Dr. Paul on the Management of CRS and ICANS After CAR T-cell Therapy in Cancer Care

Barry Paul, MD, assistant professor, the Division of Plasma Cell Disorders, the Department of Hematologic Oncology and Blood Disorders, Atrium Health, discusses the management of cytokine release syndrome (CRS) and immune effector cell–associated neurotoxicity syndrome (ICANS) following CAR T-cell therapy in cancer care.

CRS and ICANS are both adverse effects (AEs) linked to CAR T-cell therapy and any cellular-based therapy, Paul says.

CRS is a systemic inflammatory response that is secondary to the activation of bystander immune and non-immune cells, Paul adds. The activation of these cells leads to significant increase in interleukin-1 (IL-1) and IL-6, causing fever, fatigue, headaches, arthralgias, and myalgias, Paul notes. More severe cases of CRS can present with hypotension, shock, or multi-system organ failure, Paul adds. CRS can be managed with tocilizumab (Actemra) if supportive care with antipyretics, acetaminophen, supplemental oxygen, and intravenous fluids, is not effective, Paul says.

Though ICANS presents with similar symptoms to CRS, this AE can disturb the blood-brain barrier gets disturbed, allowing cytokines to penetrate the central nervous system (CNS), Paul continues. ICANs can present with more CNS symptoms, including headache, confusion, and impaired motor skills, Paul explains, nothing that more severe cases of ICANS can lead to aphasia, seizures, cerebral edema, or coma. Since tocilizumab is ineffective due to its inability to cross the blood-brain barrier, high-dose corticosteroids are utilized for patients with ICANS, Paul concludes.