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Table. 1.

Modified protocol for assessing and managing cytokine-related toxicities after CAR T-cell therapy at the Samsung Medical Center based on the ASTCT and ASCO guidelines

Toxicity Grade 1 Grade 2 Grade 3 Grade 4
CRS Fever Temperature ≥38°C Temperature ≥38°C Temperature ≥38°C Temperature ≥38°C
Hypotension None Not requiring vasopressors Requiring one vasopressor±vasopressin Life-threatening hypotension requiring multiple vasopressors
Hypoxia None Requiring low-flow nasal cannula (≤6 L/min) Requiring high-flow nasal cannula (>6 L/min), facemask, or venturi mask Requiring positive pressure (e.g., CPAP, BiPAP, mechanical ventilation)
Tocilizumab IV administration
(8 mg/kg)
Consider tocilizumab for fever not attributable to any other cause in a patient with high tumor burden or elderly frail status Repeat tocilizumab every 8 hrs; limit to a maximum of three doses in a 24-hr period Repeat tocilizumab every 8 hrs; limit to a maximum of three doses in a 24-hr period Repeat tocilizumab every 8 hrs; limit to a maximum of three doses in a 24-hr period
Steroid None Consider dexamethasone 10 mg IV every 12 or 24 hrs if no improvement within 24 hrs of starting tocilizumab Dexamethasone 10 mg IV every 6 or 12 hrs and taper based on symptoms Methylprednisolone 1 g per day IV for 3 days followed by 250 mg every 12 hrs for 2 days and slow tapering
Supportive care Antipyretics, IV hydration, empiric broad-spectrum antibiotics, GCSF, and symptomatic treatment Supportive treatment as per grade 1
Consider ICU care
Supportive treatment as per grade 2 at ICU with intensive treatments for organ toxicities (e.g., mechanical ventilation as needed) Supportive treatment as per grade 3 at ICU with intensive treatments for organ toxicities (e.g., mechanical ventilation as needed)
ICANS Consciousness Alert Awaken to voice Awaken to painful stimuli Unarousable
ICE test ICE score 7–9 ICE score 3–6 ICE score 0–2 ICE score 0
Management Supportive care Dexamethasone 10 mg IV; if no improvement, dexamethasone 10 mg IV every 6–12 hrs
If CRS +, consider tocilizumab as per CRS grade 2
Dexamethasone 10 mg IV every 6 hrs or methylprednisolone 1 mg/kg IV every 12 hrs
If CRS +, consider tocilizumab as per CRS grade 3 and ICU care
Same as CRS grade 4 at ICU with supportive treatments for organ toxicities

Abbreviations: ASCO, American Society of Clinical Oncology; ASTCT, American Society for Transplantation and Cellular Therapy; BiPAP, bilevel positive airway pressure; CAR, chimeric antigen receptor; CPAP, continuous positive airway pressure; CRS, cytokine release syndrome; GCSF, granulocyte colony-stimulating factor; ICANS, immune effector cell-associated neurotoxicity syndrome; ICE, immune effector cell-associated encephalopathy; ICU, intensive care unit; IV, intravenous.

Ann Lab Med 2024;44:210~221 https://doi.org/10.3343/alm.2023.0388

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