monitor all of this.
Ajai Chari, MD: Since you alluded to it, maybe someone could elaborate a bit more on neurotoxicity. What are the mitigation strategies that have been mentioned in the management of neurotoxicity?
Krina Patel MD: I think with ide-cel in particular there was 1 patient who apparently in previous line trials that we haven’t heard of yet had parkinsonism. A patient. I haven’t seen it, so we didn’t have to deal with it, but there’s ICANS [immune effector cell-associated neurotoxicity syndrome]. I’ve had a few patients with ICANS grade 1 or 2, usually with CRS, but it doesn’t have to be. This is where we use steroids. Toci [tocilizumab]it works for CRS, but knowing lymphoma, with axi-cel [axicabtagene ciloleucel] where we know we have a lot of ICANS that’s usually where we give a dose of dex [dexamethasone]. Sometimes we give it for a few days, but so far we’ve had this resolution, no cerebral edema or anything that we’re used to seeing with lymphoma patients. I haven’t really seen that at all with myeloma.
Ajai Chari, MD: Do you have handwriting monitoring in place?
Krina Patel MD: Yes. We write every day. We also have their caregivers watching. We ask them about ICE [immune effector cell encephalopathy] score we have, the 10 questions to make sure they get a good score. And if they don’t score well, that’s where I’m called, so we can figure out if we should give dexamethasone.
Ajai Chari, MD: Early recognition and steroids.
Krina Patel MD: Exactly.
Transcript edited for clarity.