Dr. Shah and Dr. Wang on Managing CRS and Neurotoxicity in Leukemia/Lymphoma

Bijal Shah, MD, MS, associate member, Department of Malignant Hematology, Moffitt Cancer Center, and Michael Wang, MD, professor, Department of Lymphoma & Myeloma, The University of Texas MD Anderson Cancer Center, discuss management strategies for CAR T-cell therapy–related cytokine release syndrome (CRS) and neurotoxicity in leukemia and lymphoma.

Earlier integration with tocilizumab (Actemra) and, in some cases, corticosteroids has been effective in mitigating emerging CRS in patients with leukemia or lymphoma who receive CAR T-cell therapy, Shah says. However, determining when to intervene with these therapies can be difficult and requires balance.

For example, early intervention with steroids can hinder T-cell expansion, whereas late intervention can leave a patient with more severe CRS that is associated with high fever, hypotension, and hypoxia, Wang explains. Moreover, untreated neurotoxicity can cause seizures and late-onset toxicities.

As such, one strategy for managing CRS includes early intervention with tocilizumab, punctuated doses of corticosteroids, and close monitoring, Shah explains. However, tocilizumab does not treat neurotoxicity and, although effective, utilizing steroids sparingly can exacerbate neurotoxicity. Ultimately, a balance between therapeutic intervention and managing emerging CRS and neurotoxicity is needed, Shah and Wang conclude.