Optimizing Patient Selection for CAR T, Bispecifics, Mitigates Adverse Events in High-Risk MM

Previously, Ajai Chari, MD, University of California San Francisco (UCSF), spoke to the operational challenges of integrating chimeric antigen receptor T-cell (CAR T) and bispecific therapies into clinical practice. Notably, he emphasized the need to educate providers to manage potential adverse events, such as cytokine release syndrome (CRS) or immune effector cell-associated neurotoxicity syndrome (ICANS). In this continuation of his interview with The American Journal of Managed Care^®, Chari discusses how clinicians can approach patient selection or patient monitoring strategies to consider the needs of those with higher-risk multiple myeloma.

This transcript has been lightly edited for clarity and length; captions were auto-generated.

Transcript

Given the complexity of CAR T and bispecific treatments, what steps are being taken to ensure consistent patient eligibility and monitoring protocols, especially in cases of high-risk disease?

In terms of eligibility, I would say for CAR T: fit, no significant comorbidities, and can basically tolerate a high-grade CRS, so hypotension, hypoxia, etc. Bispecifics, like I alluded to, I don't think there is any contraindication to bispecific. Where you can get into selection for bispecifics is, if you're planning on doing it as an outpatient, don't take bulky disease, make sure that the patients don't have comorbidities, that they're not frail, elderly, they have a caregiver, and are reliable for communication. But short of that, you could do all of that in inpatient, and after that's done, it's basically a subcutaneous or an intravenous medication given intermittently, like any other product.

In terms of protocols, I think CRS, those of us who were involved in the clinical trials, remember the days when every product seemed to have a different algorithm. Even within myeloma, 1 bispecific, you gave “this” for grade 1 CRS and “that” for grade 2, and the other one was completely different.

At UCSF, where I practice, we’ve decided to standardize that. And because there are now 9 bispecifics, and the inpatient team cannot be sitting there and calling the doctor for each disease, we have a 1-size-fits-all algorithm for CRS, for ICANS. [We give] Tylenol and [tocilizumab], and then if that doesn't work, add the [dexamethasone]. If that doesn't work, add the anakinra.

I think you need to have a simple protocol. If you can, also build into your electronic medical records [EMR] the drop downs for all of these medications. If somebody's never given tocilizumab, they don't know that it's 8 mg per kg. You can just click on a button, and it's ordered, and the pharmacy mixes it. It needs to be given quickly, too—that's the other thing. By putting it in an EMR, it should hopefully flag pharmacy and nursing to give it. Speaking to the interdisciplinary care, I think having those kinds of protocols helps standardize the management of these side effects.

Lastly, making sure that when there are transition points between academia and community, that you've summarized what happened in the hospital, a good discharge summary, you've summarized the dosing that should happen in the next immediate few days to weeks to months. Then the supportive care, IVIG [intravenous immunoglobulin], antimicrobial prophylaxis, all of that really needs to be spelled out.

And then the patients also should need to be educated so that, should they ever have fevers when they go to the emergency room, they either show their wallet card or tell the ER, “I'm on this medication,” so that ER doctors don't think, “Oh, this is just another fever, or it's flu and COVID.” Well, it may be something different. I think those are the systems issues that I would suggest.